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HomeMy WebLinkAboutMiscellaneous - 7 CIDERPRESS WAY 4/30/2018 \r� i AMERICAN CLAIMS SERVICE ASSOCIATION ENT INDE7ENDENT "Ics INSURANCE MULTI-LINE ADJUSTERS DJUSTi}S FDIC vl(F BUILDING COMMISSIONER OR BOARD OF HEALTH OR INSPECTOR OF BUILDINGS BOARD OF SELECTMAN 1600 Osgood Street North Andover, MA 01845 RE: INSURED: Alexandra Mandel PROPERTY ADDRESS: 7 Ciderpress Way, North Andover POLICY NUMBER: 1158753 LOSS OF: 06/23/14; Water Damage FILE/CLAIM NUMBER 30871 PD Claim has been made involving loss, damage or destruction of the above-captioned property, which may either exceed $1, 000. 00 or cause Massachusetts General Laws, Chapter 143, Section 6, to be applicable. If any notice under Massachusetts General Laws, Chapter 139, Section 3B is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim file number. Craig Gillespie Claims Representative On this date, I caused copies of this notice to be sent to the persons named above at the addresses indicated above by first class mail. Unless we hear from you within the next 10 days, we will not be obligated to pay any portion of this claim to you. Date 06/25/14 7 KIMBALL LANE, BUILDING C, LYNNFIELD, MASSACHUSETTS 01940 TELEPHONE (781) 245-9516 • FAX: (781) 245-1077 Date. 4 "ORT" TOWN OF NORTH ANDOVER ° PERMIT FOR PLUMBING ,SSACMUS� This certifies that . . . . . .f.' /I . . . . . . . . . . . has permission to perform . . . . . . . '. ... . . . . . . . . . . . . . . . . . . . . . . . . . plumbing in the buildings of . . . . . . . .. . . . . . . . . . . . . . ... . . . . . . at . . . . . _.,.c.��.1.r'�,i. .S,S. . . . . . . . . . . . . . . . . North Andover, Mass. Fee. . `'. . . .Lic. N o.. �?!$ ?. . �.`. . . . . . . . . . . . . . f:. . PLUMBING INSPECTOR Check ff J � SUJ MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS . Date Building Location Q,�Qdi� SS Owners Name Permit# " Amount T�pe of Occupancy New Renovation 0 Replacement ❑ Plans Submitted Yes ® No FIXTURES Cn z z w HCn a H 21� a,� a A A a H A �B l��v>Hrlr ZDFL OK 3MFLOCR 41 1[1+ DCR sl>At FIS snHFLOCR pmtHJ0CR sIH FLOCK (Print or type) cdA /� Check one: Certificate / Installing Company Name / / ( Ei Corp. , Address El Partner. Business Telephone (a p M:–/ 4 ElFirm/Co. Name ofLicensed Plumber: PV0 L 4A,(/1 Insurance Coverage: Indicate the of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity F1 Bond ❑ Insurance Waiver: I,the undersigned,have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner Agent E 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 Permit Issued for this application will be in compliance with all pertinent provisions of the Massachus S to P mbi g Code ter 142 of the General Laws. By: -s—ignature of Licensea PlumDer Type ofPlumbing License Title City/Town Incense NUMDer Master Journeyman ❑ APPROVED(OFFICE USE ONLY u The Commonwe(LIth of Massachusetts Department of•£ndastr ial Accidents t Office Of16ivestbQtions 600 Washington Street Boston, 02III www.1n4zS&9ov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/ lectriciaz�s/Flumbers A.n licant Tnfnrmafion Please Print Legibly Name(Business/Organization/Individual): Address: City/State/Zip: Phone#: -Are you an employer?Check the appropriate box: I.❑ I am a employer with 4. ❑ I am a FE] ype of project(required): tor and employees(full and/or part time), have hired the Sub-contractors* ❑Net-construction e 2.❑'I am a sole proprietor or partner_ Misted on the attached sheet Remodeling ship and have no employees These sub-contractors have working forme in any capacity. workers' comp,insurance. 8' ❑Demolition [No workers'comp. insuranCe 5. ❑ We are a corporation and its 9. ❑Building addition 3.[1required.] officers have exercised their 10.❑Electrical repairs or additions .1 am a homeowner doing all work right of ex Myself � empiion per MGL .I 1.EJ-Plumbing repairs or additions y [No workers comp, c. 152,§_1(4),and we have no in required.] t employees. [No workers' 12 0 Roof repairs . MP-insurance,required.] 13.[]Other re ASS'applicant that.^.I:."