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HomeMy WebLinkAboutMiscellaneous - 65 BRIDGES LANE 4/30/2018 (2) ® i 65 BRIDGES LANE /�--- 2101104 000 0 I PO Box 55098 Boston,MA 022055098 617-951-050^--.._ .r r Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS, Ch. 139, Sec. 3B To: Building Commissioner or Board of Health or Inspector of Buildings Board of Selectman City Hall City Hall NO ANDOVER, MA 01845 NO ANDOVER, MA 01845 RE: Insured: RICHARD M STANLEY and LINDA A STANLEY Property Address: 65 BRIDGES LANE,NO ANDOVER, MA Policy Number: HMA 0222247 Claim Number: BOS00061450 Date of Loss: 2/7/2015 Company: Safety Indemnity Insurance Company Claim has been made involving loss, damage or destruction of the above-captioned property, which may either exceed $1,000.00 or cause Mass. Gen. Laws, Chapter 143, Section 6 to be applicable. If any notice under Mass. Gen. Laws, Chapter 139, Section 3B is appropriate,please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim number. Lisa Monette Claim Examiner 5/28/2015 Safety Insurance Company Homeowners Claims Unit P. O. Box 55098 Boston, MA 02205-5098 Phone: 857 233-8618 Fax: (617) 535-5833 Email: lisamonette@safetyinsurance.com Date.3�3�,��p.. . . . ... .. TH OE,NOR14, o? TOWN OF NORTH ANDOVER p PERMIT FOR GAS INSTALLATION r . 'Y SA US This certifies that . . . fi'.I ��./?E: . . .,l���c. . f? !" . . . . . . . . . . 1 has permission for gas installation . . t�.N. . ` . . . . . . . . i . .t. . in the buildings of . . . /C.? . . . . . . . . . . . . . . . . . . . . . . . . . . . at . . ��.�!�.�.`1S t f L� . . . . . . . . . . , North Andover, Mass. Fee.3 . . . . Lic. No.14 . . . . . . . . C ..:._, . . . . . . . . GAS INSPECTOR Check# 7165 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) fl- NO. ANDOVER ,Mass. Date MARCH 25 2010 permit# oc� 65 BRIDGE LN. RICHARD STANLEY Building Location Owner's Name Owner Tel# 978-686-8131 Type of Occupancy RESIDENTIAL New FV1 Renovation❑ Replacement Plan Submitted: Yet No[:] FIXTURES `n4 V W � UW � � m Q) r1l 0 a S 0 w W o xw x - 40 •S zz 1:4E ¢ > z z ° F W S V` m W ¢ W W OF 55 a W Q W S x a > z W w to W Z d CL W ¢ W P F x O F Z J H z E, FW., W O O > W F U - W Z Q W Q ax >+ pa z O z �� O to W 2 0 om`) 2 Cw 3 A t¢7 a a > A a F O w SUB-BSMT BASEMENT 1ST FLOOR s ND 2 FLOOR 3RD FLOOR 4T"FLOOR 5T"FLOOR 6T"FLOOR 7T"FLOOR 8T"FLOOR Installing Company Name Eastern Propane & Oil, Inc Check one: Certificate Address 131 Water Street Corporation Danvers, MA 01923 Partnership Business Telephone# 800-322-6628 Firm/Co. Name of Licensed Plumber or Gas Fitter ROBERT WHITE INSURANCE COVERAGE: I have a cur liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. Yes ✓ No ❑ If you have c ecked ygs,please indicate the type coverage by checking the appropriate box. A liability insurance policy F✓ Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass.General Laws,and that my signature on this permit application waives this requirement. Check one: Owner ❑ Agent ❑ Signature of Owner or Owner's Agent I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application wiJIobe in compliance with all ertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gen aws. By Type of License: z•Plu ber Signature of Licensed Plumber or Gas Fitter Title fitter �✓y� �7 Master License Number City/Town •-Journeyman APPROVED(OFFICE USE ONLY) Date.Z12.yl U...... . NORTH Of ,ti0A 3? �` TOWN OF NORTH ANDOVER O F ` - PERMIT FOR GAS INSTALLATION s + � p9 �9sSAcNusE`ty y This certifies that A ! �. . . .