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Miscellaneous - 6 WALKER ROAD 4/30/2018 (3)
D r m O D C North Andover Board of Assessors Public Access ` ' Page 1 of 1 to 1 t NOR7N '1 t +► swc«us t� Click Seal To Return Search for Parcels Search for Sales Summary Residence Detached Structure Condo Commercial Parcel ID :21U/U8J.0-UU26-0006.0 r'Y:2UU9 SKETCH moh roperty Record Card nunity : North Andover PHOTO 11 Location: 6 WALKER ROAD Owner Name: MARTEL, RICHARD P & DEBRA FAMILY BANK OPERATIONS CTR Owner Address: P O BOX 8317 City: WARD HILL State: MA Zip: 01835 Neighborhood: 0 Land Area: 0.00 acres Use Code: 102 -CONDOMINIUM Total Finished Area: 955 sqft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 170,600 189,600 Building Value: 170,600 189,600 Land Value: 0 0 Market and Value: 0 Chapter Land Value: http://csc-ma.us/PROPAPP/display.do?linkld=1462673&town=NandoverPubAcc 9/16/2009 ■ Complete items 1, 2, and 3. Also complete A. Slgnatuyq Item 4 if Restricted Delivery is desired. ` X ■ Print your name and address on the reverse so that we can return the card to you. a ecei d ■ Attach this card to the back of the mailpiece, t C or on the front if space permits. 1. Article Addressed to: 11 SEP 2 2 2009 D. Is delivery address If YES, enter deiiv, 3. ype Mail ❑ Registered ❑ Insured Mail _...... ❑ Agent V ❑ Addressee d Name) C. Date of D,&livery P1 , it mJ? 13Yes ress be ❑ No , O'Bpress Mail ❑ Return Receipt for Merchandise ❑ C.O.D. 4. Restricted Delivery? (Extra Fee) ❑ Yes 2. Article Number (transfer from serfLabefp~--- 7 0 0 2 510 0001 6602 3 517 PS Form 3811, February 2004 Domestic Return Receipt 102595-02-M-1540 UNITED STATES POSTAL SERVICE First -Class Mail Postage & Fees Paid USPS / Permit No. G-10 • Sender: Please print/your name, address, and ZIP+4 in this box • NORTH ANDOVER HEALTH DEPT. 41—L 1600 Osgood Street Building 20, Suite 2-36 North Andover, MA 01845 1li}F11F}111FilFil11111il}iFilij}iF}Fli!}IliilF1ii311}Il }I}}� SAC PUBLIC HEALTH DEPARTMENT Community Development Division Richard and Debra Martel 440 South Main Street Andover, MA 01810 Date: October 29, 2009 Re: 6 Walker Road, Unit 6, Richard and Debra Martel, owners Dear Property Owners, Upon request, the Health Department conducted a re -inspection on November 19, 2009 to observe compliance to the order letter issued to you on September 15, 2009. According to a letter received by your attorney Kara Roy, these items were to be scheduled to be completed by October 1, 2009 and then subsequently you indicated they would be done by November 19'.Th e following items remain outstanding. • The slider door does not slide easily • The slider door does not have a working lock • The bathroom tub caulking is not easily cleanable and remains in disrepair • The bathroom tiles replaced are not easily cleanable This letter is to remind you that you may not re -rent this property until you have received a letter of compliance from the Health Office. It is a violation to rent a habitable space with known State Housing Code violations. Please request a final inspection when all violations have been corrected. Failure to do so prior to the renting or occupancy of the unit could result in further action within the Lawrence Housing Court. Thank you. Sincerel Sus4n Sawyer,-I�S/REHS Public Health Director - 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com pORTH O ILED qtr � 67 O S �t `� D•0_ [OCM CMlwKN _1' PUBLIC HEALTH DEPARTMENT (ommunity Development Division Richard and Debra Martel 440 South Main Street Andover, MA 01810 Date: October 29, 2009 Re: 6 Walker Road, Unit 6, Richard and Debra Martel, owners Dear Property Owners, Upon request, the Health Department conducted a re -inspection on November 19, 2009 to observe compliance to the order letter issued to you on September 15, 2009. According to a letter received by your attorney Kara Roy, these items were to be scheduled to be completed by October 1, 2009 and then subsequently you indicated they would be done by November 19u`.The following items remain outstanding. • The slider door does not slide easily • The slider door does not have a working lock • The bathroom tub caulking is not easily cleanable and remains in disrepair • The bathroom tiles replaced are not easily cleanable This letter is to remind you that you may not re -rent this property until you have received a letter of compliance from the Health Office. It is a violation to rent a habitable space with known State Housing Code violations. Please request a final inspection when all violations have been corrected. Failure to do so prior to the renting or occupancy of the unit could result in further action within the Lawrence Housing Court. Thank you. Health Director 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 918.688.9540 Fox 918.688.8416 Web www.townofnorthandover.com pORTF1 �6 OL lO r t ° COC IC lwKM 1 � �4°gAria ►'Pp`y'�5 9SS AC HUS�� PUBLIC HEALTH DEPARTMENT (ommunity Development Division Richard and Debra Martel 440 South Main Street Andover, MA 01810 Date: October 29, 2009 Re: 6 Walker Road, Unit 6, Richard and Debra Martel, owners Dear Property Owners, Upon request, the Health Department conducted a re -inspection on November 19, 2009 to observe compliance to the order letter issued to you on September 15, 2009. According to a letter received by your attorney Kara Roy, these items were to be scheduled to be completed by October 1, 2009 and then subsequently you indicated they would be done by November 19u'.The following items remain outstanding. • The slider door does not slide easily • The slider door does not have a working lock • The bathroom tub caulking is not easily cleanable and remains in disrepair • The bathroom tiles replaced are not easily cleanable This letter is to remind you that you may not re -rent this property until you have received a letter of compliance from the Health Office. It is a violation to rent a habitable space with known State Housing Code violations. Please request a final inspection when all violations have been corrected. Failure to do so prior to the renting or occupancy of the unit could result in further action within the Lawrence Housing Court. Thank you. 