HomeMy WebLinkAboutMiscellaneous - 64 SAUNDERS STREET 4/30/2018 -64 SAUNDERS STREET
210/029.0-0012-0000.0
Lib�gy" Mutual, Liberty Mutual Insurance
New England Region Central Property Unit
INSURANCE 75 Sylvan Street
Danvers,MA 01923
Tel:(800)566-0323
May 12,2015
Town of North Andover
Attn:Building Inspector
120 Main Street
North Andover,MA 01845
Re: Property Address: 66 Saunders St,North Andover,Ma 01845
Policy Number: H3221824627711
Underwriting Company: Liberty Mutual Fire Insurance Company
Claim Number:031665117-0001
Date of Loss:3/3/2015
Attn: Town/City Official
Pursuant to M.G.L. c. 139, � 3B, please be aware that a homeowners insurance claim has been made
involving loss, damage or destruction of the above captioned property, which may either exceed
$1,000.00 or causes the condition of a building or other structure to render Mass. General Laws, Ch.
143, § 6 applicable. You are required to notify Liberty Mutual by certified mail in accordance with
Mass. General Laws Ch. 175, §99, if you intend to initiate proceedings designed to perfect a lien
pursuant to Mass. General Laws, Ch. 139, S 3A &B, or Mass. General Laws, Ch. 143, � 9, or Mass.
General Laws,Ch. 111,5 127B.
This letter should not be construed as a waiver or estoppel of any of the terms, conditions or
defenses afforded by the policy or applicable law.
Please direct your notice to the attention of the undersigned and include a reference to the above
captioned property address,policy number,claim number,and date of loss.
Sincerely,
Liberty Mutual Support
Liberty Mutual Insurance
New England Region Central Property Unit
1-800-566-0323
Date.......
TOWN OF NORTH ANDOVER
0 .6091ftll 0
PERMIT FOR WIRING
qL
ACHU
This certifies that .......... ....... .............
........... ... .... ............ ... ..... ................
has permission to perform ......... ......S.......... ...............
. ........ .....
wirinw in the building of................
g ......................................
at....6-1.....
.........................................,)North Andover,Mass.
✓ Fee.... Lic.No. 9S o .................. ... .............. . ...............
EilctwcAL h4sPEc-roR
Check #
8 6 7
Commonwealth of Massachusetts
Official Use Only
r
Department of Fire Services F
rmit No. /�7
BOARD OF FIRE PREVENTION REGULATIONS cupancy and Fee Checked
[Rev. 1/07] (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00
(PLEASE PRWflV Nir{OR TYPE ALL INFORMATION Date:
Ci or Town of:
City NORTH ANDD Z
VER
To.the Inspector
By this application the undersigned gives notice of his or her intention to perform the electrical workl
ees abed below.
Location(Street&Number) t> t, vc
Owner or Tenant 0 a,
Owner's Address (a �' U(q 9 Telephone No.
Is this permit in conjunction with a building permit? Yes
�� NO ❑ (Check Appropriate Boz)
Purpose of Building
Utility Authorization No.
Existing Service Amps / Volts Overhead
❑ Undgrd❑ No.of Meters
New Service Amps ____/_Volts Overhead
❑ Undgrd❑ No.of Meters
Number of Feeders and.Ampacity
Location and Nature of Proposed Electrical Work:
Com letion of the ollowin table may be waived by the Inspector of Wires.
No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total
No.of Luminaire OutletsTransformers KVA
No.of Hot Tubs Generators KVA
No.of Luminaires Swimming Pool Above ❑ In
❑ mergency "lig g
d• rnd. Batte Units
- No.of Receptacle Outlets No.of Oil Burners �,
�E rARPvaS Nc. of::.nes
No.of Switches No,of Gas Burners No-of Detection and
tin Devices
No.of Ranges No.of Air Cond. Total Initia
Tons No.of Alerting Devices
No.of Waste Disposers Heat PSP Number Tons KW __ No.of Self-Contained
Totals: Detection/Alerting Devices
No.of Dishwashers Space/Area Heating KW Local❑ Municipal
Connection ❑ Other
No.of Dryers Heating Appliances KW Security Systems:
No.of waterNo. o. No.of Devices or E uivalent
of
Heaters KW os Ballasts Data Wiring:
No.Hydromassage Bathtubs No.of Motors No.of Devices or E uivalent
Total HP Telecommunications Wiring:
No.of Devices or E uiva
OTHER: lent
c7 Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: p( / �--�_
"0 k (When required by municipal policy.)
ti Work to Start Inspections to be requested in accordance with MEC Rule 10,and upon completion.
