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HomeMy WebLinkAboutMiscellaneous - 455 MAIN STREET 4/30/2018 / 455 MAIN STREET J 210/057.0-0016-0000.0 !I i Claim # Advantage Claim Services Adjuster Assigned: Glenn Guarente 522 Chickering Road #B North Andover, MA 01845 Form of Notice of Casualty Loss to Building Under Mass. Gen. Laws, Ch. 139, Sec. 3B To: Building Commissioner cv/ Board of Health or Inspector of Buildings Board of Selectmen Town Hall Town Hall North Andover, MA 01845 North Andover, MA Re: Insured: Everett Whipple Property address: 455 Main St. North Andover, MA 01845 Policy #: 2654015 Loss of: 2016/02/21 File or Claim No. AD 1980 Claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1, 000. 00 or cause Mass._Gen._Laws,_Chapter_143, Section 6 to be applicable. If any notice under Mass_Gen_Laws,_Ch._139 Sec. 3B is appropriate please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, ,date of loss and claim or file number. Glenn Guarente Title: Adjuster On this date, I caused copies of this notice to be sent to the persons named at the addresses indicated above by first class mail. 02-22-2016 Signature and da-te r Date JU /-*7*/ TOWN OF NORTH ANDOVER i PERMIT FOR WIRING This certifies that .� : . . . has permission to perform . :e �P� 4..+9--t �, .�./` ZZ -?. . wiring in the building of .�! , I�- at . . . :I.�. . !:/.�.� �:$� ,North Andover, Mass. FeOa . . Lic. No. . . . . . . . . . ?*1 . . . . . Gi+Cf'Lf . ELECTRICAL INSPECTO I Chkck# `f 96 11163 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance-with the provisions of M.G.L.c.143,§3L,the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166,§32,an electrical permit shall be issued to the person,firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L.c.143,§3L. Permits shall-be limited as to the time of-ongoing construction activity,and may be-deemed_by be-deemed-by-the-Inspector-of-Wires abandoned-and_invalid-if he—_. ._ or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity Slated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections.74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property,With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence"during the qualifying period beginning on August 15,2008 and extending-through August 15,2012. Mule 8—Permit/Date Closed: 171Z3ZI ***Note:Reapply for new permit 0 Permit Extension Act—Permit/Date Closed: -r lromm.onwea&of f a,4dachudeib OfficialUseOnly c� �7 Pe /Drmit No. 1 epartment 01 ire Services BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 1/071 (leave blank)' APPUCATM FOR PERMIT TO PERFORM ELECT AL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: Z e - /, / 2 City or Town of: � �✓✓�✓dt/f To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street&Number) _5— Owner or Tenant t/ eV 64 l✓61i/l.'�C Telephone o�4 Clamarc f-nrire�� �a rn Is this permit in conjunction with a building permit? Yes ,& No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. IV A Existing Service/""4,f Amps 12 s I Lgr1 Volts Overhead ❑ Und rd 7 g ,® 1\0, of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No,of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion of the followin table may be waived by the Ins ector o Wires. No, of Recessed Luminaires No. of Ceil.-Susp, (Paddle)Fans No,of Total Transformers KVA No, of Luminaire Outlets No. of Hot Tubs Generators KVA No, of Luminaires ` Swimming Pool Above ❑ In- ❑ o.o mergency ig ting . rnd, rnd. Battery Units No. of Receptacle Outlets O© No. of Oil BurnersaKWLocal E ALARMS No, of Zones No, of Switches �j No, of Gas Burnerof Detection and Initiating Devices No. of Ranges g / No. of Air Cond. of Alerting Devices No. of Waste Disposers f Heat Pump Numbof Self-Contained Totals: ction/Alerting Devices No, of Dishwashers Space/Area Heatinl❑ Municipal ❑ Other Connection No, of Dryers Heating Appliancerity Systems:* o.of