HomeMy WebLinkAboutMiscellaneous - 517 REA STREET 4/30/2018 _57 BUILDING FILE
BUILDING FILE
PO Box 55098
Boston,MA 02205-5098
617-951-0600
ARM
Form of Notice of Casualty Loss to Building
Under MASS. GEN. LAWS, Ch. 139, Sec. 3B
To: Building Commissioner or Board of Health or
Inspector of Buildings Board of Selectman
City Hall City Hall
NORTH ANDOVER, MA 01845 NORTH ANDOVER, MA 01845
RE: Insured: CONSTANCE DOTO and DEBRA CIARDELLO
Property Address: 517 REA ST,NORTH ANDOVER, MA
Policy Number: HMA 0332033
Claim Number: BOS00052151
Date of Loss: 2/26/2015
Company: Safety Insurance Company
Claim has been made involving loss, damage or destruction of the above-captioned property,
which may either exceed $1,000.00 or cause Mass. Gen. Laws, Chapter 143, Section 6 to be
applicable. If any notice under Mass. Gen. Laws, Chapter 139, Section 3B is appropriate, please
direct it to the attention of the writer and include a reference to the captioned insured, location,
policy number, date of loss and claim number.
Eric Yablonski Claim Examiner 2/27/2015
Safety Insurance Company
Homeowners Claims Unit
P. 0. Box 55098
Boston, MA 02205-5098
Phone: (617) 951-0600 EXT 3550
I, Fax: 617 531-6650
Email: EricYablonski@Safetylnsurance.com
73b$ Date. �L. . .
.I
"pR'N TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
,SSACMUSE� i1
This certifies that . . .,�/�r'
has permission to perform
n
plumbing in the buildings of . . . .#41 . . . . . . . . . . . . . . . . . . . . . . . . .
at. . . . . . . . . .4-*//'
. N9 fi . ndov �', Mass.
Fee.8Q7'�Lic. No..147 �,. ' . . .�.
PLUMBING INS CTOH
Check #i- ZZ/G
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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
- i OITYQ✓�f� /19V CIV r/c'K— MA DATE] S�/� �PERMIT it
�
JOBSITEADDRESS �^ /� I� O E !'
. � ,7 I� � WN R S NAME C�o�✓.t/ "e-
OWNERAADDRESS) _Spq i6 TEL IFAXi i
TYP.E•d(t OCCUPANCY - E COMMERCIAL ) EDUCATIONAL I RESIDENTIAL].
PRINT
CLEARLY NEW; RENOVATION:I I REPLACEMENT:f I PLANS SUBMITTED: YES N0.( )
FIXTURES 1
' R-0011-* BSM 1 2 3 4 b G 7 a 9 . 10' 11 12 13 14
BATHTUB _._I.._. ...i . .. .�. ..
.06SS CONNECTION DEVICE .. :.. _.;... . .
DEOICATEDSPECIALVVASTE-SY$TEM
DEDICATED GASIOIUSAND SYSTEM
DEDICATEO GREASE SYSTEM ' .. .. _._`...... - _.. :.
DEDICATED GRAY WATER SYSTEM _I ,._.... -...._
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN I . . .. i ...
FOOD DISPOSER
FLOOR,!AREA DRAIN I
INTERCEPTOR(INTERIOR) 1- - -,j ... .•s i_ - r
KITCHEN SINK
LAVATORYROOF DRAIN
i I
SHOWER STALL
SERAGEIMOP SINK
TOILET
URINAL i -- - -- -- -- - 1
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING —
.OTHER j _ .
i
INSURANCE COVERAGE: --' -
have a ctirront tial- �ility iusinifee poltcy.or its stlliMantial equivalent which meets the requirements of MGL Ch.142. YES INO [ I
IF YOU CHECKED YES,PLEASE INDICATE THE E OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY� OTHER TYPE OF INDEMNITY I i BOND(. I
OWNER'S INSURANCE:WAIVER:i am aware that the licensee—does not have the istirance coverage required by Chaptd 142 of tile
Massachusetts GeneralLaws,and that-111Y signature on tiff permit application waives this requirement.