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com NORTH ANDOVER HEALTH DEPARTMENT 27 Charles Street • North Andover, MA 01845 Tel. 978 688-9540 • Fax: 978 688-9542 email: healthdept@townofnorthandover.com Complaint Investigation/Inspection Report OWNER �L�d� jg./, e� ADDRESS' DATE 1, Rev. 6/04 INSPECTOR NOV-20-2009 07:44 FROM:DEMERS PLATE CLASS 19785213752 TO:19786888476 P.1 DEMERS PLATE GLASS CO. Convact Glass'Ptolessionals Since 1935 BILL To: RICH & DEBRA MARTEL HM TEL 9?8-749-9560 WK TEL r CONTACT 33526 STRY-BUC P0. Box 1298, 373 River Street • Haverhill, MA 01830 (978) 374-6387 • Fax: (978) 521.3752 SHIP TO: MEADOW VIEW CONDO'S 6 WALKER RD. UNIT 6 2ND FL NO. ANDOVER.MA OONT TEL. TO SUPPLY MATERIALS AND LABOR TO REPLACE TWO ROLLERS IN A 3FT GENERAL ALUMINUM PATIO DOOR. ADJUST DOOR AFTER INSTALLATION NEW PATIO DOOR LOCK AND HANDLE SET 2 PATIO ROLLERS #9-261 1 PATIO DOOR HANDLE & LATCH SUBTOTAL FREIGHT TAX CASH CHECK # VISA MASTER CARD DISCOVER TOTAL DEPOSIT RECEIVED BY DATE AMOUNT • Not responsible for breakage after receipt of materials in good order. DUE RT82073 We do not itemize again. • Any returns or claims must be accompanied by this receipt. .1< PRT14 EO" �� My b T O 4 0gATED pPp`y,(5 4SSAC HUS�� PUBLIC HEALTH DEPARTMENT Community Development Division NORTH ANDOVER BOARD OF HEALTH ORDER LETTER FECOPY Issued under the provisions of the State Sanitary Code, Chapter II, Minimum Standards of Fitness for Human Habitation, 105 CMR 410.000. Date: September 15, 2009 To Owner of Record: Richard and Debra Martel Family Bank Operations Ctr PO Box 8317 Ward Hill, MA 01835 Property Location: 6 Walker Road Unit 6 North Andover, MA 01845 An authorized inspection was made of your property at the above referenced address by North Andover Health Department personnel on Wednesday, September 9, 2009. This inspection revealed violations of certain regulations of the State Sanitary Code, Chapter II, as listed on the attached Violation Form. You are hereby ORDERED to correct these violations within the time allotted on the enclosed form. Failure to comply within the specified time period may result in further action by the North Andover Board of Health. You have the right to request a hearing before the Board of Health if you feel this order should be modified or withdrawn. A request for said hearing must be made in writing and received by the Health Department within seven (7) days from the receipt of this order. At said hearing you will be given an opportunity to be heard and to present witnesses and documentary evidence as to why this order should be modified or withdrawn. All affected parties will be informed of the date, time and place of the hearing and of their right to inspect and copy all records concerning the matter to be heard. You may be represented by an attorney. You have the right to inspect and obtain copies of all relevant records concerning the matter to be heard. ,-'I Slasan Sawyer, 3S Public Health Director 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 918.688.9540 Fax 918.688.8476 Web www.townofnorthandover.com ORDER LETTER An authorized inspection of 6 Walker Road, unit 6, was performed by Board of Health staff on September 9, 2009 at which violations of 105 CMR 410.000 Chapter II of the State Sanitary Code, Minimum Standards of Fitness for Human Habitation were found. All violations must be corrected within seven (7) days of receipt of this Order Letter or a professional contractor must be hired to evaluate the conditions noted below and a signed contract for work must be submitted. If a contractor is hired all compliance work must be completed within 30 days. A plan of corrective action should be submitted to the BOH. Requests for extensions must be in writing and approved in writing or the time table will remain as listed above. Note: Violation are underlined and corrections needed are in bold below Violation Regulatory reference Re inspection 1) Slider Door 410.500, 552 a. screen - gap at top b. glass pane taped on c. does not slide easily d. does not have working lock .552 The owner shall provide a screen door for all doorways opening directly to the outside from any dwelling unit where the screen door will be permitted to slide to the side. (2) shall be tight -filling as to prevent the entrance of insects and rodents around the perimeter. Repair slider and screens as needed to comply 2) Main Bedroom - Window near parking area 410.551 a. - screen not appropriate size and b. Window sill in disrepair .551 "The owner shall provide screens for all windows designed to be opened on the first four floors opening directly to the outside from any dwelling unit or room unit provided",... Said screens shall cover that part of the window that is designed to be opened, shall be tight fitting to prevent insects, and shall not be expandable temporary screens .500 Every owner shall maintain the foundation, floors, walls, doors, windows, ceilings, etc. and other structural elements of his dwelling so that the dwelling is "weather tight" Weather tight elements (A) A window shall be considered weather tight only if (1) all panes of glass are in place, unbroken and properly caulked and (2) The window opens and closes fully without excessive effort; and (3) Exterior crack between the prime window frame and the exterior wall are caulked; and etc. 