Loading...
HomeMy WebLinkAboutMiscellaneous - 57 GREEN HILL AVENUE 4/30/2018 57 GREEN HILL AVENUE 2101022.00 0 North Andover Board of Assessors Public Access !� Page 1 of 1 NORTH North Andover Board ,of Assessors , �4ip^a E�•fax - SS^�"j5 roperty Record Card Click Seal To Return Parcel ID :210/022.0-0106-0000.0 FY:2013 Community :North Andover SKETCH PHOTO Click on Sketch to Enlarge Click on Photo to Enlar e Search for Parcels i Search for Sales , �!t Summary i Residence Detached Structure Condo `°— , 57 GREEN HILCAVENUE Commercial Location: 57 GREEN HILL AVENUE Owner Name: JUDGE,CHERYL STURGIS,CYNTHIA Owner Address: 57 GREEN HILL AVENUE City: NORTH ANDOVER State: MA Zip: 01845 Neighborhood: 5-5 Land Area: 0.32 acres Use Code: 101-SNGL-FAM-RES Total Finished Area: 1436 sqft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total_Value: 335,000 318,800 Building Value:. 166,100 144,800 Land Value: 168,900 174,000 Market Land Value: 168,900 Chapter Land Value: LATEST SALE Sale Price: 100 Sale Date: 10/24/2008 Arms Length Sale A-NO-FAMILY Grantor: WHITTAKER, Code: RICHARD& Cert Doc: Book: 11354 Page: 28 http://csc-ma.us/PROPAPP/display.do?linkld=2250783&town=NandoverPubAcc 10/22/2013 Residential Property Record Card PARCEL ID:210/022.0-0106-0000.0 MAP:022.0 BLOCK:0106 LOT:0000.0 PARCEL ADDRESS:57 GREEN HILL AVENUE FY:2013 PARCEL INFORMATION Use Code: 101 Sale Pnce 900 Book P11354 "'Road Type vT__ w Inspect Date 12/23/2011 Owner: Tax Class: T Sale Date 10/24/08 Page: 28 Rd Condition P Meas Date -12/23/2011 Tot'Fm Area 1436 JUDGE, CHERYL Sale Type P` Cert/Doc: Traffic IVI _ Ent'rance _ X - STURGIS,CYNTHIA TE Land Area 0 32 Sale Valid A Water Collect Id RRC Address: `Grantor WHITTAKER, RICHARD 8� :Sewer -``� Inspect Reas C 57 GREEN HILL AVENUE Exempt-B/L% / Resid-B/L% 100/100 Comm-B/LP/o Indust-B/L% / Open Sp-B/L% / NORTH ANDOVER MA 01845 RESIDENCE INFORMATION LAND INFORMATION Style: RN` `Tot Rooms: 6 Main'Fn Area: 1.436 Attic:, NBHD CODE: 5 NBHD CLASS: 5 ZONE R4 StoryHeight 1 00 $'edrooms. 3 Up Fn Area: _. Bsmt Area: 1`172 Seg Type Code Method Sq'Ft Acres ' Influ Y/N Value Class ._ �- t 1 P 101 S_.-� �.14125 _6.'3'20-__--,--- �._,.�..168,923�4p Roof G Full Baths. 1 Add Fn Area FnBsmt Area 1050 Ext Wall:- DETACHED'AV Half Baths 2 Unfin Area � �'Bsmt Grade � � -.Mr-� � - - - - - STRUCTURE INFORMATION Masonry Tnm �Ext Bath Fix 0 Tot,Fin Area: m..-. -� -u--~ - Str =Unit IVlsr 1 Msr 2 E YR Blt Grady Cond%Good P/F7ECR dost Class Foundation. CN Bath Qual: T _w RCNLD 1639,40' .___ Kitch Qual T Eff Yr'BuiltJ7777.1" SE S 280 0.00 1990 A A 50///50 2,200 1 ' 1970 Mkt Heat Type HW Ext Kitch. Year Built: 1954 Sound Value VALUATION INFORMATION Fuel Type .. G W Grade A Cost Bldg 163,900 Current Total: 335,000 Bldg: 166,100 Land: 168,900 MktLnd: 168,900 Fireplace _ 1 Bsmt Gar Cap Condition A Att'Str Val1 f Prior Total: 318,800 Bldg: 144,800 Land: 174,000 MktLnd: 174,000 Central AC N Bsmt Gar SF Pct`Complete: Att Str Val2 �,. AttGar SF: '_ 624.%G66d'0/F/E/R: /1 06/1_00'/75_-__ Porch Type Porch Area Porch Grade Factor E 322 SKETCH PHOTO 23 E' 14 322 Sq.R 14 ;n G. FM FM%B 264 Ft -. 24 624 Sq.Ft p, 1172 Sq ft 28 4 t 57 'GREEN HILL-AVENUE Parcel ID:210/022.0-0106-0000.0 as of 10/22/13 Page 1 of 1 Date..5� �.! ................... s NORTh TOWN OF NORTH ANDOVER f � 9 PERMIT FOR GAS INSTALLATION 88�cHu5� Thiscertifies that N. .......................�.....,...........�.,........................................................ has permission for gas-installation - � -- - . in the buildings of , at......�:.�....