•=-.ire box%#' m`!si; Cf ..:the se MI out ection below=60 homeowners who submit this affidavit indicating they dog^aII: *Contractors Fh- checl,tt-bo~ s `gad'��hireoutside coaaactors dist su—,,,i[a new affidavit indicating such. mom'a chE i ail adtiirionaI sheet showing the name of the sub-contactors and their workers'comp. mP• information I am an employer that isproviding workers'compensation irz surance for my employees Beloit/is thepolicy 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 declarationpage(showing the policy number-and expiration date). Failure to secure coverage as required under Section 25A ofMGL 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 Investigations of the DIA for insurance coverage verification Office of I do hereby cer fy under the pains and penalties of perju?y th�zt the information provided above is true and correct Sigglature: _._ Date:.-. _. Phone#: [Issuirtgg l use only. Do not write'in this area, to be completed by city or town offcczaL r City Town: PermitUcense# Authority-(circle one): d of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5Plumbing Inspector rt Person: Phone#. Information an- d Instructions Massachusetts General Laws chapt-r 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statut;,an employee is defined as"...every person in the service of another under any contract of hire, tress or implied,oral or written." An employer is defined as"an individual,partnefship,-associartion, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise,and including t7ae Iegal representatives of a deceased employer, or the receiver or trustee of an individual,partnership,association om7 other legal entity,employing employees. However the owner of a dwelling house having not more than three apartroz eats and who resides therein,or the occupant of the dwelling house of another who employs persons to do maint'-Mance,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 e:mployer." MGL chapter 152,§25C(6)also states that"every state or local licensing'aDency 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 um-t2 acceptable evidence of compliance with the;ns,raw, requirements of this chapter have been presented to the contracting authority.' Applicants • Please f lout the workers'compensation of idavit 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)- *.no employees other than the members or partners,are not required to carry workers'comp enation in cu_ran ce. 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&tire to sign and date the affidavit. The affidavit should be.m nue that e a hicadon r f nP fWo 7 t d to e ct�y or w�ilia she r rpt'or licevse 4s being rea.�estsa,'nat epartwefit.of Industrial Accidents. Should you have any questions regardir s Fie law or if you are zre66/J red to obtain a workers' compensationpol cy,please call the Department at the numbe=r 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'&space at the bottom of the affidavit for you to fill out in the event the Office of lnvestigations has to contact you regarding the applicant Please be sure to fill in the permit/lic-rise number which will be-used as a reference number. In addition;an applicant that must submit multiple permit/license applications in any given years 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 lie to than 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,telephono and.faxnumber— The Commonwealth of Massachusetts. Department ofIndustrial Accidents -O ce of Inies igations 600 Washington Street Boston,MA 0211 I Tel. # 617-727-4900 ext 4-0..6 or 1-8 T7-MA s.sA.FE Revised 5-26-05 Fax#6.17-727-7749 � '� ' -vrvrw mass._ ovfdia Date. . . �l.f . . . ..... T/y Of 3� TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION S^CHUSEt This certifies that . . . . .l•.r. .�. . . . . . .��`�. . . .!r�.f. . . . . . . . . . . has permission for gas installation . . . ./z::. . . . : . . '. . . . . . . . . . . in the buildings of . . . . . . . . . . . . !.. '. .. . . . ... !:� : .s. . . . . . . . . . . . at . . . . . . . t !:. .?). . . . . . . . . . . . .. North Andover, Mass. Fee.,. . �?L. . . Lic. No.. ' .'