— - CHECK-ONE ONLY: OWNER AGENT -
SIGNATURE OFOWNEUR AGENT
I hereby certify that all of[lie details and Ififormallon i Ima ubinitled of entered regard[ng;this applicalioti ate true ' Mural to t e t of m oerlddg'e
and that all plumbing work and installations performed under the permit issued for this applical[on W11.ba in con eAlh all P' ' e T the
Mas5achusetls State-Plumbing Cale and Chapter 142 of the General Laws. j
,O O !!
PLUMBER'S NAME 7t,[�•11m ow, 4H4b LICENSE It 101S7 ( AT E �~ I
I
' MP( .1PCOIZPORATIONI jIt' IPARTNERSH.IPj jiff 19I
COMPANY NAME( e I i , L, 71.E J ADDRESS I
CITY t"tJfjj !�� (STATE ,Ur( ZIP TEL ZJ GAJ
FAX CELL I EMAIL {
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-ROUO-H JPL.TJMWG WST.'J,'MONXOTE9 AELOW MR 0-MCiCE URI ONLY MAL tNSPrMON NOTES
ell i
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•
Date.. .
N°RTh
TOWN OF NORTH ANDOVER
F P
4411
• PERMIT FOR GAS INSTALLATION
�9SgACHUgE�
This certifies that . . !!.Q �i' . . . . . .
has permission for gas insta at�i n . . . . . . . . . . . . . . .l. . . . . . . . . . . .
in the buildings of . . . . . . !.`�. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
at . . . . S�?. .req . .ST. , North n over Mass.
FeeA'?U �OLic. No.�Z9S�. . . . . . . . . . . . .
GAS INSPECTO
Check# Z24-
8108
2/ -
81U8
F
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
CitylTown•_ 11/0 d lYPtJ elQyle MA. L Date: / Permit#
Building Location: )Cl/� Owners Name: pylu;G `I �
Type;7AIteration: E]
pancy: Commercial❑ Educational El Industrial❑ Institutional E] Residential
New: Renovation: ❑ Replacement: ❑ Plans Submitted. Yes❑ No❑
FIXTURES-
- - - - - - - -
IXTURES- - - - - - - - - vi - -
LLI w
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O c= IY
Z W w � Q 0. w w ' m > O Z O c4 ~ > Z F- x
V D o a 0 0 x z � 0 a � � Iw— > > > � 0 1Al
SUB BSMT.
BASEMENT
1'sT FLOOR
2 FLOOR
3 FLOOR
4 FLOOR
6 FLOOR
6 FLOOR '
7 FLOOR
8 FLOOR
Q •
Installing Company Name: /` J� Check One Only Certificate#
, 7 , !�7 r7
❑Corporation
Address: _ � 1,� City/Town: ✓Itti State:
❑
Business Tel:�op223���� Fax: Partnership
irm/Company
Name of Licensed Plumber/Gas Fitter:
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Yes No❑
If you have checked Yes,please indicate the type of coverage by checking the appropriate box below.
A liability insurance policy [t Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage reuired b
Massachusetts General Laws,and that my signature on this permit application waives this requirement y C hapter 142 of the
Check One Only
Sign re of Owner or Owner's Agent Owner ❑ Agent ❑
By checking this box EJ;I hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and
accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be In
compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General L s.
By Type of License:
❑Plumber
Title El Ms Fitter Si ure f�LU' eed 1 be /Gas Fitter
(aster
Cit y own ❑Journeyman License Number:
APPROVED-(OFFICE USE ONLY ❑ LP Installer
The Commonwealth of Massachusetts
Department of Industrial Accidents
Ogee ofInvestigations
..600 Washington Street
Boston, AM 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A licant Information
' Please Print Le ibl '
Name(Business/Organizafion/Individual):
- - --Address: - -
City/State/Zip:_ -rel a�y i` �� G� ) Phone#:
r2.E]
an employer?Check the appropriate boa:
am a employer with 4. Type of project(required):❑ I am a general contractor and Iemployees(full and/or part-time).*• have hired the sub-contractors 6 ❑New constructionI am a sole proprietor or partner- listed on the attached sheet.t 7• ❑Remodeling
ship and have no employees These sub_contractors have
working for me in any capacity, workers' comp.insurance. g' Demolition
[No workers'comp.insurance 5. ❑ VJe are a corporation audits 9• ❑Building addition
3.E1required.] officers have exercised their 10.❑Electrical repairs or ac1ditions
.1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
Myself [No workers'comp. c. 152,§I(4),and we have no
insurance required.]t employees. 12-❑Roof repairs
• [No workers' j
comp.insurance required] 1311 Other
*A-ny applicant that checks box#1 must also fill out the section be?ot� awon
• ,;_ =s eati
__ _
T Homeowners who submit this affidavit indicating they are doing all work and then hire out=
side 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 their workers'comp•policy information.