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 fax 978.688.8476 Web www.townofnorthandover.com Repair screens as needed. Repair sill 3) Window street side - 410.551 a. no screen, b. pane not secure c. Does not stay open Repair screens as needed. Fix window unit. 4) Bathroom Toilet 410.350 a. Toilet loose b. Toilet flusher not working properly 410.350 (B)Every provided toilet shall be connected tot eh water distribution system in accordance with the accepted plumbing standards 410.351 The owner shall install or cause to be installed, in accordance with accepted plumbing, gasfitting electrical wiring standards and shall maintain free from leaks, obstructions or other defects. Repair Toilet 5) Bathroom wall 410.500 a. Large hole near light fixture Owner must maintain structure Repair Wall 6) Bathroom window 410.500 a. Does not open easily b. Tiles duct taped c. Tiles disrepair d. Screen ripped Repair window, screens etc 7) Bathroom tub caulking in disrepair; area not 410.500 Easily cleanable Repair tub area to make non -porous and easily cleanable 8) Office window screen not correct size 410 551 Repair screen 9) Bedroom #2 - ceiling shows old water damage 410.500 Owner must maintain ceilings in good repair. If old damage; repair, replace or paint as needed 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com A t NOTE: Windows throughout the rental unit must all open and close easily, have proper screens without defect, have window panes without defect. Have all windows checked and repaired to meet the code. 10) Kitchen a. Vent over stove danerous, rusty uncleanable Replace old stove vent b. Sink flourescenet light fixture missin cover Replace cover or unit as needed c. Kitchen cabinets to left in disre air. Drawers not secure Owner must maintain all owner installed elements to work as designed. Repair cabinets 11) Noa; of owner information 410.481 'An owner of a dwelling which is rented for residential use, who does not reside there and who does not employ a manager or agent for such dwelling who resides there, shall Post and maintain or case to be posted and maintained a ... a notice constructed or durable material, not less than 20 square inches in size, bearing his name, address and telephone number..." Post information in unit Cc: John and Jennifer Costa, tenants 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 918.688.9540 Fax 918.688.8416 Web www.townofnorthandover.com DelleChiaie, Pamela From: Sawyer, Susan Sent: Wednesday, November 18, 2009 8:33 AM To: DelleChiaie, Pamela Subject: 6 walker road, #6 Do you happen to have written down the number for this owner? I can do the 10 tomorrow, but the office would be empty for a bit. I don't know how far he comes, but if he can do it earlier, it would be less busy here. 8:30 - 9. Maybe he'd even prefer it. I actually could do it today after lunch and before 3 as well. If you can find it, can you call and ask for me? Susan � f%h: Pa m e q WER TOW p H�N 0 H ALNDO ME L F No T r TH 1) _ DelleChiaie, Pamela From: DelleChiaie, Pamela Sent: Monday, November 02, 2009 3:32 PM To: 'rpmassoc@yahoo.com' Subject: FW: Housing - 6 Walker Road - Unit 6 Attachments: SKMBT_60009110216210.pdf Attn: Richard & Debra Martel: Attached is the approval for your extension re: 6 Walker Road, Unit 6. sop Health Department Assistant TOWN OF NORTH ANDOVER Health Department 1600 Osgood Street Building 20; Suite 2-36 North Andover, MA 01845 978.688.9540 - Phone 978.688.8476 - Fax pdellechiaie@townofnorthandover.com - E-mail http://www.townofnorthandover.com/Pages/index - Website Notes. ff copied to BOH Members - Reference Copy Only - no response requested at this time From: noreply@townofnorthandover.com [mailto:noreply@townofnorthandover.com] Sent: Monday, November 02, 2009 4:21 PM To: DelleChiaie, Pamela Subject: Housing - 6 Walker Road - Unit 6 y �S�,av Ibt ro© PUBLIC HEALTH DEPARTMENT Community Development Division Richard and Debra Martel 440 South Main Street Andover, MA 01810 Date: October 29, 2009 Re: 6 Walker Road, Unit 6, Richard and Debra Martel, owners Dear Property Owners, The Health Department has received your second request of extension in response to the official Board of Health Order Letter, issued to the property above, on September 9, 2009. According to conversation held with you, the tenant has vacated the property, the work is approximately 70% complete and an additional contractor needs to complete the final 30%. This letter is to inform you that the Health Department has approved your request for a 30 -day extension as written in your proposal of October 19, 2009, however please note that you may not re -rent this property until you have received a letter of compliance from the Health Office. It is a violation to rent a habitable space with known State Housing Code violations. It is up to you to contact this office, and obtain a re -inspection prior to renting this property. Failure to do so could result in further