. .'.'. . . . . . . . . ��i��. . . . . . . . . . . . . GAS INSPECTOR Check# _ 72 `; ) J v MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS FITTING (Type or print) Date -711 WA) NORTH ANDOVER,MASSACHUSETTS Building Locations / Cif &��S Permit# Amount$ Owner's Name L 4 New Renovation ❑ Replacement ❑ Plans Sub ed ❑ d U z 99 a m x C7 G a F O Z x W d w O CCCCdLLLL COO W FG U U 4 0 W5 OyF W > Z a O ar. 17 >4 W) FO LT, a a U U > o�. SUB-BA SEM ENT B A S E M ENT 1ST. FLOOR 2ND . FLOOR 3RD . FLOOR 4TH . FLOOR 5TH . FLOOR 6TH . FLOOR 7TH . FLOOR 18-T H . FLOOR (Print or type) Check one: Certificate Installing Company Name ❑ Corp. Address ❑ Partner. 0-7 usrness Telephone ❑ Finn/Co. Name of Licensed Plumber or Gas Fitter 14-4, 7/677 INSURANCE COVERAGE Check I have a current liability Insurance policy or it's substantial equivalent. Yes No❑ If you have checked yes,please inqjpate the type coverage by checking the appropriate box. Liability insurance policy 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: Signature of Owner or Owner's Agent Owner ❑ 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 Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Cha 1 f the General Laws. By. Signature of Licensed Plumber Or Gas Fitter Title ❑ Plumber /r f' 7 City/Town ❑ Fitter License Number Master APPROVED(OFFICE USE ONLY) ❑ Journeyman r r The Commonwealth of Massachusetts Department o f Industrial Accidents Office of investigations 600 Washington Street Boston, MA 02111 www.mass.g ov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lea><bly Name(Business/Organization/Individual): Address: City/State/Zip: Phone#: 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 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 t ?• ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. com . insurance 5. 9 Building addition [No workers p.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.❑Plumbing repairs or additions myself. [No workers' comp, c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.] t employees. [No workers' comp.insurance required.] 13.❑Other ; any aplicaat that check -box#I must also fill out the sectio^bellow s-N."iaR _ w� o 'comu�sstion no?icy infonaa ion. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. lContractors that check this box must attached an additional sheet showing the.name of the sub-contractors and their worker;'comp,policy information. lam an employer that isproviding workers'compensation insurance for my employees. Below is thepolicy andiob site information. Insurance Company Name: Policy#or Self-ins.Lie.#: 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 Si ature: Date.: Phone#: Official use only. Do not write in this area, to be completed by city or town officiaL Cita 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 an 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 p=rson 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 apart caents 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 coxnpliance 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 stare to sign and date the affidavit. The affidavit should be returned to the city or town that the applicadon 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 m 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 burn 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 east 406 or 1-877-MASSAFE Revised 5-26-05 Fax#617-727-7749 v nArv,.mass.-Qov/dia Date.-...... "'..12-... f �apRTM 4 /� 3?;a_�,``°:•_�."�o� TOWN OF NORTH ANDOVER \, A PERMIT FOR WIRING CHUS This certifies that ......................!el. !9 4........ has permission to perform T''� ©� ...�/�12AI7-.. �r���7 wiring in the building of..... ....ff.(w.&....az.y...4.r— (mak}. ,North Andover,Mass. .... . .......... .......^^..`.... ........................... . Fee.: S. ... Lic.No.!.. }�-� ............. i rRICAL INSPE Check # 27 �I 0 6 L,. 