I am an employer that is providing workerscompensation i
information. nsurance for my employees Below is the policy andjob site
Insurance Company Name:
Policy#or Self-ins.Lie.#:
Expiration Date:
Job Site Address:
City/State/Zip:
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 ofMGL c.152 can lead to the imposition of criminal fine up to$1,500.00 and/or one-year imprisonmnal penalties of a
ent,as well as crmcivil penalties in the form of a STOP 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 DTA for insurance coverage verification.
I do hereby ce der the pat pen sfer is th p J rJ e information provided abov is tru and correct
Sienature•
Date:
Phone#:
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); j
L Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing
6.Other b Inspector
Contact Person:
Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer.,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than-three apartments and who resides therein,or the occupant of the
dwelling house-of another_who.employs persons to-do-maintenance,.construction or-repair-work on-such dwelling-house-
or
welling--house-or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152;§35C(6)also states that"every state or local licensing*agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their cerdfrcate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members orartners.are not required to ca workers'p qurr rry s compensation insurance. If
P an LLC or LLP does have
employees,a policy is required. Be.advised that this affidavit maybe submitted.to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and datethe affidavit. The affidavit should
be returned 10 the city or town that li c for � e_a `Rcenq`i5 bY't'^requested, t 'fl r
t3a s the�y tre�C&elvu J!tLEp t a re moues ed,n� t—�JepaTttT:ent or
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant..
Please be sure to fill in the permit/license number which will be-used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)"A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business.or commercial venture
(i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations woit1 like to thank you in advance for your cooperation and should you have any questions,
please do not-hesitate to give us a call.
The Department's address,telephone and fax number.
The Commonwealth.of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
Tel. #617-727-4900 ext 406 or 1-8.77-M.AS.SAFE
Revised 5-26-05 Fax 4 6.17-727-7749
......................
y µORTN
°f t"`°:• '"° TOWN OF NORTH ANDOVER
p PERMIT FOR WIRING
This certifies that ..................... -..... ........ ...�. . ..
C. � ��/ dJz. ..� ..............L
has permission to perform .... .... . j,�......
.. ....C'��v.............
wirjr4 in the building of...................J.).P..TO...................................................
OUA
at..�. J. S ... Vorth Andover,Mass.
Fee.3................ Lic.No.. l '.. ....................
EL CTRICAL INS
PECI�R
Check # 13
10821
nLl
Commonwealth of Massachusetts Official Use Only
Permit l= No. f. Department of Fire Services
Occupancy and Fee Checked
>. BOARD OF FIRE PREVENTION REGULATIONS [Rev. 11/99] leave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL 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 IM-i
TION) Date:
City or Town of: Nor+t, 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) A(cA
Owner or Tenant Co kivi i 2 -�bo 4p Telephone No.
Owner's Address
I
Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box)
Purpose of Building I;7VW e— Utility Authorization No. �
Existing Service Amps / Volts Overhead ❑ Undgrd❑ No.of Meters
New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: -�-`y (C.,CAJ"-yds b S e,t del'
Completion of the ollowin table may be waived by the Inspector of Wires.