�!T/P '!�"'1 . . . . . . . . . . . . . . has permission for gas installation . . . . . . . . . . . . . . . . . . - ,, . in the buildings of . ��. . .�n.! ��S. . . . . . . . . . . . . . . 17 , North A dover, Mass. at . . U. U Fee.3 . . . . . . . Lic. No.. . . . . . . . f p— GAS INSPECTOR Check 0 Ti 33 MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS FITTING (Type or print) Date )—A- NORTH ANDOVER,MASSACHUSETTS Building Locations __ S / Permit# Amount$ Owner's Name New Renovation Replacement ❑ Plans Submitted C7 a W ° VO N x rA �. Gw W z v w W w O a O1 c > w ., d F C > W U H z H 9 w F a W W ¢ o o w ° ° W o w 3 v CQ7 .� v a > ❑ a W. p V SUB -BASEMENT � B A S E M ENT 1ST. FLOOR 2ND . FLOOR r 3RD . FLOOR 4TH . FLOOR 5TH . FLOOR 6TH . FLOOR 7TH . FLOOR STH . FLOOR (Print or type) ,,pp / �� Check one: Certificate Installing Company e Name_ .`d / �lr¢/��v+tit _e ❑ Corp. Address S-p 6d��'Pd 2 J <,_ _ Partner. o � /,t'��'�-�----v-- 'mac•rf� ale nuauicsa 1 cicpnone -Q y a �Firm/Co. Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. yesNo If you have checked Les,please indicate the type coverage by checking the appropriate box. Or Liability insurance policy Other type of indemnity 1:1Bond 13 Owner's Insurance Waiver: I am aware that the.licensee does not have the Insurance coverage required by Chapter 142 of the Mass.General Laws,and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent g a 1 hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and instal tions performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massach s St Gas Code and C ap t 14 rof the eheral Laws. By. Signature of Licensed Plumber Or Gas Fitter Title 13—plumberZ2) L City/Town 1:3 Gas Fitter icense um er . Master APPROVED(OFFICE USE ONLY) Journeyman 4 , ► .. ,.,, 4 .<... _. .. .. `� �. �I The Commonwealth of Massachusetts Department of industrial Accidents Office of investigations 600 Washington Street Boston, 1114 02111 www mas&gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lec-qbly Name(Business/Organization/Individual): Address: City/State/Zip: Phone#: Are you an employer?Check the appropriate box: 1.ElI am a em to er with 4. Type of project(required): p Y ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet 1 7• ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition ' working for me in any capacity. workers' comp.insurance. [No workers comp.insurance 5. 9. E]Building addition ' p ❑ 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.[]Plumbingrepairs or additions myself. o workers'c � LN comp. C. 152 p , §1(4),and we have no 12. Roof repairs insurance required.]t employees. [No workers' ❑ us comp.insurance required.] 13.7 Other *Any applicant th_9T checks box#1 mus"180 ftll out the section below show;.g=h eir workers!compensationpolic information- Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the.name of the sub-contractors and their workers'omp policy information. I am an employer that is providing workers'compensation insur¢nce for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains 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#: Il Information as d 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 apartrnents and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented.to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)narne(s),address(es)and phone number(s)along with their certificate(s)of r 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 Stmt Boston,MA 0.2111 Tel. # 