action. Please contact this office when the property is ready for a re -inspection. Thank you. Sincerely lie Health Director Cc: John and Jennifer Costa, tenants 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fox 978.688.8476 Web www.townofnorthandover.com 0 r tAORT1{ ✓ 0� S�eD r '9ti <6, 00 �'� ' r� - - F a L 0 70 n 4M O coc.iX.2 wr.cw 9 'Q �9so SSAC US PUBLIC PUBLIC HEALTH DEPARTMENT Community Development Division Richard and Debra Martel 440 South Main Street Andover, MA 01810 Date: October 29, 2009 Re: 6 Walker Road, Unit 6, Richard and Debra Martel, owners Dear Property Owners, The Health Department has received your second request of extension in response to the official Board of Health Order Letter, issued to the property above, on September 9, 2009. According to conversation held with you, the tenant has vacated the property, the work is approximately 70% complete and an additional contractor needs to complete the final 30%. This letter is to inform you that the Health Department has approved your request for a 30 -day extension as written in your proposal of October 19, 2009, however please note that you may not re -rent this property until you have received a letter of compliance from the Health Office. It is a violation to rent a habitable space with known State Housing Code violations. It is up to you to contact this office, and obtain a re -inspection prior to renting this property. Failure to do so could result in further action. Please contact this office when the property is ready for a re -inspection. Thank you. Sincerely Director Cc: John and Jennifer Costa, tenants 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 918.688.8476 Web www.townofnorthandover.com �79 q q V� t t G C t:'� LHEALLTHOPARWEN rOFT-tDoti C �7 ©� c�� 2 Co VC's Da--�' 10 -IQ -BP Vel 3 3�� OCT 19 ZOOS TOHEALLTH TMENT NORTH G� t►.eD '9ti O 6�A O 7D PUBLIC HEALTH DEPARTMENT (ommunity Development Division Richard and Debra Martel 440 South Main Street Andover, MA 01810 Date: October 29, 2009 Re: 6 Walker Road, Unit 6, Richard and Debra Martel, owners Dear Property Owners, The Health Department has received your second request of extension in response to the official Board of Health Order Letter, issued to the property above, on September 9, 2009. According to conversation held with you, the tenant has vacated the property, the work is approximately 70% complete and an additional contractor needs to complete the final 30%. This letter is to inform you that the Health Department has approved your request for a 30 -day extension as written in your proposal of October 19, 2009, however please note that you may not re -rent this property until you have received a letter of compliance from the Health Office. It is a violation to rent a habitable space with known State Housing Code violations. It is up to you to contact this office, and obtain a re -inspection prior to renting this property. Failure to do so could result in further action. Please contact this office when the property is ready for a re -inspection. Thank you. Sincerely Director Cc: John and Jennifer Costa, tenants 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com r Iq L 7 9 s� q V E V! r l/Va �Jf,r5, TC WN OF NORTH ANQOVE.: HEALTH DEPARTMENT I%�.�l y�Z) s m L4 lAC, v� �'� Ca v�1/' do b q rleVC ` ' --Co r o n 6 W a tKer, RamIle : r o rk � { c 0 ec--k=- � ate.� doc o � Some -7�0 Y5 u / d-AAe. n In eza Yc/V 339a NORTH O? F616 0 A� p FILE C �C.M O .wN w Ty SSACHUs���y �. PUBLIC HEALTH DEPARTMENT (ommunity Development Division Kara Roy, Esq. 105 Kenoza Ave. Haverhill, MA 01830 Date: September 23, 2009 Re: 6 Walker Road, Unit 6, Richard and Debra Martel, owners Dear Attorney Roy, The Health Department has received your request of extension in response to the official Board of Health Order Letter, issued to the property above, on September 9, 2009. This letter is being sent to you as the representative to the owners. The Health Department has approved your request for a 30 -day extension as written in your proposal of September 21_, 2009. Please contact this office when the property is ready for a re- inspection. Thank you. Si waii oawylzr, rCJ/r= //Public Health Director Cc: John and Jennifer Costa, tenants 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com pORT11 O�4.,%Leo ,s'9q, O? �° OOZ.H CO[NIi N[MKN 1' PUBLIC HEALTH DEPARTMENT fommunity Development Division Kara Roy, Esq. 105 Kenoza Ave. Haverhill, MA 01830 Date: September 23, 2009 Re: 6 Walker Road, Unit 6, Richard and Debra Martel, owners Dear Attorney Roy, The Health Department has received your request of extension in response to the official Board of Health Order Letter, issued to the property above, on September 9, 2009. This letter is being sent to you as the representative to the owners. The Health Department has approved your request for a 30 -day extension as written in your proposal of September 21, 2009. Please contact this office when the property is ready for a re- inspection. Thank you. uzau oawyzr, tc�irc�1 /Public Health Director Cc: John and Jennifer Costa, tenants 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com PUBLIC HEALTH DEPARTMENT Community Development Division Kara Roy, Esq. 105 Kenoza Ave. Haverhill, MA 01830 Date: September 23, 2009 Re: 6 Walker Road, Unit 6, Richard and Debra Martel, owners Dear Attorney Roy, The Health Department has received your request of extension in response to the official Board of Health Order Letter, issued to the property