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HomeMy WebLinkAboutMiscellaneous - 550 JOHNSON STREET 4/30/2018 (2) 550 JOHNSON STREET 210/038.0-0133-0000.0 Safety Insurance 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 001845- NORTH ANDOVER, MA 001845- ` RE'. Insured: SALVATORE D'AGATA and DOROTHY D'AGATA Property Address: 550 JOHNSON STREET,NORTH ANDOVER, MA Policy Number: HMA 0275954 Claim Number: BOS00044531 Date of Loss: 7/15/2014 Company: Safety Property and Casualty Insurance Company Claim has been made involving loss, damage or destruction of the above-captioned property, which may either exceed $1,000.00 or cause Mass. Gen. Laws, Chapter 143, Section 6 to be applicable. If any notice under Mass. Gen. Laws, Chapter 139, Section 3B is appropriate,please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim number. Stephen Desrosiers Claim Examiner 7/30/2014 Safety Insurance Company Homeowners Claims Unit P. O. Box 55098 Boston, MA 02205-5098 Phone: (617) 951-0600 EXT 5463 Fax: (617) 531-6658 Email: StephenDesrosiers@Safetylnsurance.com Date. ,,ORT" of TOWN OF NORTH ANDOV 49 PERMIT FOR GAS INST TION 1 CNUSEt This certifies that . .??' . . .!.. . .. . .. . . . . . . . has permission for gas installation . . S �.U.�. . . . . . . . . . . . . . . . in the buildings of / � . . . . . . . . . . . . . . . . . . . . . . . . . . . at ". . . A w !!�.S. vJ''` . . . . :Z .., North Andover, Mass. CJ // Fee. ^. . Lic. No.. + . � ! ., . . . GAS INSP G`TOR Check# ! 3 7654 -1 I MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS FTrnNG (Type or print) Date NORTH ANDOVER,MASSACHUSETTS Building Locations S �t �l /; cam,_ Permit# Amount$ Owner's Name 0 f 4� New❑ Renovation ❑ Replacement Plans Submitted ❑ rA W U x � a o ] H U x z Gdoa ° w w w z x x �a w x O a w H a N w w w F w m x w > d > o o w U W > SUB -BASEM ENT B A S E M ENT IST. FLOOR 2ND . FLOOR 3RD . FLOOR 4TH . FLOOR 5TH . FLOOR 6TH . FLOOR 7TH . FLOOR_ 8TH . FLOOR or type) j ._ /��� �� Check one: Certificate Installing Company Name �/ 11 Corp. Address Uo � S' partner. �1,T usmess a ep one 4 7,Flw 77n- C' X7-0 Firm/Co. iso Ste/ Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE Check one: I have a current Iiability Insurance policy or it's substantial equivalent. Yes 13— No If you have checked Les,please indicate the type coverage by checking the appropriate box. Liability insurance policy Er Other type of indemnity 1-3 Bond E3 Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass.General Laws,and that my signature on this permit application waives this requirement. Check one: ❑ Signature of Owner or Owner's Agent Owner 0 Agent I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and insta o p edand r Permitissued for this application will be in compliance with all pertinent provisions of the Massach efts ate as ode an Chapte 42 of th eneral Laws. BY: _,Signature of Licensed Plumber Or Gas Fitter Title Plumber k7� ? t, City/Town Gas Fitter License Number Master APPROVED(OFFICE USE ONLY Journeyman 4 The Commonwealth of Massachusetts Department ofIndustrial Accidents Office oflnvestigations 600 Washington Street Boston, AL4 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: Phone#: Are you an employer? Check the appropriate bog: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. E]New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- Iisted on the attached sheet. t 7• ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for in any capacity. workers' comp. insurance. 9. ❑Building addition [No workers' comp. insurance 5• ❑ We are a corporation and its required.] officers have exercised their 10.El Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 1 l.❑ Plumbing repairs or additions ` myself. [No workers' comp. c. 152, §1(4),and we have no 12•❑ Roof repairs insurance required.] t employees. [No workers' comp. insurance required.] 13.