617-727-4900 ext 406 or 1-877-MAS.SAFE Revised 5-26-05 Fax# 617-727-7749 wv<rva.mass._govf dia Commonwealth of Massachusetts - - W City/Town of NO Andover 1 C 2014 System Pur��ping Record Form 4 DEP has provided this farm for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Hsalth or other approving authority within 14 days:rom the pumping date in accordance with 310 CiViR 15.351. A. Facility Information Important:When filling out forms 1• System Location. on the computer, use only the talo 65 Br LAn! key to move your Address --- —_ � Cursor-do not No Andover MA I use.the return � �-....T� _.._�.,_.. .�-- _..—• -- — :. key.' Qityfi"own Mate Lip Code 2. System Owner: tsb Stanley � �_ Name "Y Address(iF diFferent From location) Cityll'own State Zip Code Telephone Number B. Pumping Record 1. Date of Pum ic te15— aa ae 2. QuantitY Pum ed: Gallons 3. Type of system: _F] Cesspool(s) ., -Septic Tank Q Tight Tank Grease Trap E] Other(describe): 4. Effluent Tee Filter present? © Yes 0 No if yes, was it cleaned? Lj Yes No 5. Condition of S�etem IIII oma ., 5. System Pumped By: Name Vehicle License Number Stewart's Septic Service _ Company - — 7, Location where contents were disposed: Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 Signature of Haul Date i igna t re c Date CSform4.doc+03!06 � System Pumping Recon•Page 1 of 1 1 .. Address 5- 13 P t Title of File Page of Date File Open: Date file closed: Doc Document/Action Title Date of Refer to other Purpose of Document/Action and notes action Document/ document/ filum• Action Department Board of Appeals — Board of Health — Planning Board _ Conseruatiion Commi-ssion — BLildin DDepartmerkt � G TO OF NORTH ANDOV EP, STS M PUMPING RFCORj-) SYSTEM OWNF,Rdt ADDRESS SYSTEM LOCATION �S-k/)k , ot 5 612�d;es line., AD DATE OF PUWNQ:_._f, PUMPED: �:LSSPOOL: NO —_..... YES.. Stlptic Tank: NU, N^ rUKE OF SERVICE: KUU'rINE..._ _ f~Mi✓RUIrNC'Y DEC 0 7 2004 OBSERVATIONS: GOOD CONDITION PULL TO COVER SOV R TGV" �T HEAVY ORWE BAFFLES IN PLACE. �( - ROOTS _. LE;ACKRELD RUNBACK ... J``_ BXCUSIVE SOLIDS—— FLOODED SOLID CARRYOVER,_. _.OTHER EXPLAIN SY.tem Pumpcd by WMMLNTS. �'VN PEN'I'S rKANSF'Ir(KBD I'L) Location 0 Q � No. Date %ORT#1 TOWN OR NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ �,SSACMUSE� Foundation Permit Fee $ Other Permit Fee ov L• $ 3S /D Sewer Connection Fee $ Water Connection Fee $ TOTAL $ 3� 2- S h� Building Inspector } 3 'z_, ,,07722/99 13:26 35.00 PAID Div. Public Works e-.C,r- r?&,`I'�, 7���� PERMIT NO. 28o APPLICATION FOR PERMIT TO BUILD********NORT -I ANDOVER, NIA !r NIAPNO. /e>41) e> I LOT NO. � � 2. RECORDOFOWNERsuB' V DATE BOOK PAGE ZONE 51111 DIV. LO NO. LOCATION L PURPOSE OF BUILDING 14I.� OWNER'S NAME ` NO.OF STORIES SIZE OwNER'S ADDRESS S 2i 1 BASEMENT OR SLAB ARCMT -rEC 'S NAME L• SILE OF FLOOR r1�IDERs I I 2"� 3RD BUILDER'SNANIE S` SPAN DISTANCE TO NEAREST BUILDING DIMENSIONS OF SILLS DISTANCE FROM STREET DIMENSIONS OF POSTS DISTANCE FROM LOT LINES-SIDES Ff'REAR 3o r r- + DINIENSIONS OF GIRDERS AItEA OF LOT' FRONTAGE IIEIGIIT OF FOUNDATION Assmefvs cow IS BUILDING NEW \,'C-S ��� u 9' aL SILE OF FOOTING Y"ERIY/�IT ISSUED IS BUILDING ADDITION MATERIAL OF CIUNINEI' PERMIT I("EItlD'plG IS BUILDIN ALTERATION 6 BUILDING ON SOLID OR FILLED LAND �tl WILL.BUILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECTED To TONVN WATER BOARD OF APPEALS ACTION, IF ANY IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE INS FLICTIONS 3. PROPERTY INFORMATION LAND