above, on September 9, 2009. This letter is being sent to you as the representative to the owners. The Health Department has approved your request for a 30 -day extension as written in your proposal of September 21, 2009. Please contact this office when the property is ready for a re- inspection. Thank you. W5cul aawy)n' too/r�1 ublic Health Director Cc: John and Jennifer Costa, tenants 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com KARA E. ROY, Esq. 105 Kenoza Avenue Haverhill, Massachusetts 01830 Tel: (508) 450-5370 September 21, 2009 Town of North Andover ATTIN: Health Department 1600 Osgood Street Building 20; Suite 2-36 North Andover, MA 01845 Re: Sanitary Inspection of 6 Walker Road, Unit #6 Dear Ms. Sawyer, Fax: (978) 687-9607 Kara E. Roy, Esq. RECE1 En SEP 22/200 /,/e T4O�Ef HEALTH DEPARTMENT Please be advised that this office represents the owner of the property, Mr. Richard P. Martel. Your office conducted an inspection of the above-mentioned address on September 9, 2009 and found some violations of the town's sanitary code. This letter serves as a plan to correct the violations found and to request a 30 day extension to cornplete all the corrections. Some violations have already been corrected. Corrections already made: o The gap on the sliding door screen has been fixed o The toilet in the bathroom has been tightened o A new handle has been installed on the toilet and it now flushes properly o The window on the street side has had a new screen installed. The plan to correct the remaining violations: o The sliding glass door is scheduled to be fixed on September 25, 2009 o Mr. Martel is awaiting an estimate from the glass company to fix the master bedroom window screen and the bathroom window o The parts have been ordered for the window on the street side o The bathroom will be repaired not later than October 1, 2009 o The screen will be sent out for repair on September 25, 2009 o The bathroom tile damage will be assessed not later than September 25, 2009 and fixed not later than October 15, 2009 o The caulking on the bathtub will be cleaned. o The hole in the bathroom will be fixed not later than October 16, 2009 o The ceiling in the bedroom will be fixed not later than October 16, 2009 o The kitchen light cover will be replaced not later than October 16, 2009 o The cabinets and drawers will be fixed not later than October 16, 2009 If there are any questions please feel free to call me at (508) 450-5370. Sincerely, Kara E. Roy, Esq. -' Counsel for Richard P. Martel 2 DelleChiaie, Pamela Subject: Complaint - 9/9/09 - 6 Walker Road - Unit 6 - REQUEST FOR EXTENSION - 9/21/09 Start Date: Monday, September 21, 2009 Due Date: Tuesday, September 22, 2009 Status: Not Started Percent Complete: 0% Total Work: 0 hours Actual Work: 0 hours Owner: DelleChiaie, Pamela ,Order letter sent out re: inspection on 9/9/09. Response to letter received today requesting a 30 day extension to. complete the repairs. Brought by Martel's attorney, Kara E. Roy at 1:10 p.m. Folder in your inbox ------------ From: DelleChiaie, Pamela Sent: Wednesday, September 09, 2009 10:23 AM To: Sawyer, Susan Subject: Complaint - 6 Walker Road - Unit 6 Attachments: GeoTMS Complaint Tracking.rtf Inspection on 9/9/09 at 11:00 or after TRC. EJ Complaint - 6 Walker Road - Un... 1 Free People Search I WhitePages WhitePages Rick P Martel H 440SMain St Andover, MA 01810-6119 View phone Age: 55-59 Household: Taylor L Martel, Debra L Martel, Cortney Martel, Adam R Martel c� 'N Rocky Hill Rd �. crse Z 't a Ix % �. F 1 500 yds 2W)9 Microsoft Corpor Listing date: Aug. 2009 Advertise with Us Page 1 of 1 http://www.whitepages.com/search/Replay?lower=4&more info=l&search id=64161350... 9/16/2009 440 S Main St, Andover, MA 01810 - Zillow O Zillow.com, 440 S Main St Andover MA 01810 3 beds, 1.5 baths, 1,252 sq ft Zestimate®: $324,500 My Estimate: Monthly Payment: $ 1,394 edit Click here for your Credit Report Bird's Eye View see a :_Home Info Public Facts: • Single family • 3 beds • 1.5 bath • 1,252 sqft • Lot 30,400 sgft • Built in 1957 Neighborhood Nearby Schools: District: Andover Primary: Bancroft Elementary ... Middle: Doherty Middle Schoo . . High: Andover High School See more Town of Andover schools Charts & Data ZESTIMATE®: $324,500 Value Range: $275,825 - $400k $347,215 $382k 30 -day change: $9,000 _$360k Zestimate updated: 09/14/2009 _ $340k Last sale and tax info {SZillaw.[ -$310k Sold 09/05/1989: Jan05 Jan07 dan09 $165,000 2009 Property Tax: $3,689 Get Score Page 1 of 2 http://www.zillow.com/homedetails/440-S-Main-St-Andover-MA-01810/56032409_zpid/ 9/16/2009 I 3437 Department of the Treasury - Internal Revenue Service Form 668 (Z) Certificate of Release of Federal Tax . Lien (Rev. 10-20001 Area: Serial Number SMALL BUSINESS/SELF EMPLOYED AREA #1 Lien Unit Phone: (800) 913-6050 188186104 1 certify that the following -named taxpayer, under the requirements of section 6326 (a) of'the Internal Revenue Code has satisfied the taxes listed below and all statutory additions. Therefore, the lien provided by Code section 6321 for these taxes and additions has been released. The proper officer in tha office where the notice of internal revenue tax lien was filed on Auqust 31 2004 , is authorized to note the books to show the release of this lien for these taxes and additions. For Name of Taxpayer RICHARD P. DEBRA L. MARTEL Residence440 S MAIN ST6 ANDOVER, MA 01810 COURT RECORDING INFORMATION: Liber Page UCC No. Serial No. n/a n/a n/a 40923 Tax