No.of Recessed Fixtures No.of Ceil:Susp.(Paddle)Fans No.of Total
Transformers KVA
No.of Lighting Outlets No.of Hot Tubs Generators KVA
No.of Lighting Fixtures Swimming Pool Above ❑ In- ❑ o.o mergency Lighting
rnd. rnd. Battery Units
No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones
No.of Switches No.of Gas Burners No.of Detection and
Initiating Devices
No.of Ranges No.of Air Cond. Total No.of Alerting Devices
Tons g
No.of Waste Disposers Heat Pump Number Tons I KW No.of Self-Contained
Totals: Detection/Alerting Devices
No.of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other
Connection
No.of Dryers Heating Appliances KW Security Systems:
No.of Devices or Equivalent
No.o Water No.of No.o
Heaters KW Data Wiring:
Signs Ballasts No.of Devices or Equivalent
No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring:
No.of Devices or Equivalent
OTHER:
I
Attach additional detail if desired,or as required by the Inspector of Wires.
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:)
Estimated Value of Electrical Work: (When required by municipal policy.) (Expiration Date)
Work to Start: 1 l J— Inspections to be requested in accordance with MEC Rule 10,and upon completion.
I certify,under the pvqins and penalties of perjury,that the information on this application is true and complete.
FIRM NAME: CAS LIC.NO.:
Licensee: —e�le V(rt�'i f Signature LIC.NO.:
(If applicable, enter "exempt"in the license number line) Bus.Tel.No.:
Address: Alt.Tel.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's agent.
Owner/Agent
Signature Telephone No. PERMIT FEE: $
`� I�
��
Date. 74? .......
f NOR7M
3?�t';�``•'-:°!°"�o� TOWN OF NORTH ANDOVER
p PERMIT FOR WIRING
�,SSACMU�� ''
t �J
This certifies that .`f ........................................................................................
has permission to perform
`t ...
wiring in the building of
at...........�17...... POS-.....................�..
,North Andover,Mass.
Fee -3 ..... Lic.No.'!, .� .......... ...... ... .
ELECT IC R
Check #
10794
} Commonwealth of Massachusetts � Official I'S-c�nly
7
Permit No.
- - Department of Fire Services
Occupancy and Fee Checked
BOARD OF E=IRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL 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 INFORIYL4TIOV) Date: V12-3b2_
City or Town of: NORTH ANDOVER _ To the Inspector of'Wires:
By this application the undersigned gives notice of his or her intention to,perrforrmm theelelectrical ork described below.
Location(Street& Numb er) L7 '`•�4 S-� 'JQJ
__
Q� cTP(fy.Q,�'
Owner or Tenant_ /¢� vyu, Telephone No. -�—
Owner's Address
Is this permit in conjunction with a building permit? Yes E No (Check Appropriate Box)
Purpose of Building CF ,D Utility Authorization No. _I Z. S_14�
Existing Service Amps / Volts Overhead Undgrd❑ No.of Meters
New Service 2Da Amps Lv ; ?,Yn Volts Overhead tlndgrd No.of Meters
Number of feeders and .A.mpacity
Location and Nature of Proposed Electrical Work:
Cofnpletion of the following table roar be waived by the Inspector of Wires.
No.of Recessed Luminaires _�No.of Ceil.-Susp.(Paddle)Fans No.of Total
o Transformers KVA
No.of Luminaire Outlets iNo.of Hot Tubs Generators KVA
No.of Luminaires 2-7 !Swimming Pool Above ❑ In- o.o mergency ig mg
grnd. Bred. Battery Units
r
No.of Receptacle Outlets 60 No.of Oil burners FIRE ALAR. SNo.of Zones
No.of SwitchesNo.of Gas Barriers No.of Detection and
Z _ InitiatingDevices
No.of Ranges — �No.or Total
g Air Cond. -tons No.of Alerting Devices
No.of Waste Disposers I Heat Pu Mp 1") 1 KW No.of Self-Contained
f'otals: Detection/Alertin Devices
No.of Dishwashers 'Space/AreaPleating KW' �Local ElConne un'ctioln El Other
No.of Dryers [ Pleating Appliances KW Security Svstems:x
_ No.of Devices or Equivalent
No.of Water (N�oofof No.of Data Wiring
_Heaters K Signs _ Ballasts No.of Devices or Equivalent
y No, Hydromassage Batihtu_bs.^� _ Telecommunications Wiring:i oof2otors____ Total i�
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: /d/o 0 d •d 9 (,When required by municipal policy.)