�`...:................................................................. North Andover, Mass. Fee. ....:.... Lic. NA . ... .......... GAS INSPECTOR Check# 9317 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY North Andover MA DATE PERMIT# JOBSITE ADDRESS 57 Green Hill Ave OWNER'S NAME GOWNER ADDRESS Same ITE FAX TYPE OR OCCUPANCYTYPE COMMERCIAL® EDUCATIONAL❑ RESIDENTIAL PRINT CLEARLY NEW:® RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES[ N0[j APPLIANCES Z FLOORS— BSM 1 2 . 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER eplace 1 Gas Meter x INSURANCE COVERAGE I have a current liabilit insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY EOTHER TYPE INDEMNITY ® BOND OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER E] AGENT SIGNATURE OF OWNER OR AGENT 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 pliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. <. PLUMBER-GASFITTER NAME Joseph Marino LICENSE# 8736 SI NATURE MP EI MGF® JPEI JGF LPGI® CORPORATION # 3285C PARTN` HIP # LLC # COMPANY NAME: RH White Construction Co. ADDRESS 41 Central St CITY Auburn STATE=ZIP 01501 TEL F508 832-3295 FAX 508-926-4347 CELL 508-832-4614 1 EMAIL JMarino@RHWhite.com .5 ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES cep � = Ct3J111Nd;0_iVi�VBAL.TH OF N9A,SSl :U ;'_— •"1P�L M BERS ANEW GASF1T1-7 K--.— A..Maw- � EFd F!;LUNfCi��R�=• - fSSUE5 TH '%(BClVE LICENSE l(5 - _ - GTON 8T Wi7 _G' S"TER 1/14 ;�l'=_G;®it)i41 0NWEAL.TH OF MASS la4m. -E-.I TS;= -I PLILItilI8ERS AND GAIERS:. '_: LAS A JOUR 7 'fSSUES THE ABOVE'L10EfVSE TW ' IN G TO '�71J1G%E=STER �9A Ci 16'0. ;. 4=3. 09= i _ ® DATE(MMMDNVW) ACORD----'' CERTIFICATE OF LIABILITY INSURANCE page 1 of 1 08/29/2013 THIS CERJIFICATE Is ISSUED ASA MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the Certificate holder is an ADDITIONAL INSURED,the policy(ios)murt be endorsed. If SU 13 ROGATION Is WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does notconferrights to the Certificate holder In lieu of such endorsement(s). PRODUCER CONTACT 94ii1i4 Of Massach ootts, Inc. NAM I PHONE c/o 29 cettusy Blvd. NO.-Qg)• 877-945-7378 Fa off: 888-467 2378 P. o. Box 305191 ft- AIL RS -Cex't;.fiaate r�willia.cozn Na9k)�alla, TN 37230-5191 -fl. INSURER(-AFFORDINGCOVERAGE NAICo' INSURED �JNSUEREEERA_-The CbArt9z Oak ri:CA Znaurancg Company 25615-001 White Construction Company, Ync. :TravaZgXD property Casualty GOtgpalzy oP Am 25674-003 41 Cantral Street INSURER C:NatiOnAl Union Piro Ineuranca Company o£ 79445-001 P• 0. Box 257 Auburn, MA 013ol INSURER D;Travelers Indamnity Company 25658-001 INSURER F; INSURER F. COVERAGES CERTIFICATE NUMBER:20267680 REVISION NUMBER; THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN($SUED TO THE INSURED NAMED,ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER OOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPEOFINSVRANCE DO, SUB POLICY NUMBER POLICY EFF POLICY EXP LIMITS A GENERAL LIABILITY VTC2000 97789948-13 9/7./2013 '9/1/,2014 EACNOCCURRENCE E 2 000 p00 X COMMERCIAL GENERALUABII.ITY ETORENTF,D ��� �Eg_(Ea oceu encc 1 _ 3 0 0,0-0 0 CLAIMS-MADE OCCUR MED EXP(Any one eraon $ 10�000 PERSONAL&ADV INJURY S 2 000,Q00 GENERAL AGGREGATE $ 41000 000 GEN'LAGGREGATFLIM17APPLIESPER; PRO PRODUCTS-COMP/OPAGG $ 000,000 POLICY LOG AUTOMOBILE LIABILITY VTJC .P 977R955A-73 /1/20x3 9/Z/2014 OM13 NEOSINGLF.LIMIT X ANYAUTO .assldent g 3,000,000 ALI.OWNED SCHEDULED BODILY INJURY(Perpemon) $ AUTOS AUTOS BODILY INJURY(Peraccident) $ X HIREDAUTOS X NON-OWNED Co DeflcTl1-Bed eraccldenl a 9 S C UMBRELLA LIAR X OCCUR 5 6786140 9/1/201,3 9/1/2014 EACHOCCUFRENCE $ S"000,000 P�ICESS LIAa CLAIMS-MADE AGGREGATE $ $1000'00 DEDF. IRETENTIONS 10,000 D WORKERSDEMPL COMPENSATIONILII VTRRUB 82 05 - AND EMPLOYER&'LIABILITY A1as 13 9/1/2013 9/1/2014 x rAr�Y-u D ONY FFICER RIETORlPARTNDED? CU?NE NN NIA VTC2XuB ®203A71A-13 9/7./2013 9/1/2014 E.L.FACH ACCIDENT s 1,000000 ml MarlOFFICERlAlEMBFR EXCLUDED? IUfirys etorrtn d E.L.DI$EA9E-EAEMPI,pYEE