Period Date of Last Day for Unpaid Balance Kind of Tax Ending Identifying Number Assessment Refiling of Assessment (8) rbc fol ld) !e1 ff) 1040 12/31/1997 029-40-4525 07/06/1988 N/A 2150.10 1040 "12/31/1998 029-40-4525 06/07/1999 07/07/2009 10787.72 1040 12/31/1999 029-40-4525 05/29/2000 06/28/2010 2638.96 1040 12/31/2000 029-40-4525 05/14/2001 06/13/2011 2518.12 1040 12/31/2001 029-40-4525 12/09/2002 01/08/2,013 1325.61 1040 12/31/2002 029-40-4525 07/05/2004 08/04/2014 4586•.49 Bk 107,90 P's 95 17264 06--05-2007 02442P Place of Filing Registry of Deeds Northern Essex County Laawrence,'MA 01840 This notice was prepared and signed at the , 23rd day of May , 2007 MANHATTAN, NY Total 1$ 24007.00 , on this, Signature A Title Director, Campus Compliance ` Operations (NOTE: Certificate of officer authorized by law to take acknowledgments is not essentialto the validity of Certificate of Release of Federal Tax lien Rev. Rul. 71-466, 1971 - 2 C.B. 409) Form 668 (Z) (Rev. 10-2000) Part I - RECORDING OFFICE CAT. NO 600261 Sk 11735 P984 :24197 08-17-2009 a 02212P Prepared by/Record and Return to: ANGELICA LAGUARDIA Chase Home Finance LLC Reconveyance Services 780 Kama Lane, Suite A PO Box 4025 Monroe, LA 71203 Telephone Nbr: 1-800-848-9136 Min: 100122200003168249 MFRS Phone, if applicable: 1-888-679-6377 DISCHARGE OF MORTGAGE MORTGAGE ELECTRONIC REGISTRATION SYSTEMS, INC., holder of a mortgage from: RICHARD P. MARTEL AND DEBRA L. MARTEL, to MORTGAGE ELECTRONIC REGISTRATION SYSTEMS, INC. AS NOMINEE FOR BNC MORTGAGE, INC., A DELAWARE CORPORATION dated May 8, 2007, recorded on May 10, 2007 Volume/Book 10746 Page 323 Document 14493, with ESSEX NORTH County Registry of Deeds, also known as 6 WALKER RD UNIT 6, NORTH ANDOVER, MA, 01845, acknowledges satisfaction of the some. IN WITNESS WHEREOF, the said corporation MORTGAGE ELECTRONIC REGISTRATION SYSTEMS, INC. has caused its corporate seal to be hereto affixed and these presents to be signed in its name and behalf by Uhinda Willis, a(n) Vice President and ALLISON COLEMAN, Assistant Secretary. MORTGAGE ELECTRONIC REGISTRATION SYSTEMS, INC. WITNESS the execution hereof under seal this 08/11/09 Witnesses: j/, Klh Y THOMAS P ELA CARR By: Ulanda Willis Vice President State of: Louisiana Parisb/County of° OUACHITA Y S1:A1. -Nt' loop fir 40 Attest: ALLISON CO Assistant Secretary Then personally appeared this 08/11/09 the above named Ulanda Willis, Vice President who acknowledged the foregoing instrument to be the fiee act and deed of said corporation before me, LL% t' V j 9'. KARIN W. HARRIS - 58150 Notary Public LIFETIME COMMISSION Loan Number: 24452492 County of: ESSEX NORTH Investor Number: D34 Investor Loan Number: 0124680810 Outbound Date: 07/29/09 MA00 12/30/ I JM P. CUh'E S of 4 Pony Stmt, Arooklim, forfolk �" f3 County, .Wasmac6setts e:v*we") for aoaaeideration of ninety Eight Thousand ($96.W.00)psid g>raat to 11CMD P. #MTV. sed BSBttA L. tMt'Ctx,, busbsnd and w#fee, se telames by the oetifety Keith of itid4letoa Essex County Nssaachusetts, ("arsntee") 2tit QUZTCLAXM C09!~NAt0�8, the e~oadooelidum nit ice ted at 6 vol%sx load in Borth Andover 'Ism County, *08acbusstts, wag" *6 gait 00. 6 of the ca;Aomixtium karave as Meadow View 0"Aastatiwa, mated tin aaeaerdanee with and subject to On provisions of Cha ov 183A, Maaesaehuaae to do aeet�ol Love, so amended, by hast** Deed dated August 21, 11 Mo+rdod with 88siex Causty Worth itistrict esgistry of Daedo is soon 1527, Page AM . , The unit is conveyed topother with an undivided JAM prrceots t inewNst in the eoaaa~n Amass and 140110a8 of the eoted"twIeaa as sot forth lea thio Waster Dead and In the Nsmdov vier Condeeaioeium Trust recorded with said Deeds In Book 1528, page 1. The quit aeataiees 9$5 square fist and is Laid out as ohms on a plan xeoorded with said Deads to Spok 15416 Drage 7$1, which - is a copy of the portion of tho plans recorded with sola vtaet:ar Dead and to whith is affismd a verified Atat+s O"t to the fora Provided for to Nstaaahusotta 0moral Tars, Chapter 183A. The unit is to be used only for vesidentfal purgosas and uses accessory thereto perseitted feria tiles to time by the Zoning by -Law of the Town of north A"Over Ono for no otherarposoo eYtcept as my be expsassly persittsd br the Ttustiea Ie aaeordanco with the provisions of the Dfaadow View Condomisiana Trust. The =vaatso aoraetires flat Veit with the beeetaEft *to and stab east to, the pweowia'1ea+s of O.L. 6.18SAl relatina to e lnlaaseo, as that At;aatuts is writemo as of the date ltNME and as it besladit&f be close dad, tits inr44e9 Dead and C we"Mus Tewst tefemd to eb&W and arty bT-iaw asd' raise and vegulatt"4 Ev" tfses to rises adapted thowa sdaev. aid all scatters o!' record stated or refertoed to to the Master Dead rat , ontrieletely, as if each wove biliy let f+birth 1leTr16i am subject to rwi estate taaoes attributable to the unit which atrr aft YOU Acv sed payable, --�. .. e.vs�..:•ais:.yp,l.w-.-� •. •.vax.�»vyesisacmer.,...