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HomeMy WebLinkAboutMiscellaneous - 71 PEMBROOK ROAD 4/30/2018Cunningham Lindsey U.S., Inc. P.O. Box 703689 Cunningd.n1 Dallas, TX 75370-3689 Lindsey Telephone (888) 738-8714 Facsimile (214) 488-6766 CLCAT@CL-NA.COM Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS Ch. 139, Sec 3B Building Commissioner or Inspector of Buildings 1600 Osgood Street, Building 20, Suite 2035 North Andover,MA 01845 Claim Number: 3017568 Policy Number: 3017568 04 Company Name: BAY STATE INSURANCE COMPANY Date of Loss: 02/20/2015 Insured: JOSEPH & JAMES D'ANGELO Property Location: 71 PEMBROOK RD, N ANDOVER, MA 01845 Claim has been made involving loss, damage, or destruction of the above captioned property, which may either exceed $1,000 or cause Massachusetts General Laws, Chapter 143, Section 6, to be applicable. If any notice under Massachusetts General Law, Chapter 139, Section 3B is appropriate, please direct it to the attention of the writer. Kindly include a reference to the captioned insured, location, date of loss and claim number. Section 3B. No insurer shall pay any claims (1) covering the loss, damage, or destructions to a building or other structure, amounting to the one thousand dollars or more, or (2) covering any loss, damage or destruction of any amount, which causes the condition of a building or other structure to render section six of chapter one hundred and forty-three applicable, without having at least ten days previously given written notice to the building commissioner or inspector of buildings appointed pursuant to the state building code, to the fire department or arson squad of the city or town and to the board of health or board of selectmen of the city or town in which the same is located. If at any time prior to the payment the said city or town notifies the insurer by certified mail of its intent to initiate proceedings designed to perfect a lien pursuant to section three A, or to section nine of chapter one hundred and forty-three, or section one hundred and twenty-seven B of chapter one hundred and eleven, the said payment shall not be made while the said proceedings are pending; provided, however, that said proceedings are initiated within thirty days of receipt of such notification. Any lien perfected pursuant to section three A, or to section nine of chapter one hundred and forty-three or section one hundred and twenty-seven B of chapter one hundred and eleven, shall extend to and may be enforced by the city or town against any casualty insurance policy or policies covering any loss, damage, or destruction pursuant to which the proceedings to perfect the lien were initiated. No insurer shall be liable to any insured owner, mortgagee, assignee, city or town, or other interested party for amounts disbursed to a city or town under the provisions of this section, or for amounts not disbursed to a city or town under the provisions of this section. 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. Cunningham Lindsey Catastrophe Department cicat@cl-na.com 800-867-3885 i � Location No. DateG /r5 �,. TOWN OF NORTH ANDOVER � A ♦ i .; # Certificate of Occupancy $ r CMUs t�' Building/Frame Permit Fee $ (� Foundation Permit Fee $ Other Permit Fee $ TOTAL $+ Check # �t Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT MEAM BMSMAM OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUII.,DING PERMIT NUMBER: DATE ISSUED: SIGNATURE: Building Commissioneffl or of Buildings Date SECTION 1- SJTE INFORMATION 1.1 Prop y ddress: j� 1.2 Assessors Map and Parcel Number: Map Number Parcel Number 1.3 Zoning Information: Zoning DiArid Proposed Use 1.4 Property Dimensions: LA Area Fronts fL 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided 1 1.7 Water Supply MG.L.C.40. 34) 1.3. Flood Zone Informstioa: 1.8 Sewerage Disposal System: Public ❑ Private ❑ Zaae Outside Flood Zane ❑ Mmici l 1 ❑ On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSI3IP/AUTHORIZED AGENT ' N i -cd 1C;'i �.tr!Ct: No 2.1 Owner of Record C -7/ /ZD Address f/orServic Si re Telephone 2 e f Record: Name Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Licensed Construction Supervisor: Address Signature Telephone Not Applicable 0 License Number Expiration Date 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number ` Address Expiration Date Signature Telephone Ar I SECTION 4 - WORKERS COMPENSATION (KG.L. C 152 f 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building D=it. Si ed affidavit Attached Yes .......0 No ....... 