Work to Start: i-112,1 /IS — 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 electricai 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 V BOND L; 01'FIER ❑ (Specify:)
I certify,under the paints noel penalt'es of per�vry,that the information or,this application is true and complete.
flROI NAME:_� i -1 rt o __ LIC.NO.: 61rb
Licensee: Cl���s ��M ��_ _Sige;ataire_� LIC. NO.: &31 Z,&'
(if applicable, enter ""emptthe ire i se numbe7e.) Bus.Tel.No.:
Address: Alt.Tel.No.: 06/0
*Per M.G.L c. 147,s. 57-61 j,security work requires Department of Public Safety "S" License: Lic.No.
OWNER'S INSURANCE WAIVER: I am aviare that the Licensee dioes nol have the liability insurance coverage normally
required by law. By my signature below, I hereby waive this requirement. 1 am the(check one)❑owner ❑owner's a(>ent.
Owner/Agent
Signature — _ Telephone No.___ PERMIT FEE: $
i �'
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The Commonwealth of Massachusetts " 11 #.lar yam;
+ Department of Industrial Accidents
Office of Investigations
I Congress Street,Suite 100
Boston,MA 02114-2017
www.fnass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant In ormation Please Print Legibly
Name(Business Organization/Individual): CCS etu-,,�U 4-�_L
Address: (o fl)v X-c,.e_r 2 �
City/State/Zi : P,vvlcr 4't0- Phone#:
Are you an employer?Check the appropri to box: Type of project(required):
1.01 am a empl Dyer with (~l 4. ❑ I am a general contractor and I
employees full and/or part-time).* have hired the sub-contractors 6. [ New construction
2.❑ I am a sole roprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g, E]Demolition
working for mein any capacity, employees and have workers'
9. ❑ Building addition
[No worker;' comp. insurance comp.insurance.'
required.] 5. We are a corporation and its 10.E]Electrical repairs or additions
q ]
3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions
myself. [Ne workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.]t c. 152, §1(4),and we have no
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.
t 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.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Compar y Name: (✓,C, nS CC,
Polic #or Self-in .Lic.#: (nl C� Zlo s l� t
y Expiration Date: 7 � 1 J ! 1 Z
Job Site Address: J t City/State/Zip: aim
N� Ahs=
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
fine up to$1,500. 0 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 tie DIA for insurance coverage verification.
I do hereby certify under the pains and enaldes ofp!:Iur
y that theinformation provided above is true and correct
S4mature: Date 7 ZZt
Phone#: f'" L — o r—
Official use o y. 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 H alth 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
i
Contact Person: Phone#:
f µORT# q
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PUBLIC HEALTH DEPARTMENT
Community Development Division
1
David Valley
21 Winstead Ave.
Methuen, MA 01844
October 11, 2007
Re: Order Letter, 517 Rea Street
Dear Mr. Winstead,
This correspondence is a follow up to the Order Letter sent to you on September 19, 2007. Thank
you for the immediate response to the order to remediate the unsafe situation at your property,
517 Rea Street,North Andover, MA. I personally observed the filling and crushing of the old
well that was on your property and can verify that the well has been physically rendered
harmless. It no longer poses a risk to the health or safety of the public, therefore the order has
been complied with. Your cooperation in this matter was greatly appreciated.
Since ,
� '°�'~
S san Sawyer, REHS/RS
Public Health Director
Cc: Curt Bellavance, Community Dev. Director
&Perald Brown, Inspector of Buildings
1600 Osgood Street,North Andover,Massachusetts 01845
Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com
Date..... ..:.....................
NORTH
°f�"`°:•�"� TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
•O•�r�°•^� 4y
&SACMUS�
This certifies that
........... ...... ................. - ....,v.... ...-r!.�...
has permission to perform .'�.. ......- ...........................................
wiring in the building of.........T--�Q .
e
. ..........................................................................
1 .............. .North Andover,Mass.
Fee '`�............ Lic.No./o?GYG. ..�-�..—......v..�;?�c �......
ELECTRICALINSPECIOR�
V
t Check # _
7111
Commonwealth of Massachusetts Official Useonly
Department of Fire Services Permit No. 2111f
Occupancy and Fee Checked �6(6.