❑ Other *:,:y applicant that checks box 9; mass cls:P11 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 their workerscomp.policy information. I am 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: 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 of MGL c. 152 can lead to the imposition of criminal penalties of a 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 andpenalties ofperjury that the information provided above is true and correct Signature: 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): 11 1.Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other 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 on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(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-contractor(s)name(s), address(es)and phone number(s)along with their certificate(s)of _ insurance. Limited Liability Companies(LLC)or Limited Liability.Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit -The affidavit should be returned to the city or gown that the application for the permit or license is being requested, not the Deparnnent of 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 tine. 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 permittlicense 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 would 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 021.11. Tel. # 617-7274900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-72.7-7749 www.mass.aov/dia •' MASSACHUSETTS unwoRM APPLICATION.FOR.PERM T ' O0 PLUMBJ1 Q (Type or Print) r t , NORTH ANDOVER ,Mass , . Date: Building Location Permit 1 3203 ►:.a: mo , n nd o U er f�? d _ Owners Name S / I t'AA7-4 > Zvi New Renovation Replacement Plans Submitted ❑ FI TURE = 0 a i-. Y!d • W J Ar '• ..Q h z N % Q � __ O Z a. O W t- w ttl 1- V ic F` .+ a v v _ ¢ Q w v z cc a t7 I o = o a a Q WCC Q W o a e» z ae a ae J•. a. u�i S I.- ~ W � O O � ...t a: F. a Id 4. w Q = � x Y. 54 n o .( W IL X W Q H > N O N N O N 1- Z O G cr1 _2 _x W 1- O V x Q = Q Q O Q A J Q 'cc it W a 0 4 1- 3 Y J m to o o J = H N a. v v o t a m o j SUa ,SSMT. • . , r BASEMENT I i' 1ST FLOOR 2N0 FLOOR 1 31113 FLOOR 4TH FLOOR STH FLOOR 6TH FLOOR 7TH FLOOR _ ( STH FLOOR i i J (Print or Type) Check one: Certificate 1I Installing Company Name le )Cd 611 P /Y (QrP (� Corp. / Q C AddressPartner. iyo . Rnc1 D v Pr ; lvfQ' d l��1' - C) Firm/Co. Business Telephone !17K 27S 42, �V Name of Licensed Plumber: RQ 6(�j-�' f3 . (� to h C h e I --- Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy " Other type of indemnity ❑ Bond Insurance Waiver: I, the undersigned, have been made aware..that the licensee of this application does not have any one of the above three insurance coverages. 4 Signature of owner/agent of property Owner l__1 Agene,,10 i I heoeby ecttify that all of lie details and information 1 have submitted lot,entered)in ahavc application arc true and'4Csuale to We beat o1 any { I -• - knowledge and that all plumbing work and installations performed under rcruiit issued for this application will be in eonsplianoe with all pesl6tet►t pt4qje.4 j wisions of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. BY , ii Title . Signature of Licensed Plumber Cit Town- Tvpe of Plumbing License Y/ ' License Number Master ❑ Journeyman 1 I� :APPROVED ZOFFICE USE ONLY) . Location -'5- o No. r)6 Date ' /U OS- 01 gORTN TOWN OF NORTH ANDOVER 41 9 Certificate of Occupancy $ �'�s''• E<t' Building/Frame Permit Fee $ �wcMus Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # _ -0 f �j7 Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REP RENOVA OR DEMOLISH A ONE OR TWO FAMILY DWELLING s . M BUILDING PERMIT NUMBER [DATE ISSUED SIGNATURE: 'ldin Commissioner for of Buildings ate zr SECTION 1-sITE INFORMATION 0 l 1 Property Address: 1.2 Assessors Map and Parcel Number. 33 Map Number Parcel Numbs 1.3 Zoning Information: 1.4 Property Dimensions: 1� Zoning District Use Lot Area Fronts g 1i 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Rcqwmd Pmvided RegWred Provided 1.7 Water Supply M.G.L.C.40. 