COST EST. BLDG.COST 3oCb. t70 PACE I FILI.OUT SECTIONS 1-3 EST.BLDG. COSTPER SQ. FT. EST. BLDG. COST PER ROOM ELECTRIC METERS MUST BE ON OU'T'SIDE OF BUILDING SEPTIC PERNirr NO. y AT'I'ACIIED GARAGES NIUST CONFORNI TO STATE FIRE RF.GIIL.ATIONS d. APPROVFD UY: PLANS MUST RE FILED AND APPROVED Bl'BUILDING INSPECTOR BUILDING INSPECTOR ._ DATE FILED OWNERS TEL# Tu►�E 2� 159 SIGN:ITURE OI' OWN ER OR ALI"x110121"LED ACENI' CONTIt.LIC# el FEE: $ �j 7- PE RNIIrGR:kNTE D 7 Revised 5/5/99 JNI 4R �!'Si � 1. Y tAORTFi S copy T D Raw QMME-10 0 E MIT' ISSUED W.4 r; EXR T_ N o. O PERMIT PENDINQ 0 MAP 0 COIN,H L I E dover, Mass., T�Ame 3c:1 PARCELjjq .4l 0RATE D P,0L\I- %C7 .4f BOARD OF HEALTH Food/Kitchen PER 1 D Septic System THIS CERTIFIES THAT............................. "q BUILDING INSPECTOR ......... Foundation has permission to erect.................... on .....4?.5 ....................... Rough to be occupied as................ ....;5. .... ...... Chimney... ... provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTION STARTS ELECTRICAL INSPECTOR Rough .................................................................... .............. .......................... Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done Until Inspected and Approved by the Building Inspector. Burner FIRE DEPARTMENT 2,7- Street No. -J 77_z--�_7 SEE REVERSE SIDE Smoke Det. 1 RICHARD M. STANLEY :60/113 77Jc- LINDA A. STANLEY65 BRIDGES LN. q 53- NORTH ANDOVER, MA 01845 DATE / - ! / ORDER OF PAY TO THE Tl; /`� DOLLARS oe�.ie o�ee�x. NoRTHMARK° BANK �NORTH ANDOVER,MA 01845 FOR p0".fes zl�W IW 4w- �I� N 1:0113026031:- 100316L, 3911' 2775 i • FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. * ** ************************APPLICANT FILLS OUT THIS SECTION********************'tai` APPLICANT ►ti r)ri 4 , 3"k7+-x-- PHONE LOCATION: Assessor's Map Number D PARCEL / / �( Tn0S�c 2'� SUBDIVISION LOT (S) rta`5VT STREET ,e/ CGS -G.r9 ST. NUMBER 6 � ** ******************************OFFICIAL USE ONLY** * **** * * RE ENDATIONS OF TOWN AGENTS: CONSERVATION ADMINISTRATOR DATE APPROVED o2 f `I DATE REJECTED COMMENTS TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD INSPECTOR-HEALTH DATE APPROVED DATE REJECTED SEPTIC INSPECTOR-HEALTH DATE APPROVED to DATE REJECTED COMMENTS /,Q EJ7/11E,e A e&& ) GL)1/,0 lS Ur61 .DE i/C PUBLIC WORKS -SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE lO Revised 9197 jm 1 � t 1 a \ i C •.\ pt IIIA qbl t� z L7- oil o Vi .ND .54'+ `t ®jo 8 cj 7� ' 't•�;I: •� '� $ f re .,� �' :Rec`o,CaM. OVER M� SE 1-7 • ,'II�;I;�;� ,�.l,.�i,�''�b'f�'�,�,,:.',•' �I'„�„I'::, AUG 6.2009 �O�P.hai plorlded "vr.. ., lhl+ Iorin aoerc 'pp1A( fJFNORTH(�NDOVER Oo r' drl`Iliod Io illy loch ac+r�: r pp,;n or c , ALj L.F DEFA /MEN'T, = . .. A' FacilityIn(fo)rHon A -^a � •a� oca�on. - („ '�, Sya►em Owner, �,-,; ,. .R , �•►+ (II/Vf+rinl rpin buVon! I , — ;BIVPumno r d ' Oe.e o!Pvm'pinq �1 3, TO! ql lyil1em;., Ce�9�ool(�� ;'.;.. SevflC Tan,. Q%Ocher (descri0e�;' • htuen,l leo FII►o� �1,9,„J o n i? � Y oCD N 0I a� s r, c:aanao7 '�? es fJ•.i•�lvri:,rl ,r.` . '� i�i•iY 'f',I '''''J'/,I�r'Y,1'fi•��!1!'�',�'1'rY I(�', Vf ' 1 . �^,,�;'!�s��'/�IrfttillM1.'�' �' .'1;l'' �� ';I;� 1 • �• r Yi�lcli Jcenf 1 n•'.'^.:lr _ '1,I '�/•'t'`f! ✓t'w/wl I S�I,rf�'� I 'I��f'I'” fV�; I'1� � l •!' .� ,j;,�a/,� �1i1 IS,11�G 6d,l;I' fS'/,IJjttf.t;�"� �I W er�`�pr�lenU;w@re dl�posea: %•,;rr.; ';'l, S�nllryl of h'lv4(y�,'y,;.,.,,:.,,, �• .;�I .mesa.govldep�weierleDDr9Ye/J✓Iblo(T11J.n:maln