INSURANCE COVERAGE: Unless waived b p
y the owner,no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including`completed operation coverage of its substantial equivalent The
undersigned certifies that such coverage is in force, and has exhibited roof of same t
CHECK ONE: INSURANCE BOND p o the permit issuing office.
I certify, ❑ OTHER ❑ (Specify:)
under the pains and penalties of perjury, that the information on this application is true and complete-
FIRM NAME:
Licensee: LIC.NO.:
I ,� Signature '
(If applicab e, enter"exempt"in the license number line.) LIC.NO.:_
Address: �,2 jC> ()I(� Ii Bus.Tel.No.:� 6 , 7/�
*Per M.G.L c. 147 s.57-61requires Alt:Tel.No.:
_,-- ,security work D �����'��« r
Department of Public Safe " "
OWNERS Safety S License: Lic.No
INSURANCE WAIVER: I am aware that the Licensee
does not have the liability insurance coverage normally
required by law. By my signature below,I hereby waive this requirement. I am the(check one) ❑owner owner's agent
Owner/Agent
Signature Telephone No. PERMIT FEE: $
l
The Commonwealth of Massachusetts
'
aitrnent De o
P f Industrial Accidents
Office o
.f Investia Q ations
600 Washington Street
dam, L'oston MA 62111
wwrv.rizass.gov/dia
Workers' Compensation Insurance.A:ffidavjt: $uddrs/CAa Icant Information ntractors/Electricians/Pium
hers
n \ Please PrinLeoibiyNELme .
(Business/Organization/individual):Address:
City/State/Zip: �D Phone#: ?l
91 6 45
Are you an employer?Check the appropriate box:
1.❑ I am a employer with 4. ❑ I am a ganeral contractor and I . Type of project(r-equired):
mployees(full and/or part-time).' have hired the sub-contractors 6 ❑ New construction
[2. I am a sole proprietor or partner. Iisted on the attached sheet $ ?. ❑ Remodeling
ship and have no employees These sub-contractors have
workingac
for me in any capacity. workers g ❑ Demolition
P t1'• ' comp. insurance.
[No workers' comp. insurance 5.,E] We are a corporation and its 9' ❑ Building addition
required.] officers have exercised.their 10:0 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
insurance required.] t employees. [No.workers' 12:17 Roof repairs
comp, insurance required.] 13.7 Other
*Am;appli„ant.that checks box#I.must also fill out the section below showing their workers'compertsaiion poiic} information.
t Maintownert w1w subimtl.thls aiidevit indicatitIG tiled-are duiil•-•Eel c:•;:f;:
tContn ctors Thai check this box.must attached an additional sheet showing hen*ne hire�c�u 4iae eoniraciurs must su'omit a new a`ndavii indicating such.
of the s•b_contractors and their workers'comp,policy information.
i am an.employer that rs providing workers'compensation insurance or ,employees. Below is the ofi ,
information fP cy and job site
Insurance Company Name:
Policy#or Self-.ins. Lic.#:
Expiration Date:.
------------
.lob Site Address:
_
City/State
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.5250.00 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.
A
I do hereby ce 0,under the pains and penalties of perjury that the
information provided above is true and correct
}.
Signature: ZL-a
Phone#:
Official use only. Dn not write in this area, to be completed b3; city or town of icial
City or Town: PermitlLicense#
Issuing use
(circle one):
I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
(.Other
Contact Person:
Phone#t
Information 'r .nd 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 "..--�ver-y person in the service of another under any contract ofhire
;
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 inciudin.g 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 ap artments 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 bean employer."
MGL chapter 152,§25C(6)also states that"every state o r 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 mf 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 comps-etely,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 athciavit maybe submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the.affidavit. Theaffidavit 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 regL�-Nrdirg the la a, or if you are required to obtain a workers'
compensation policy,please call the Department at the nm
self-insurance
below. Self insu,-ed con;panies should enter their
self-insurance license.number on the appropriate tine.
City or Town Officiais
Please be sure that the'afdavit 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 mist submit multiple permi0icense applications in an), 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 starnped 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 Iicens- 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. J
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of lidustrial Accidents.
Office of Investigafioas
600 Waslii gmon Street
Boston; 1A G2111
Tel. # 617-727-4900 m-t 406 or 1-8.77-MASSAFE
Revised 5-26=05
Fax 4 617-7-7-7749
W"'.Mass.gov/dia