34) 1.3. Flood Zane Informstios: 1.8 sewerap Disposal system: Public ❑ Private ❑ Zone Onaide Flood Zane ❑ Municipal ❑ On Site Disposal System ❑ —k SECTION 2-PROPERTY OWNERSE"MUTHORM11 AGENT "�' %i {% iStf!Ct; u 2.1 Owner of Record Name(Print) �— Addre or Service: L, Signature Telephone 2.2 Owner of Record: 4 CName Print Address for Service: C Signature Telephone SECTION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ C) Licensed Construction Supervisor: License Number ' 5�, `5 Ad ss �1" � G ����� ra O Expiration Date Si cure V Telephone r-" -� 3.2 Registered Home Improvement Contractor Not Applicable ❑ 1 ( Cal, 1 er p��ay Company Name I�lF (all- Registration Number rse's Addre LowJIMENEW Expiration Date Z Si na re Telephone SECTION 4-WORKERS COMPENSATION(M.G.L C 152 ¢ 25c(6) f Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building unit. Si ed affidavit Attached Yes.......0 No.......0 SECTION 5 Description of Proposed Work check v applicable) New Construction ❑ Existing Building ❑ Repair(s) 0 Alterations(s) 0 Addition 0 Accessory Bldg. 0 Demolition 0 Other ❑ Specify Brief Description of Proposed Work: .� f D d"I SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be OFFICIAL USE ONLY Completed by permit applicant 1. Building �7 (a) Building Permit Fee ✓,400 Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(a)x tbl 4 Mechanical HVAC 5 Fire Protection J 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERf AGENT OR COTRACTOR APPLIES FOR BUILDING PERMIT I, as Owner/Authorized Agent of subject property Here authorize to act on My behalf,in all matters relative to work authorized by this builduig permit application. Si iature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, ,as Owner/Authorized Agent of subject t/ property Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief Print Name Si ture of Owner/Agent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 23RD SPAN DIMENSIONS OF SELLS DIMENSIONS OF POSTS `. DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X — MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE r North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11, S150A. The debris will be disposed of in: G'✓(�� (/e1, foams//1 ft/J27 (Location of Facility) PJwf-s Signature ofit Applicant 5J610S Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector a ✓/ee {oomma�zwea�i a���sc�u�ael7k BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR I Number: CS 059233 Birthdate: 12/08/1961 Expires: 12/08/2003 Tr.no: 11626 Restricted: 00 M JAMES A GALLAGHER 352 HOWE ST - METHUEN, MA 01844 Administrator The Commonwealth of Massachusetts d Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers'Compensation Insurance Affidavit Name J e Please Print Name: To rrI e.> Location: Citv Phone # I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity E2( I am an employer providing workers' compensation for my employees working on this job. Company name: ``VA011 r-V 1/I U Address x ou/t S]� City: 'eZA(/i°h // Phone# / 3 C916'3 3j L2 2kC'c7�l Poli # Insurance Co. Company name: Address City: Phone# Insurance Co. Policv# Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of,a fine up to$1,500.00 and/or one years'imprisonment_as vwb-as_civil.pienaMesin-thefnrmda.SIOP WDRK_ORDER..and..a fine of_(.5100.00)ailay against.me I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. L I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature Date Print name Phone# Official use only do not write in this area to be completed by city or town official' City or Town Permit/Licensi ❑Check if immediate response is required Building Dept 0 Licensing Board p Selectman's Ofce Contact person: Phone#. r-1 Health Department Other NORTH Town of Andover No. G ~ - �- _ �o CON overMass., 0 LA COC HICHEWICK TE D C:) BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System A on 2>0404 S- 00A BUILDING INSPECTOR THISCERTIFIES THAT.................................................................71 ........................................................................................... Foundation has permission to erect... ................. buildings on.... ....... 