+••• lit SIMS . tf Wd {Mit to tbm saimis 6DOWbad to a d"d in* Jay 1. pausam am chow Af palascle to J49 P. -cortill deter Ibrah 30, 1944. nmogdW with said NWS Is Nok 17911 Pfta 109. MOM,* beta dqw @"I this Ott do of July, 19". P-6- Caft-111-1- LAI. **"*Man w nummum am, aa. Ady so 1"S. 0 I "t"all ""A"d tba, above-willalw John F *w- A, the fo.tiWaS imt t to bm his ftv Wep" PUbne 4-1111111M joy 41190 at 3119M #10100 k so AUX ON mum a seem CNIO erns MM Na. S0 2: fry tu" Geneeoip ee am is g 2rdstso NAee W vim vaafexis s lmbm awl asb iadi Puna" r . MOM Po X1101. aid DOWS 1W ROMA 1: 11B111bt 1RN: IgIAMllbtfdt i'Algf1' 16 a non -p :alit orge41ivatles duty breate0 41ad oxietiop huger kke In $ of the tsMwrstlb of Ne"0*0ettf with Ate principal place of esiatoaao in Nash Aedover. i>araaobsserete. !kt ft"t as a sett wmese� 4rganigtioa os!eated pmreuaat to. $*novel wre, a.tM to managet sairtai6. proteot 4164 presarre the comma asean -of ANANOW V38V CON00111010k orsuaA by Nastoe . Awed rowded with Xuth twos ppiatrr of looda at seek 1911, pupa 111. '. 1 e$, the liatetiett is a somber of tm a"" of froate" of ANADO VIM,OgNNOa ZWVN ' and ` bas bden apeeiftaalip autbadsed by as eeganiiaeiea's by -tars 4140 y ie r4N of Of sajotitx of the lass# eE Truiteoo In a loll emanated sottng to leiag lkis aetioa oa E behalf of tM Oagsaisatinn ed ,gait .*"ad Y 36 the 11ef"destes are Wis OWWW of a tt 4.0 is meow law 0�101= heated st 1•14 tRelker ie�,e, Nrr1:1s Iledvns• sempe�areetse J and bait' the =ft deovribed is a decd reaordad with the Nord,• Nacos fagietey of b0,440 #g . peek 2765, tees 31,, jwy aWeMtly IMi#ds at 6 Volker Goad, Kirit ii fifth lbidoves, NsaeacAusettse C Ibis utEim is brmmbt pwrawnt to fbas+eal Leaar ,so lay►, aftlax 1 ad amoral mast a.2540, section 5 and 5h«' Ile coastal Gwr a.163A, $"ties per pWLdes in pertinent parts A. bat cab Hair wast 0%41 be paxwiaiauy liable'` far' 631 mums 3saeftily aatossw for Us Noire of the aotrsI espeaters. •, Suoh resit awserle dura at the Commmon nrpenaoe shall constitute a tion am his cane mtoroeablo and pith the priority set forth U *meat Laos, a.254r, Section 6 and me ti 'Ale sy-zw wa at ttnaJ" met emodI tom Soxe F and rule" a" regulations promulgated thereto by the award of Trost**$ provide that the Mount of Saab ah MOIR arca a?harp shall be a perianal liability of tM sent Owners, speed it pot paid when doe► stall constitute a lien on the Unit of the Unit Owner 66sesaed. Furtber, a con -paring Unit Owner *hail be required to psy the outs and ettpen*ee, In- aludinq reasonable attorney'.s lees, located by the. "bed of ftmeteo" is the Collection of Common ares abame* and in the safarcessak of such lion. 1« qhs tpj► "ova *4 Nomor vx= Coatnmmut %=IT and rules cad reyulatiens proswlgstad tMrato r' �•.s.�•4. 4.. _.A�I : '.'?i','.' -.V . '�.� •' _•r � .' ',,'Y''�� �.� '1', g": I'�ij.t r i' . k 4�- �.IwMM�11U•.�ww�..�rrrrlrnr w.r�..n..•.`. _ _.__...... and bait' the =ft deovribed is a decd reaordad with the Nord,• Nacos fagietey of b0,440 #g . peek 2765, tees 31,, jwy aWeMtly IMi#ds at 6 Volker Goad, Kirit ii fifth lbidoves, NsaeacAusettse C Ibis utEim is brmmbt pwrawnt to fbas+eal Leaar ,so lay►, aftlax 1 ad amoral mast a.2540, section 5 and 5h«' Ile coastal Gwr a.163A, $"ties per pWLdes in pertinent parts A. bat cab Hair wast 0%41 be paxwiaiauy liable'` far' 631 mums 3saeftily aatossw for Us Noire of the aotrsI espeaters. •, Suoh resit awserle dura at the Commmon nrpenaoe shall constitute a tion am his cane mtoroeablo and pith the priority set forth U *meat Laos, a.254r, Section 6 and me ti 'Ale sy-zw wa at ttnaJ" met emodI tom Soxe F and rule" a" regulations promulgated thereto by the award of Trost**$ provide that the Mount of Saab ah MOIR arca a?harp shall be a perianal liability of tM sent Owners, speed it pot paid when doe► stall constitute a lien on the Unit of the Unit Owner 66sesaed. Furtber, a con -paring Unit Owner *hail be required to psy the outs and ettpen*ee, In- aludinq reasonable attorney'.s lees, located by the. "bed of ftmeteo" is the Collection of Common ares abame* and in the safarcessak of such lion. 1« qhs tpj► "ova *4 Nomor vx= Coatnmmut %=IT and rules cad reyulatiens proswlgstad tMrato r' �•.s.�•4. 4.. _.A�I : '.'?i','.' -.V . '�.� •' _•r � .' ',,'Y''�� �.� '1', g": I'�ij.t r i' . k i 1118138 by the Now provide thak the coadesietwe bard of lruatoes- BU*is hots the poor t4 levy late ame w is the saawnt -oft logo png moth of me amts lest paid where due aefalnst unto oe6are for san*pay"nt of ooII arca owls$ and tha4 f ellee6les of GM4 late eh"s way be Worosd as 11 the late -a"" Ware *~is orn Ourga6. g. in ne"danee with the gy-Lwe ¬ ales "d regulationsp tb bard of tivar:ees have dilly assessed Lets cholvss against, the 0sleedsst far violation of the iy-"" sad auios and rapatatiaee of the 17ondomiAi60.. - !. #A of lits to 1"0 the gslsedaati erere Jateliy and severally indebted ka tow pWotift Soy snpsid oras ahatleso lat4 fres• and eupsness, and tskoresk them" to :the %out amount of $100".04. The oessadasts beve failedo roluasd and nplootrd to soy 6414 ow6 daspita dsmand is Writing far seas. 011 M AI M P the tlalMtiff peaty thot 4040aht, bo after -cosines the blendseta ter follows as..tim gsent tent the notatil0 malost the aefawarits. ysiatir and Severally to the sabov t d $1o409o40 tot watery draaspss Goya 1"torest tbot*w puo esaw"ble attasosyoa fors ism Bred to puMUM tt}ie as Jttdgt n sou the !14166111 AVOINu4 tete Oeloadestap #;lady ad gMftUf# to the aw6uSt Of .611 USPIO OOMS 4M 09rgs6r lots. ge"i !less. alterwy'o too MA 01"w"n reseed. O"int the delesiarN ! al o Pon~ Adbeein" Roca"40 Jay 661994 xt 2AGM #14169 subms"fit to fty, it IM plus lnt�Kask :'i Um"" t4 the ditto the 4mdpWjjt js 4*"%Qd On'd IN ORUM it obtained. Retablista"t of a ties against the 40serbed above is taimir *9 tine qUiAtile Womat to the powlel"s, of CMI&I low, 0,183A, $motion to Orlackiwo Iran "0 date of the illNp of 018 -Owlsint with the C&Wt to 111ho EM SMUnt of the 114kintiff Is daws"s beroin* 1+' That the Court- SHOW the 4014 of the Doe fonds e' nieius nnit VUVMuan% to tM r"vi, go Ito of "agra ' L4v$ c. e. 3enklona and M to order to satisfy the 1484 "ObLIM" IS ftrOVCM& C above. 