9 a - - Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. ID[-�-L Occupancy and Fee Checke BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical CodeC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 2-1 t t2- -City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) G SJ 0 QH O'SS w Owner or Tenant "r— Telephone No. (�7 -?j63 j Owner's Address 12-1 Is this permit in conjunction with a building permit? Yes ET No ❑ (Check Appropriate Box) Purpose of BuildingUtility 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: U- ,-o Completion o the ollowin table maybe waived by the Inspector of Wires. No.of Recessed Luminaires 1' o.o No. Ceil:Sus Paddle Fans No.of Total "1 p•(Paddle) Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires 40 Swimming Pool AboveElIn- Elo.o Emergency Lighting rad. rnd. Batte Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS I No.of Zones No.of Switches No.of Gas Burners No.of Detection and fl Initiatin Devices No.of Ranges No.of Air Cond. Tonal No.of Alerting Devices No,of Waste Disposers Heat PumpNumber .Tons KW........... No.of Self-Contained Totals:I Detection/Alerting Devices No.of Dishwashers S ace/Area Heating KW Local❑ Municipal [J Other p g Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Eq uivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value 9f E ectrical Work: Coo., ` (When required by municipal policy.) Work to Start: t L- Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such cover is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE [`BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME:��n�.vl i4 L �l-[%C�•t��G_ LIC.NO.: M,►24"'(,1 Licensee: A-t kC_, 0.,j4-v` Signature LIC.NO.: (Ifapplicabl ent r"exempt"in the license number line.)- Bus.Tel.No.; Z- Address: `V - N Alt.Tel.No.:9 *Per M.G.L c. 147,s.57-61,sec rity work requires Department of Public Safety"S"License: Lic.No.-�- OWNER'S 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.$ . r ELECTRICAL PE+RMU No., :4 SPECUON REPORT. ) LEC'TRTCAL IWSP]ECTOR-- Z. OUC7 .XN_SP C IO_N_ Passed--[ ] Failed--[ ] Re-inspectionrequizecT($50.00)-•[ ] ikspectors'comments: (Inspectors'Sigratvxe no inztials} - Date rlk')WAL INSPECTION; Failed--[ ) Re-inspection requiued($50.00)--[ors'comments: - fts hectors'Sign re no initials) Date i 3.UNDER GROUND WSPECZ`ION: Passed—[ j Failed—j ] Re-inspection required($50.00)- [ ] Inspectors'comments: (Inspectors'Signature-•no initials) Date 4.INSPECTION—SER VICE: - DA! ,CALL E1)NATIONAL G M; NA1YlE•. Passed—[ ) Failed—[ ] Re-inspection required($50.00)-[ ] Inspectbrs'commenfis: (luspectors'Signature-io initials) Date 5.INSPECTION•-OTHER:' Passed—[ j Failed—r Re-inspection required($50.00)-1 7 Inspectors' coDinxents: (Inspectors'Signature••no lwffals) Date DO OR TAGS.ARE TO BE FMLED OUT AND LEFT ON SITE 1F THE AREA TO BE INSPECTED IS NOT ACCESSIBLE AND A RE-INSPECTION OF X50,00 XS TO BE CHARGED. a b The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 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): L« Address:_ ��, R,� rpm N •-�� City/State/Zip: Com,4s�L Phone V6 Aree u an employer?Check the appropriate box: Type of ject(required): 1.a I am a employer with 4. ❑ I am a general contractor and I 6. 2 New construction employees(full and/or pdrt-time).* have hired the sub-contractors ' 2.El 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 10.0 Electrical repairs or additions required.] officers have exercised their 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.]t employees. [No workers' comp.insurance required.] 13.❑ Other *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 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 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 ame:_Policy#or Self-ins.Lic.#: Expiration Date: \ Job Site Address: C�l c S l City/State/Zip: J-110, A_�pyf:a,C Attach a copy of the workers'compensation policy decl ration 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. Ido hereby certify nder the pains and penalties of perjury that the information provided above is true and correct. Si nature: ��� � Date: — l Z.