S 1,000,000 Et5 tdlell+I lUN OF VI'4RATlON3 BeIOW E1,D13EASE•POLICY LIMIT 9 1,000,000 )ESC RIPTION OF OPERATIONS/LOCATIONS I VEHICLES(Avelcll Acord 101,Addltonpl Remake Sehodula,If more ep eco la raqulroc :ERTIFICATE HOLDER CANCELLATION SHOULD ANY OF TWE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIiI?D REPRESENTATNE Evidence of Inmuzance CoII44297604 xp1:1694012 Cext;:20287680 ©1988-2010ACORD CORPORATION.All dQh'tsreserved. ,CORD 25(2010105) The ACORD name and logo are registered marks of ACORD NEW ENGLAND CLAIMS SERVICE, INC. Incorporated 1985 0 El Reply To - Reply To Mansfield, MA 02048 131 Dodge Street,Suite 6 P.O. Box 345 x5WAl- sice Beverly, MA 01915 MONT TEL. {508} 337-8058 IN s As' TEL. {978}927-3000 FAX{508}339-5835 FAX{978}927-3002 wrandall@newenglandclaims.com Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS, Ch. 139, Sec 3B To: Building Commissioner or Inspector of Buildings City Hall North Andover, MAO 1845 RE: Insured: Stephen&Kimberly Kochakian Property Address: 57 Green Hill Ave North Andover MA 01845 a Cause of Loss/Date: Wind Damage/9/6/2014 File or Claim No: BOS052752 Claim has been made.involving loss, damage or destruction of the above captioned property, which may. either exceed $1,000.00 or cause MASSACHUSETTS GENERAL LAWS, CHAPTER 143, SECTION 6, to be applicable. If any notice- under MASSACHUSETTS GENERAL LAWS, CHAPTER 139, SECTION 3E 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. Section 3B. No insurer shall pay any claims (1) covering the loss, damage, or destruction to a building or other structure, amounting to one thousand dollars or more, or (2) covering any loss, damage or destruction of any amount, which causes the condition of a building or other structure to render section six of chapter one hundred and forty-three applicable, without having at least ten days previously given written notice to the building commissioner or inspector of buildings appointed pursuant to the state building code, to the fire department or arson squad of the city or town and to the board of health or board of selectmen of the city or town in which the same is located. If at any time prior to payment the said city or town notifies the insurer by certified mail of its intent to initiate proceedings designed to perfect a lien pursuant to section three A, or to section nine of chapter one hundred and forty-three, or section one hundred and twenty-seven B of chapter one hundred and eleven, the said payment shall not be made while the said proceedings are pending; provided, however, that said proceedings are initiated within thirty days of receipt of such notification. Any lien perfected pursuant to section three A, or to section nine of chapter one hundred and forty-three or section one hundred and twenty-seven B of chapter one hundred and eleven, shall extend to and may be enforced by the city or town against any casualty insurance policy or policies covering any loss, damage, or destruction pursuant to which the proceedings to perfect the lien were initiated. No insurer shall be liable to any insured owner, mortgagee, assignee, city or town, or other interested party for amounts disbursed to a city or town under the provisions of this section, or for amounts not disbursed to a city or town under the provisions of this section. On this date, I caused copies of this Notice to be sent to the persons named above at the addresses indicated above by First Class Mail. Very Truly Y urs, Mark Randall Adjuster m.randallnecs@comcast.net (978)223-7332 cell Date... 10247 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ..................................... .............................................................................. has permission to