16 Sub fUtb*r VOILOf to' this honorable C*kvtt Ghali d*w just. Mt"" VZO O=wxtnm AWWJMIOM by its attorawy, WOO (NMI de3-1411 Pon~ Adbeein" Roca"40 Jay 661994 xt 2AGM #14169 A NO W Ln y y w 6 0 a� G7 a A N y y w 6 G7 a A N � � o A 0 U W O e s v rO cl O N p ,Ln O b CA N r o O [� O O �o r U N O 00 .4: Uo or a C — a cc as U y y w 6 OWNER ADDRESS DATE NORTH ANDOVER HEALTH DEPARTMENT 27 Charles Street • North Andover, MA 01845 Tel. 978 688-9540 • Fax: 978 688-9542 email: healthdept@townofnorthandover.com Complaint Investigation/Inspection Report +l - U ' ' 4 Z ca Pnr)' _ 1^,L' a►- n v� e ��' GL Jt'!nJ-1CIIX) e)V-t a,pjoe�rp!'la±i e S 2,-r y 9^ If � S��iv-� gy'► -tom � � ��� ►' Y- � � 1L'C;`r S1a-V c212 Il f�� h !.J r S f reL-►_ H� Galst� s12-(`�� -e7& Y. - i Rev. 6/04 �Dt. Z NORTH ANDOVER HEALTH DEPARTMENT J 27 Charles Street • North Andover, MA 01845 Tel. 978 688-9540 • Fax: 978 688-9542 email: healthdept@townofnorthandover.com Complaint Investigation/Inspection Report OWNER I, b ADDRESS _ DATE D 11 � f19Cr_ CZ �� t ✓`k A "M�cL, 71' V q O N O aA qq Q ar � o � 0 Ey Q% U 'C O � sem. � v�Ra.N�a o � acn O N 0 U zo d c ui c 0 . 15 0 U) M a U c a� J N N O O N C0 2 O N :7 � o 0 U 'C a0 a � � e H U 3 o o U�ornxaach ti rn b� a O y G cu o � acn O N 0 U zo d c ui c 0 . 15 0 U) M a U c a� J N N O O N C0 2 O N :7 NO RM 1'45 This certifies that ......... �� {... has permission to perform ...�....5 ................................. plumbing in the buildings.. ............. 6pe.Z at ... .., ................. � ' �� ....................... North Andover, Mass. ..................................................................... Date.... d.�.. �.�. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING Fee .*5..... Lic. No. la!) .................................PLUMBBIN...I...G ........INSPECT............O...R ...................... Check # M� INSUKAN" 4WV=r%+vr-: I have a current liabilityinsurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES E] NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [j OTHER TYPE OF INDEMNITY C] 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 ® AGENT El SIGNATURE OF OWNER OR AGENT I hereby certify that allR the details and information I have submitted or entered regarding this application are true andVi! to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in comp' egwit e nt vi S� Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME lEric C. Foster LICENSE # 9311 SIGNA MP[3 JP[] CORPORATION [# PARTNERSHIP# LLCE1# 3092C COMPANY NAME Eric C. Foster Plumbing & Heating LLC ADDRESS 145 Stedman Street CIN Chelmsford !I STATE MA ZIP 101824 1 TEL 978-256-5976 FAX 978-452-4711 CELL I � u EMAIL It, Vdv� mail � �� 1k 0 FOR A PERMIT TO PERFORM PLUMBING WORK MASSACHUSETTS UNIFORM APPLICATION MA DATE IQ -1 a -1 PERMIT # JLL CITY OWNER'S NAME L. JOBSITE ADDRESS ,�G� TEL FAX P OWNER ADDRESS TYPE OR OCCUPANCY TYPE COMMERCIAL ® EDUCATIONAL RESIDENTIAL (d PRINT ® RENOVATION: ® REPLACEMENT: PLANS SUBMITTED: YES[] NO(] Ed CLEARLY NEW: 4 5 6 7 8 9 10 11 12 13 14 FIXTURES Z FLOOR- BSM 1 2 3 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR 1 AREA DRAIN INTERCEPTOR INTERIOR KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL ,SERVICE I MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER INSUKAN" 4WV=r%+vr-: I have a current liabilityinsurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES E] NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [j OTHER TYPE OF INDEMNITY C] 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 ® AGENT El SIGNATURE OF OWNER OR AGENT I hereby certify that allR the details and information I have submitted or entered regarding this application are true andVi! to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in comp' egwit e nt vi S� Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME lEric C. Foster LICENSE # 9311 SIGNA MP[3 JP[] CORPORATION [# PARTNERSHIP# LLCE1# 3092C COMPANY NAME Eric C. Foster Plumbing & Heating LLC ADDRESS 145 Stedman Street CIN Chelmsford !I STATE MA ZIP 101824 1 TEL 978-256-5976 FAX 978-452-4711 CELL I � u EMAIL It, Vdv� mail � �� 1k 0 C 0 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Iliennt Name (Business/Organization/Individual): Eric C. Foster Plumbing & Heating LLC Address: 145 Stedman Street City/State/Zip: Chelmsford, MA 01824 Phone #: 978-256-5976 Are you an employer? Check the appropriate box: 1. I am a employer with 22 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ 1 am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t employees and have workers' comp. insurance.$ 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.0 Plumbing repairs or additions 12.17-1 Roof repairs 13. ❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation p lio cy 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, tContractors 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 Company Name: Guard Insurance Group Policy # or Self -ins. Lic. #: ERWC321586 Expiration Date: 6/11/15 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 and penalties ofperjury that the information provided above is true and correct. Sisnature: Dat e Phone #: Official use only. Do not write in this area, to be completed by city or town official. City or Town: Issuing Authority (circle one): Permit/License # 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #•