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Home My WebLink AboutMiscellaneous - 63 AUTRAN AVENUE 4/30/2018 (2) 63 AUTRAN AVENUE \ f 2101045.C-0010 pOp -. 0.0 / I I i 330 Bear Hill Rd. Suite 201 Cunnin ham Waltham, MA 02451 (781)890-1696 Lindsey Date: 9/10/14 Building Commissioner/Inspector of Buildings Town of North Andover North Andover, MA 01845 NOTICE OF CASUALTY LOSS TO BUILDING UNDER MASSACHUSETTS GENERAL LAWS, CHAPTER 139, SECTION 3B Claim has been made involving loss, damage or destruction of the property captioned below, which may either exceed, $1,000.00 or cause Massachusetts General Laws, Chapter 143, Section 6 to be applicable. If any notice under Massachusetts General Laws, Chapter 139, Section 3B is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss, and Cunningham Lindsey file number. Insured: Difruscio, Rocco & Heather Property Address: 63 Autran Ave., North Andover, MA 01845 Policy No: FP2498779 Loss of: 9/6/14 Date of Loss: 9/6/14 Cunningham Lindsey File No: 100859569748 Dave Scanlon Title: General Adjuster On this date, I caused copies of this notice to be sent to the persons named above at the addresses indicated above by first class mail. Dave Scanlon Date.. NOR7M 3? �` TOWN OF NORTH ANDOVER • - PERMIT FOR GAS INSTALLATION SACMUSE�t �... This certifies that ./.�. `. . '. . . . . . .... . . . . . . . . . . has permission for gas installation . 'Q. 'P . . . . . . . . . . . . . . . in the buildings of . .��. �l.... �. . . . . . . . . . . . . . . . . . . . . . . . . . at North Andover, Mass. Fee. Lic. No.. . GAS INSPECTOR Check# S 695 MASSA CHI1 SETTS UNIFORM APPUCATON FOR PERMIT TO DO GAS FnTING (Type or print) NORTH ANDOVER, MASSACHUSETTS Date Building Legations Permit# Owner's Name Amount$ New❑ Renovation v Replacement � Plans Submitted ❑ w r:. Cc e a z zz c U {y W ee� a � u w x WW LD ° y°y a o � F C W C x W g w H C > W > O Z W W SUB -BASEM ENT C Qb N O B A S E M ENT U C > Q a 1ST. FLOOR 2N D . FLOOR 3R D . FLOOR " 4TH . FLOOR TH . FLOOR 6TH . FLOOR 7TH . FLOOR. STH . FLOOR. (Print or type) Name Check one: Certificate Installing Address p FU ❑ Corp. Company Partner. usmess a ep one 1. ['Firm/Co. Name of Licensed Plumber'or Gas Fitter INSURANCE COVERAGE 11 I have a current liability lnsurance•policy or it's substantial e i Check one: If you urval have q en Y ve checked yes,please indicate the t Yes .type coverage b No cher Liability � Y ki ty insurance policy ^/ ng the appropriate box. L� Other type of indemnity ❑ Bond 0 Owner's Insurance Waiver. 1 am aware ware that the licensee doe Mass. G snot ha General Laws,and that m signature on this. —" =e the Insurance coverage required by Chapter 142 0 Y ; permit application waives thisP f the requirement. q iremerrt. Signature of Owner or Owner's Agent Check one: I hereby certify that all of the details and information I have submitted ore.. Agent best of my knowledge and that all plumbing work and installations 1 Bred)in above a ii compliance with all pertinent provisions of the Massachusetts PP catron are true and accurate to the Performed under Permit Issued for this application will be in e Code d Chapt 142 df th eneral Laws. By: Signature of Licen Title Plumber Or Gas Fitter Q�Plumber City/To% nm Gas FiLitter Master 'um er _ APPRO V,ED(oFFtcE USE ONLY) Journeyman I I f ..•,,�•r-�acza QJ Massachusetts ( P meat o Ft. De art f Ind vtri-t Accidves. i O fice o .1F Investigations t,. 600 W ashine'toa Street Bastn rz, 1VI,4 (12111 Workers, Compensation Insurance .Hid rnass,gov�dia P Aciavit: guilders/Contractors/Electricians/Plumbers A Iicant Information Name (Busin--ssior Please Print�biv ganization/individtral}; Addrss: City/State/Zip: Phone# Are you an employer?Check the appropriate box: 1.❑ I an a employer with employees4 ❑ I� a 0`'neml contractor and I _ Type of project(required): e(full proprietor part-time).* have hired the sub-contractors b• ❑ New construction �.❑ I am a sole proprietor ar partner- Iisted . ship and have no employees o attached sheet 7• ❑ RemodeIing wori.�ing forme in any capacity. These sul�-contractors have work 8- E] Demolition [Noworkers'comp. insurance 5. �� camp. insurance.. required_] ❑ We are,a corporation and its 9' ❑ Building addition 3•❑ 1an ahomeowner doing 8.11 work Officers nit of have exercised-their 10:❑ Electrical repairs or additions myself. [No workers' "motionMOL comp. C. I$2, l(4j,and we Per e o I I.0 Plumbina repairs or additions insurance required_] t employe— 12.[] Roof repairs S. [No workers' 'r Any appfimnt.that checks box#1.must also'i3fl our the section bew camp,o nsurance reQ►yred 13.❑Other showing their work ] t i-Iamcowners whu submit.t]iis&t�idavit intiicatiit�u,e;,erg�otr: pertsation fi 2Convantars that eheo}:this box mtrst ers'eom Pn o}'into allot tied an additional sheet showing the information, Eh�hire outside coniructors snail submit a new atnriavit indiciin t am v1r e^�lcyer thcti is r rt"�e oft;.. tt co�uactots and to eir workers'tom F ouch. p ovidino w[tr et5'OCt—enNaiion : P.policy i�nnation. . �forrrnatcon. -�surrtnce for M!'employees, Below is lhr o ' Insurance Company Name: p ajo�sire Policy#orSelf.ins. Lid,.#: Expiration Date: Job Site Address: Attach a copy of the workers' compensation ii deela City/St�/Zip: r-ation a Failure to secure coverage as required under Section 25A of l�ae(showin;the poiicy ,number and expiration date fine up to $#,500.00 and/or one-year imprisonment as well MGL c. I52 can Iead to the imposition of criminal penalties of a Of up to.5250.00 a day against the violator. Be advised that as civil penalties in the form cpyof a ST'Dp WpRR O Investigations oftDIA for insurance coverage v:rifi;ati.on_ of this statement ma, OR and a fine be forwarded to the Office of I do hereby certify Umier the pater and penal&: r of perjury,thzfhef or Simafion provided above is true and srtatttre: correct Phone#: Date; official use onip. Do not write in leis area, to be compl��.h 3 C'f.P or town of cia( City or Town: IssuingAutho Permit/L,icense# e riff (circle one): I. Board of Eiealth 2. Bujidiing Department 3. C 6. Other �3'/TOwn Clerk 4. Eiectrfcal fns e P ctor 5. Plumbing Inspector Contact Person: Phone#: 1i11V! wa.LIVU canu i-ast uenons � Massachusetts General.Laws chapter 152 requires all em"i lovers to provide workers' compensatiorfor their employees. S Pursuant to this statute,an employee is defined.as"..tver-y person in the service of another under any contract of hire, express or implied,oral or written.^ i An employer is defined as"an individual,partnership,association, corparation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,,and incluci-iTi.g the legal representatives of a deceased employer,orthe receiver or trustee of an individual,partnership,associati on or other legal entity,employing employees. However the owner of a dwelling house having not more than.three ap,za -tments and who resides therein, or the occupant of the dwelling house of another who employs persons to do runt it►tenance,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 o►r local iicensin;g a°ency shall withhold the issuance or renewal of a ficense or permit,to operate a business or- to construct buildings in the commonwealth for any appiicaat who has Dot 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 ofcompliance with the insolence requirements ofthis chapter have been presented to the contracting authority.". kppficants Please fill out the workers'compensation affidavit com?Vetely,by checking the boxes that apply to yoir situation and,if necessary;supply sub-c6ntra.ctor(s)namm(s), address(es) am.d phone number(s)along with their certificates)of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships(LLP)with no employees other than the members or.partners,are not required to carryworkers'compensation insurance, if an LLC.or LLP does have.. employees, a policy is required. Be advised that this.afficl-avit maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and elate the affidavit Theaffidavitshould r be returned to the city or town that the application for the penn.it or license is being requested,not the Department of Industrial Accidents, Should vou.have any questions res*�rdirg the.�t1, if you are rrqui -„d to obtain a workers' compensation noliay,please call the Depairrin-rit at the ii��nber:listetl belovr. Self-insured companies should enter their self insurance lieges--number on the sispropria�,line. City or Town Officiais Please be sure fhat the affidavit.is complete and printed leThe Department has provided a space at the bottom of the affidavit foryou to fill out in the.event the Office of Investigations has to contact you regarding the applicant Please be sure to fill in the permit11ic=se number which will be used as a reference number. In addition, an applicant that must submit multiple perZnMicmise applications in arty given yew,need.only submit one affidavit indiratina current policy information(if necessary)and under"Job Site Add-ress"the applicant should write"all locations in a(city or town)." A copy of the affidavit that has been officially st3rnped 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 Iicenses. A new affidavit must be filled out each year. Mrh= a horn--owner or citiz--n is obtaining a Iicens� or permit not related to any business or commercial venture (i.e. a.dog license or permit to burnleaves 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 CommonweaLith of M=achusetts Department of lmdmtrial Acrad=ts Office of JEjavestigatiorn 600 Washi ngton Street Boston, MA 62111 Tel. 4 617-727-4900 e�rt 406 or 1-8—/7 MASSAFE Revised 5-26=05 Fax 661 7-7?7-7749 ��'-1'�3SS.DOV�dtB