BOARD OF FIRE PREVENTION REGULATIONS ev.9/05J leave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code( EC), 27 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATIOA9 Date: G
City or Town of: or-j tJ ov&t2 To the I ect r of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location(Street&Number) Ree. 6
er or Tenant
Ow>z Telephone No.
Owner's Address sc
Is tWs permit in conjunction with a building permit? Yes ❑ No (Check Appro
purpose of Building Lek tn� Utility Au orization No -
Eifisting Service ps / Volts Overhead❑ Undgrd❑ No.of Meters
New Service 10(�)_ Amps '��/ Volts Overhead ] Undgrd❑ No.of Meters
Number of Feeders and Ampscity
Location and Nature of Proposed Electrical Work: —t- n yt ltil
c
Co letion o the ollowin table ma be waived by the Ins ctor of Wires.
( r No. of Recessed Luminaires No.of Cell.-Susp.(Paddle)Fans o.o of
Y Transformers KVA
No. of Luminaire Outlets No.of Hot Tubs Generators KVA
No. of Luminaires Swimming Pool Above ❑ - ❑ o.o Emergency Lighting
crud. rnd. BaWe Units
No. of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones
No. of Switches No.of Gas Burners o.o Detection an
Initiating Devices
No. of Ranges No.of Air Cond. Total Tons No.of Alerting Devices
No. of Waste Disposers eat Pump I Number I Tons IKW of Self-Contained.
Totals: Detection/Alerting Devices
No. of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other
Connection
No. of Dryers Heating Appliances KW echo.oSystems:*
Devices or Equivalent
No. of Water KW o.o o.o Data Wiring:
„ Heaters Signs Ballasts
No.of Devices or Equivalent
i No. Hydromassage Bathtubs No,of Motors Total HP a ecommn ca onsWiring:
No.of Devices or E uivalent
OTHER:
Attach additional detail if desirei4 or as required by the Inspector of Wires.
Estimated Value of Elec 'cal Work: AQ. O 0 (When required by municipal policy.)
Work to Start: o'C Inspections to be requested in accordance with MEC Rule 10,and upon completion.
INSURANCE C GE: 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 co rage is in force,and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) e-A . 1,2-31—Or
I eerdfy, under the pains and penalties of perjury,that the information on this application is due and dompleta
FIRM NAME: S L , LIC.NO.:
Licensee: o „ it
Signature ' LIC.NO.:�.
(If applicable,enter"ex t" ' the lice e n r line. •Bus.Tel.No. - rp d
Address: Alt.Tel.No..
*Security System Contractor License required for this work;if applicable,enter the license number here:
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(clieck one)[I owner ❑owner's a lent.
Owner/Agent
Signature Telephone No. PERMIT FEE. 5�25_
INSP E TIQN9
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Postage $
M Certified Fee y
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C3 Return Receipt Fee /� Postmark
O (Endorsement Required) Here
O Restricted Delivery Fee
Q^ (Endorsement Required)
Total Postage&Fees $
Ln /
O Sent To �` ��
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or PO Box No. pL/ ��//mfr ...- 17-!'4/x_---
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Certified Mail Provides: (es�eney)ZOOZ eunr'ooes wio�sd
■ A mailing receipt
• A unique identifier for your mailpiece
■ A record of delivery kept by the Postai Service for two years
Important Reminders:
■ Certified Mail may ONLY be combined with First-Class Mail®or Priority Mail®.
■ Certified Mail is not available for any class of international mail.
■ NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For
valuables,please consider Insured or Registered Mail.
■ For an additional fee,a Return Receipt may be requested to provide proof of
delivery.To obtain Return Receipt service,please complete and attach a Return
Receipt(PS Form 3811)to the article and add applicable postage to cover the
fee.Endorse maiipiece"Return Receipt Requested".To receive a fee waiver for
a duplicate return receipt,a USPS®postmark on your Certified Mail receipt is
required.
■ For an additional fee, delivery may be restricted to the addressee or
addressee's authorized agent.Advise the clerk or mark the mailpiece with the
endorsement"Restricted Delivery".
■ If a postmark on the Certified Mail receipt is desired,please present the arti-
cle at the post office for postmarking. If a postmark on the Certified Mail
receipt is not needed,detach and affix label with postage and mail.
IMPORTANT:Save this receipt and present it when making an inquiry.
Internet access to delivery information is not available on mail
addressed to APOs and FPOs.
s �
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��SSACHUS����
PUBLIC HEALTH DEPARTMENT
fommunity Development Division
David Valley
21 Winstead Ave.
Methuen, MA 01844
BOARD OF HEALTH ORDER LETTER
Re: 517 Rea Street,previously known as 133 Summer St.
Dear Mr. Valley,
Please be advised the North Andover Health Department has been informed of an unsecured well
at your property noted above. A member of the Building Department has reported observing an
old shallow dug well; covered with a metal plate, possibly greater than 20 feet deep and with a
diametereat t
gr enough g o allow o accidental entry.
Records from 1987 show this well as unused, in addition this property is currently under
construction and unoccupied. (see attached for location) This well is considered permanently
abandoned; therefore its condition is a violation to the North Andover Board of Health Well
Regulation, section 6. PERMANENT OR TEMPORARY WELL ABANDONMENT.
6.1 All permanently abandoned wells shall be tightly sealed by approved methods to prevent
pollution of the ground water. Prior to plugging,the well shall be checked for debris that may
interfere with the process. If the integrity of the original well seal is in doubt,the casing shall be
removed or perforated..."
This is a serious and immediate threat to human safety. You are here by ordered to abandon this
well immediately according to the North Andover Regulations. Within twenty-four(24)hours
1 you must engage a professional to effect the abandonment of this well. This professional must
contact the Health Office to discuss proper procedures and must be available to complete the
project no greater than and additional forty eight (48) hours. Be advised that an improperly
abandoned well may cause a future public health and safety hazard.
1600 Osgood Street,North Andover,Massachusetts 01845
Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com
1
Failure to abandon the well properly within the time allotted may result in a fine of not less than
50 dollars nor greater than 500 dollars per violation. Each day would be considered a separate
violation. Thank you for your anticipated cooperation in this important matter of public health.
Sincer ,
san Sawyer, S/RS
Public Health Director
Cc: Curt Bellavance, Dir. of Community Development
Gerald Brown, Inspector of Buildings
1600 Osgood Street,North Andover,Massachusetts 01845
Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com
%4ORT11
6* O
O
SS4C NU`����h
PUBLIC HEALTH DEPARTMENT
Community Development Division
David Valley
21 Winstead Ave.
Methuen, MA 01844
October 11, 2007
Re: Order Letter, 517 Rea Street
Dear Mr. Winstead,
This correspondence is a follow up to the Order Letter sent to you on September 19, 2007. Thank
you for the immediate response to the order to remediate the unsafe situation at your property,
!L1-7 Rea Street,North Andover, MA. I personally observed the filling and crushing of the old
well that was on your property and can verify that the well has been physically rendered
harmless. It no longer poses a risk to the health or safety of the public, therefore the order has
been complied with. Your cooperation in this matter was greatly appreciated.
Sincer ,
S san Sawyer, REHS/RS
Public Health Director
Cc: Curt Bellavance, Community Dev. Director
Gerald Brown, Inspector of Buildings
1600 Osgood Street,North Andover,Massachusetts 01845
Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com
pORTM
TOWN OF NORTH ANDOVER
OFFICE OF
o . *�** BUILDING DEPARTMENT
Eta`' 400 Osgood Street
`Nus North Andover,Massachusetts 01845
Telephone(978)688-9545
Gerald A Brown Fax (978)688-9542
Inspector of Buildings
September 13, 2007
David Valley
21 Winstead Ave
Methuen MA 01844
Re:517 Rae Street
Dear Mr.Valley:
Please be advised that as owner of record of the above property the foundation and
building site remains in an unsafe condition . You are in violation of 780 CMR 12 1.0 Unsafe
Structures.
The following are the issues of concern:
➢ Foundation needs a fence, (plastic fence is not secure falling in). Needs chain link fence,
➢ The well cover is not secured.
➢ Dumpsters needs to be removed from the site.
In accordance with Sec. 118.4 Violation Penalties of the Massachusetts State Building
Code 780 CMR—Sixth Edition your failure to both cease and desist the non-permitted demolition
work and obtain the required demolition permit within thirty days of receipt of this violation
notice letter will result in criminal charges being filed against you in District Court, with possible
fines of$1000 being levied for each day such violation exists.
Please call me at the Building Department telephone 978-688-9545.
Sincerely,
Gerald Brown, Inspector of Buildings
Cc: William Martineau, Interim Fire Chief
Curt Bellavance,Director
Mark Rees,Town Manager
Mark Finn,Hunter Group
BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535
OF pORTH q
tt�eo •a .�.
3� e� '6
O A
0"ArID 0-
SRCHU
BUILDING DEPARTMENT
Community Development Division
May 28,2009
Property Preservations
Countrywide Home Loans
Bank of America
Loan#142963189
Re: 517 Rae Street
To whomever it may concern:
Please be advised that as owner of record of the above property the foundation and building site
remains in an unsafe condition. You are in violation of 780 CMR 121.0 Unsafe Structures.
The following are the issues of concern:
➢ Foundation needs a fence; plastic fence is not secure falling in). Needs chain link fence around
all of the foundation.
In accordance with Sec. 118.4 Violation Penalties of the Massachusetts State Building Code 780
CMR—Sixth Edition your failure to both cease and desist the non-permitted demolition work and obtain
the required demolition permit within thirty days of receipt of this violation notice letter will result in
criminal charges being filed against you in District Court,with possible fines of$1,000 being levied for
each day such violation exists.
Please call me at the Building Department,978-688-9545.
Sincerel
Gerald Brown,Inspector of Buildings
Cc: William Martineau,Fire Chief
Curt Bellavance,Director
March Rees,Town Manager
1600 Osgood Street,Suite 2-36 North Andover,Massachusetts 01845
Phone 978.688.9545 Fax 978.688.9542 Web www.townofnorthandover.com
'17(76 r�
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Brown, Gerald
From: Cheney, Skip
Sent: Thursday, May 15, 2008 2:50 PM
To: Brown, Gerald; Leathe, Brian
Cc: Rees, Mark
Subject: Potential Danger M: 38 P: 40
1 was inspecting this lot at 133 Summer Street. M: 38 P:40 owned by David Valley, he took a demo permit out in
4/06 and tore the old house down, in 10/06 in took out a building permit for a new s/f. to date all he has is an open
foundation on the lot(see attached Photos).
Facing the foundation from Rea Street there is an open drainage sump on the right hand side. My concern is that
there is at least several inches of water in this. And it is possible that a little kid or someone's pet could fall fail
into this.
Thank you for looking into this Matter
Samuel G. Cheney, Jr.
Asst/Assessor-Field Appraiser
5/15/2008
NORry
TOWN OF NORTH ANDOVER
oft
OFFICE OF
BUILDING DEPARTMENT
"SSacHus�� 400 Osgood Street
North Andover,Massachusetts 01845
Telephone(978)688-9545
Gerald A Brown Fax (978)688-9542
Inspector of Buildings
September 13, 2007
David Valley
21 Winstead Ave
Methuen MA 01844
Re:517 Rae Street
Dear Mr.Valley:
Please be advised that as owner of record of the above property the foundation and
building site remains in an unsafe condition . You are in violation of 780 CMR 121.0 Unsafe
Structures.
The following are the issues of concern:
➢ Foundation needs a fence, (plastic fence is not secure falling in). Needs chain link fence.
➢ The well cover is not secured.
Dumpsters needs to be removed from the site.
In accordance with Sec. 118.4 Violation Penalties of the Massachusetts State Building
Code 780 CMR— Sixth Edition your failure to both cease and desist the non-permitted demolition
work and obtain the required demolition permit within thirty days of receipt of this violation
notice letter will result in criminal charges being filed against you in District Court, with possible
fines of$1000 being levied for each day such violation exists.
Please call me at the Building Department telephone 978-688-9545.
Sincerely,
Gerald Brown, Inspector of Buildings
Cc: William Martineau,Interim Fire Chief
Curt Bellavance,Director
Mark Rees,Town Manager
Mark Finn,Hunter Group
BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535