Devices or Equivalent No, of Water KW No. of No. of Data Wiring: Heaters Signs Ballasts No.of Dvices or E uivalent j No. Hydromassage Bathtubs No, of Motors Total HP Telecommunications firing: No.of Devices or E uivalent OTHER: Attach additional detail if desired, or as required by the Inspector of wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent, The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office, CHECK ONE: INSURANCE ❑ BOND ❑ OTHER (Specify:) G✓at #'a er+ I certify, under the pains and penalties of perjury, that the information.on this application is true and complete. FIRM NAME: LTC,NO,: 2_/Z-7 % Licensee:_2a / ? C14 / 3natur LIC.NO. �3 (If applicable, enter "exempt"in the licens number line.) g Bus, Tel,Nc�:_ 7�)L� /- Address: S �.1"0'a 0 ��. Ga �✓• ��a� , ��� yJ Alt. Tel.No.: *Per M.G.L, c. 147, s, 57-6 , security work requires Department of Public Safety"S"License: Lic. No. OWNER'S INSURANCE WAIVER. I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement, I am the(check one) ❑ owner ❑owner'sa ent. Owner/Agent Signatures t &'r-,-._--\ ✓ Telephone No. �, j� PERMIT FEE: $ -t r� The Commonwealth ofMassachusetts r. Department Ike of Industrial Accidents P Office of Investigations 600 Washington Street Boston, ISA 02111 -tJ www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant�nforuruation Please Print Lejobl� Name (Business/Organization/Individual):�:L:>at Address: Ci /State/Zi a r.✓ . /��, U«t� �' P Phone ''�' 6� Are you an employer? Check the appropriate box: I am a employer with 4. [] I am a general contractor and I Type of project(required): 1.❑ err�ployees(full and/or part-time).* have hired the sub-contractors 6 El New construction 2. am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g• E] Demolition working for me in any capacity. employees and have workers' [No workers' comp.insurance comp. insurance.t 9. ❑Building addition required.] 5. We are a corporation and its 10. lectncal repairs or additions 3.E] I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [Noworkers'. comp. right of exemption per MGL insurance required.] t c. 152, §1(4), and we have no 12.E] Roof repairs employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: ,. Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address:_ s$� � i� f, City/State/Zip:N• X vc1o✓C e Y-Y J Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a e fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties ofperjury that the information provided above is true and correct. Signature: a—" Date: Z-- Phone 9 Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/]License# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: Date.. 1 . ©� . ..... . NORTH o? TOWN OF NORTH ANDOVER • 'PERMIT FOR GAS INSTALLATION s �9SSACHUSE4 This certifies that . . .1.ty4! 4 5 . . /?��`�!�*h k 'fes has permission for gas installation . . . . . 0�4. M44. . . . T in the buildings of . . �?�?!?`�. .1�. f����v. . . . . . . . . . . . . . . . at . . . . .'h :�. . . . . . . . . . .AGAS�INSPECTO North ndover Mass. Fee. P' Lic. No.ZG°3� . . . . . . . . . Check# A el 8008 ca y wco � Gd �IW14tvw �� � d� i C) q Sj . 54 9 t4 00000t 0 000006001.1 % CP . , • `" •C ' Jq GRS row (f ,� C, OVICN9 IDATINGDOILHIRS I�[JRNACEs � Era �• • � �-`1 � � kINCCXJCA'9'ICt28 o cn ' WATER WATERS r buyuns GAS of�NiCRA'!'QI2�f M k4 _ I+A1110ItA'i'OXxlf COCKS r t CONVERSION BURNER 11 El 11 ,� ' RooleTar UNITS e� p1. m � � , VENTED ROOM II'IY2�l. t+a veers '� I W" s. .M.r M.. inpwV....ww+r..nwM.tiwMh.ww..r `t CP,V O'i'I#LR w Date. 9263 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING 49 ,SSACHU 'w This certifies that . ., �a�!!?S. . ./T�L�pj"4.j?. . . . . . . . . r has permission to perform plumbing in the buildings of .J/7!ZQ. /lt�� t��. . . . . . . . . . . at. . .0-Y ./1.1�?.i . . . . . . . . . . . . . . . . . . , Nor thAndo Rr, Mass. Fee. �- PLUMBIN . Check # / £'