perform........... ...........................................................t&./,1 cA.0--, plumbing in the buildings of ............................................................................. ............................... at..........5.1...... North Andover, Mass. Fee-..N, ...Lic. No-7111-.K. B. 6.............................. PLUMBING INSPECTOR Checkit Zen-- 14 oil Z-L' r MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY for � MA DATE 1' PERMIT# lba JOBSITE ADDRESS � OWNER'S NAME p�q POWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL © RESIDENTIAL R9 PRINT CLEARLY NEW: [] RENOVATION:0 REPLACEMENT: ] PLANS SUBMITTED: YES Q NO© FIXTURES Z FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM I _ [ DEDICATED GRAY WATER SYSTEM 1 I f _~- DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN ._I .---_._..i .----_� [ f I f __..._f. � ..._...__1 _..._.. I ._._.._( FOOD DISPOSER1—JI FLOOR/AREA DRAIN __..__.j ____.__f .._-.._-_.f INTERCEPTOR(INTERIOR) I f � ._J .___..._f ( � KITCHEN SINK ---- LAVATORY ROOF DRAIN �.1 .__._J ._..._j ._.__� _.__J . f. � f. ,----r SHOWER STALL SERVICE I MOP SINK __I TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING I _.___f f _.-__ -f f J __----- OTHER J __..__.._1 __-._I ._-__.__I ._...__ _f ____-_.._I _I ._.___ INSURANCE COVERAGE: [� 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW . LIABILITY INSURANCE POLICY M OTHER TYPE OF INDEMNITY _-i BOND M OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER _i AGENT JE] SIGNATURE OF OWNER OR AGENT 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 co4"', ce with all Pertinent rovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. � PLUMBER'S NAME � �`!'2 4CAI C _ I LICENSE# J I SIGNATURE MPA JP Q CORPORATION PARTNERSHIP®#=LLC COMPANY NAME Lj, ADDRESS CITY STATE �ZIP 163d73 �� TEL j CELL i FAx -- EMAIL _---- - --- -— ----._._....__..._._.._..---... ----_.- -N' --- � v ROUGH PLUMBING INSPEC.TION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES i t Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ �. FEE: $ PERMIT# PLAN REVIEW NOTES • 9 Date:..i..# NORTH TOWN OF NORTH ANDOVER 9 q`= PERMIT FOR GAS INSTALLATION ,88ACHU5� This certifies that .... , ..1.11:x....... ......Q..J.p..!......................................................... has permission for gar, installation ..�..P1.`..... . in the buildings of... .Va.L6n\A'-�. ............................. ........................................ ,r at .........45.1......................° ::1�........................ North Andover, Mass. Fee.....:. :.....;Lica No..f64....... M. ................. ....................................... GAS INSPECTOR Check# 81954 EL MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY _/l/aj^�b► �/y,C��/. Y?_ MA DATE PERMIT# i JOBSITE ADDRESS -51 �9Vr- OWNER'SNAME 5--leve- CA GOWNER ADDRESS TEL ]FAX TYPE,0R OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW:Q RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES 7 NO APPLIANCES 7 FLOORS- BSM 1 2 3. 4 5 6 7 8 9 10 11 12" 13 14 BOILER BOOSTER .- CONVERSION BURNER COOK STOVE --- DIRECT VENT HEATER + DRYER - FIREPLACE -- FRYOLATOR �_ - .I !� ( - L FURNACE GENERATOR GRILLE INFRARED HEATER - LABORATORY COCKS ( E _ [ J _...- i ---_.-l _-! _ _ -� I -- Y-- - _ MAKEUP AIR UNIT - �� _._� _ _ OVEN _ . I- POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST — UNIT HEATER UNVENTED ROOM HEATER l WATER HEATER OTHER ' _._ .... ........ . .._...._........ ..... -� - -- -- - INSURANCE COVERAGE -� have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITY © BOND OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information 1 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.- r Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUM BER-GASFITTER NAME L-P LICENSE# IP / SIGNATURE MP 0 MGF 0 JP® JGF Q LPGI® CORPORATION PARTNERSHIP LLC D#= COMPANY NAME: -�- _JJADDRESS CITY STATE LVJZIP TEL FAX CELL __EMAIL ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES //- Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ �� l� f FEE: $ PERMIT# PLAN REVIEW NOTES The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations kqip 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Tyg lie s 6Q -zix,- Address: 7Y City/State/Zip: ���r ®�d l�- Phone#: Z S �i��%'' 7� p` Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2. I am a sole proprietor or partner- listed on the attached sheet. �• E]Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me 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.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]i 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 ire 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 workers'comp.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 requiredunder 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 and penalties of perjury 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): 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-contractors)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 town that the application for the permit or license is being requested,not the Department 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 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 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 02111 Tel,#617-727-4900 ext 406 or 1-877rMASS.AFE Revised 5-26-05 Fax#617-727-7749 www-mass,gov/dia 0 . _.,—._�...r.�.. . CMMONWEALTH 0 MAS��FiUSETYS � ` •... • • • • i� nBERsNq r� aYT �s $ I i il�E i Ami f! J.E?UFiNf�Ym N nJ ;ISSUES THE ABOVE LICENSE TO {' GFR'E E I4`E 7 � RIDGE ST $ ' S11' t NH 0 0 7 > ' t5 � x. 1678 05!0.1./14 1tS, 5c G BUTTERWORTH & O'TOOLE, INC. P.O.BOX 8294 SALEM,MA 01971-8294 ADJUSTERS/APPRAISERS FOR INSURANCE COMPANIES ONLY TELEPHONE(978)741-5731 FAX(978)740-9109 September 04, 2007 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 Selectmen City/Town Hall City/Town Hall ADDRESSES North Andover, MA 01845 North Andover, MA 01845 RE: Insured: Richard and Virginia Whittaker Address : 57 Green Hill Avenue RECEIVED North Andover, MA 01845 SEP 1 U 2007 TOWN OF NORTH ANDOVER Policy No. : F0118323 HEALTHDEFAR1Iv1ENT ,Loss of : 08/31/07 File or Claim No. : 77-1039 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. If no reply is received from your office within ten days, we will assume you have no liens of any type against this property and we will recommend to the insuring company that this claim is paid. David Vincent, AIC Adjuster 0� Member of -National Association of Independent Insurance Adjusters BUTTERWORTH & O TOOLE, INC. P.O.BOX 8294 SALEM,MA 01971=8294 ADJUSTERS/APPRAISERS FOR INSURANCE COMPANIES ONLY TELEPHONE(978)741-5731 FAX(978)740-9109 September 04 , 2007 RECEk,r...,.Rr� �. SEP 10 2007 FORM OF NOTICE OF CASUALTY LOSS TO BUILDING i TOWN OF NOK7 u�r� y UNDER MASS. GEN. LAWS, CH. 139, SEC. 3B HEALTH DEPkF,'i n��e:.;a TO: Building Commissioner or Board of Health or Inspector of Buildings Board of Selectmen City/Town Hall City/Town Hall ADDRESSES North Andover, MA 01845 North Andover, MA 01845 RE: Insured: Richard and Virginia Whittaker Address : 57 Green Hill Avenue North Andover, MA 01845 Policy No. : F0118323 Loss of : 08/31/07 File or Claim No. : 77-1039 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. If no reply is received from your office within ten days, we will assume you have no liens of any type against this property and we will recommend to the insuring company that this claim is paid. David Vincent, AIC Adjuster >:Cuse. .sx Member of National Association of Independent Insurance Adjusters