___ Phone#: 1 7 fS 3 —2�'—o S"/D Z 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#: r. �1 J 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 r Please fill out the workers' compensation affidavit completely,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 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 f 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 burn 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 1-877-MASSAFE Revised 5-26-05 Fax# 617-727-7749 www.mass.gov/dia .0 4 / ti / Date...�P...._a:. ...... NORT" °ft"`°:•�"° TOWN OF NORTH ANDOVER PERMIT FOR WIRING ��SSACHusE� This certifies that 4��" has permission to perform ...��al .................................................................. wiring in the building of... T-ic at.......l... �E/Z �jC. ...... .......... ... .North Andover,Mass. Fee............ . '. Lic.No3 �� '�� .. .... ............ .. ... ..... .. ....... LECTRICALINSPECTOR Check # Commonwealth of Massachusetts Official Use only HELMDepartment of Fire Services Permit No. ��' BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked �Vj [Rev. 1/07] (leaveblank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEQ) 527 C R 12.00 (PLEASE PRINTININK OR TYPE ALL INFORMATIOl9 Date: 6 0 City or Town of: NORTH ANDOVER To.the Inspector of fres: By this application the undersigned ves notice of his or her intention to perform the electrical work described below. Location(Street&Number) G/1'� �S-S �✓/� Owner or Tenant c. Md✓J L L- Telepho a No. Owner's Address o�l d C Is this permit in conjunction with a building permit? Yes No �. ❑ (Check Appropriate Bo ) Purpose of Building �, ry&Ijn 7'r e Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd❑ No.of Meters New Service Ifa2 Amps1,,2'f Volts Overhead❑ Undgrd No.of Meters Number of Feeders and.Ampacity, Location and Nature of Proposed Electrical Work: �r .✓ &CIA Completion of the followin table m be waived b the Inspector of Wires. No..of Recessed Luminaires No,of CeiL-Susp.(Paddle)Fans No.of Tots—d— iTransformers. KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires SwimmingPool A ove - o.o Emergency g d• ❑ d. BatteryUnits No.of Receptacle Outlets No.of Oil Burners .�: FIRE ALARMS No.of lanes No.of Switches No.of Gas Burners INo.of etection and Initiating Devices . No,of Ranges No.of Air Cond. Total Tons No.of Alerting Devices No:of Waste Disposers eat Pump umber Tons � o.o ontaine Totals: Detection/tllertin Devices M No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other No,of Dryers Heating Appliances KW Security Systems:" o.o atero.of No.of Devices or Equivalent Heaters KWoof.Signs Ballasts. DataNWiring: o Devices or E uivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications icing: OTHER: No.of Devices or E uivalent. Attach additional detail if desired,or as required by the Inspector of Wires, Estimated Value of Electrical Work (When required by municipal policy.) Work to Start Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE 2�—BOND ❑ OTHER ❑ ,(Specify:) t" I certify,under the airs and enalties ofperjury, fiat the information an this application is true and completes FIRM NAME: e, i„ ,�� C . LIC.NO.: Licensee: �^ Signature LIC,NO.: ' (If applicab a enter"exempt"in&Zjr cense number line.�Dp Address: rs-r�7 S � Bus.TeLNo.:'C1i Alt:Tel.No.: �*Per M.G.L c. 147,s.57-61,security work requrres eartment of Public Safety"S"License: Lic.No. OWNER'S 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:$ 6z C 2 ' Meetinghouse Commons LLC 115 Carter Field Rd. North Andover,MA 01845 Phone: 978-687-2635 Fax: 978-689-2310 March 14, 2011 Mr. Peter Murphy, Electrical Inspector Town of North Andover Building Department 1600 Osgood Street North Andover, MA 01845 RE: Electrical Contractor at 6 Ciderpress Way Dear Pete, As discussed, we are releasing the previous electrical contractor at 6 Ciderpress Way (building permit#124-2011), which was Kevin Warren Electrician. This work was completed and inspected through the rough stage as of September 20, 2010. We will now continue with the finish portion of the work at this location with Brimac Electric. Please feel free to contact me with any questions or concerns, or to address any administrative items. Sincerely, omas D. Zahoruiko, Manager