6....... Rough ........... ............. .......... .... ......... ..... ... to be occupied as.......5.44.19.......... ....... .......b100#1146 Chimney ..................................... provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Lawl relating to the Inspection, Alteration and Construction of V 'MR Buildings in the Town of North Andover. 3ig 1113 PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTION STARTS ELECTRICAL INSPECTOR Rough .................................................................... Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. Date.................................. 0 TOWN OF NORTH ANDOVER PERMIT FOR WIRING ;J� 0 CHU Ak This certifies that ....... . 0. ............;YAAM�4' has permission to perform ?�.1 �` ......................................... ;q 1 a wiring in the building of.. .. ..1... b ,.... .......... ..................... orthAndover,Mas )Fee..................... Lic.NZ-e;�� .............a. S... ELECTRICAL INSPECTOR Check tt 5753 1 rm WIVILVIULY ryrdli"n Vr 1 �•• �� DEPARDIENT FPUNKSAFM Permit No. BOARDOFFIREPREVFNHON NS5l7C1NRizo IOccupancy&Fees Checked APPUCATTONFOR PERMITTO P ORMELECTRICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASS CHUSSTS ELECTRICAL CODE,527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical workd scribed below. Location(Street&Number) !jC�p T��� `-- Owner or Tenant Owner's Address Is this permit in conjunction with a building permit: es��No (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service .) Amps(20/2' Yolts Overhead El Underground No.of Meters j New Service Amps Volts Overhead = Underground No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work No.of Lighting Outlets No.of Hot Tubs No.of Transformers Total KVA No.of Lighting Fixtures Swimming Pool Above Below Generators KVA round 0 ground No.of Receptacle Outlets No.of Oil Burners No.of Emergency Lighting Battery Units No.of Switch outlets No.of Gas Burners No.of Ranges No.of Air Cond. Total FIRE ALARMS No.of Zones Tons No.of Disposals No.of Heat Total Total No.of Detection and Pumps . Tons KW Initiating Devices No.of Dishwashers Space Area Heating KW No.of Sounding Devices No.of Self Contained Detection/Sounding Devices No.of Dryers Heating Devices KW Local Municipal Other ID Connections No.of Water Heaters KW No.of No.of Signs Bailasis No.Hydro Massage Tubs �( No.of Motors Total HP OTHER ���0�� �— �' `J�1 h1 ck se(Zl1 ti Ce d A uc) Sl f wJ�-c� To TnattaroeC mWt Aaalattbthe te#=m aftdMaswh>setlsG=n1Laws AmaamatL&ih yhwmn1eF0kYm YA9Crnlpl&- C0 aessubsllNW allIlydat YES 0 NO IhareahrxwdvaMptocfafsmwlDde0fficr-YES E l . lfyvuhamed�edWYES plea9eic�dralede ypeofooweby INSURANCE BOND � OIH1R a1•� �Sf Esti n*dvatledEbcvbcal Wcik$ Wodctostat �" lilspvdmE)a FWWe*d Rough anal signedtlrltr&P&laltiesaf FIRMNAME _ L Lim1eNa t iaeyt� 3`E' I Sigrdtae ' LioaLseNo IM'f(07-- � Busk=TdNa -V5C'/� t,/ Q AILTUNo. ``OWNER'SINSURANCEWAIVER,IamlawatethattheLio wdoesnothavetheinSagreoohailsak a Watrmhtasta}ritedbyMasmdRmMGalealIam and abet my sgnahn en this pmritt apphcu*m wa m ft legtlitm= (Phase check one) Owner Agent Telephone No. PERMIT FEE$ Signature ot Ownergen r • Dates.? �`7 3703 NORTIy °'<•�•° .1"o TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING 'SSACHUS� This certifies that ;—.�1. has permission to perform . . . .�}.r. r. . . . . . . . . . . . . . . . . . . . . . . plumbing in the buildings of .`�.`�1wov . . . . . . . . . . . . . . . . . . S. at . . J.° .�.l o . .S . . . . . . . . . . . . .. North Andover, Mass. Fee./- �. . .Lic. Noj- �7. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . PLUMBING INSPECTOR 05/19/98 08:57 15.00 PAID WHITE:Applicant CANARY: Building Dept. PINK:Treasurer