0 SECTION 5 Description of PrOPOSed Workduak aR a ble New Construction ❑ Existing Building ❑Repairs) 0 Alterations(s) 0 Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description 4 Proposed Work: „ CF.VTTnN 6 - WNTiMATR.n rnNCTi2TTVT1rnN rneTC Item Estimated Cost (Dollar) to be Completed bpermit applicant OMCIAI. USE ONLY _ 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) x (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number 0 i VR w11V1\ iV DL' %-%J1nrL151E11 W1Mf4 OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I• as Owner/Authorized Agent of subject property r Hereby authorize to act on t My behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, ,as Owner/Authorized Agent of subject Property Hereby declare that the statements and information on the ,foregoing. application are true and accurate, to the best of my knowledge and belief Print Name Signature of Owner/Agent Date NO. OF STORIES SIZE BASEMENT OR SLAB . SIZE OF FLOOR TIMBERS 1 2 NU 3 RU SPAN DIMENSIONS OF SILLS DIN ENSIONS OF POSTS DIMENSIONS OF GMDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHININEY 1S BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE f W a 0 � W a o ra a � �• � _O H a Ci t� CLezC O O w° U W. a w w°' w m _O a c O o z CL p u .A m Z Q I CO3 Q MOD Q m C as v ev W CO3 O Q .CL Co Q Q C cc y is CM C CID m 3� o C- CL c_< �..1Q 'C 0 CD Z CD CL C LLI W W W U) o ra �• � _O H Ci t� CLezC O O O EQ m _O O �r U Co c C E O y = � C 7 c c •Em m � S 0 ,r e N � 0 tic m ID = m CL p Q w v� • ~ h C �' w = • _ � W E W.,e�O QZ a' 0 Cm0 *0 C* 5 z .0 aim o p u .A m Z Q I CO3 Q MOD Q m C as v ev W CO3 O Q .CL Co Q Q C cc y is CM C CID m 3� o C- CL c_< �..1Q 'C 0 CD Z CD CL C LLI W W W U) ACORDTM CERTIFICATE OF LIABILITY INSURANCE 6/17/2 05 PRODUCER $'ewksbury Insurance 885 Main Street Tewksbury, MA 01876 978-851-9600 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC# INSURED Brandon Giardina Brandon Giardina Construction 26 New Foster Ave Billerica, MA 01821 INSURER A: Western World Insurance Company INSURER B: INSURER C: INSURER D: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR DD'L NSRD TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE MM/DD/ POLICY EXPIRATIONYY DATE MM/DD/YY LIMITS AU1,�REPRESENTAa,� GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY ENTED PREMISES Ea occurence $ 50 , 000 CLAIMSMADE CI OCCUR MED EXP (Any one person) $ 5,000 A NPP 890358 07/29/04 07/29/05 PERSONAL &ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 LA A LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG. $ 2,000,000 POLICY PRO LOC JECT AUTOMOBILE LIABILITY ANYAUTO COMBINED SINGLE LIMIT $ (Ea accident) BODILY INJURY (Per person) $ ALL OWNED AUTOS SCHEDULED AUTOS BODILY INJURY (Peraccident) $ HIRED AUTOS NON-OWNEDAUTOS - PROPERTY DAMAGE $ (Peraccident) GARAGE LIABILITY AUTOONLY- EAACCIDENT $ OTHERTHAN EAACC $ ANYAUTO AUTOONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CI CLAIMSMADE AGGREGATE $ $ $ DEDUCTIBLE $ RETENTION $ WORKERS COMPENSATION AND WCYLIMIT OTH- WCST TU- E_R EMPLOYERS' LIABILITY E.L. EACH ACCIDENT $ ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. DISEASE - EA EMPLOYE $ OFFICER/MEMBER EXCLUDED? Ifyes, describe under SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS / LOCATIONS /VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT/ SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION ACORD 25(2001/08) ©ACORD CORPORATION 1988 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Joe D' Angela DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN 71 Penbrook Road NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL N. Andover, MA 01845 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AU1,�REPRESENTAa,� ACORD 25(2001/08) ©ACORD CORPORATION 1988 .) I ne Commonwealth of Massachusetts Department of Industrial Accidents 4 Office of Investigations 600 Washington Street Boston, MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/Organization/Individual): Address: City/State/Zip:; / ter,° �i /Phone #: �179, Are you an employer? Check the appropriate box: 1. ❑ . am a employer with 4. ❑ I am a general contractor and I employee's (full and/or part-time).* have hired the sub -contractors 2. I am a sole proprietor or partner- listed on the attached sheet t ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comm. insurance required.] 34�,®--0G Type of project (required): 6. ❑ New construction 7. [T Remodeling 8. ❑ Demolition 9.❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12. Roof repairs 13. ❑ Other ...,-`o`w``ers• .�.... ­­ " n, ""' a., n,i out me secnon oetow 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 employee& Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #: J?- /og � � Expiration Date: Job Site Address: �4r.,. City/State/Zip: ��,K�v�t v/�Y!' 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`tinprisonment, 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 ce er the pains nalties of perjury that the information provided above is true and correct c -- Signa 7 Date: Phone #: Oficial use only. Do not write in this area, to be completed by city or town ojj`iciaL 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 #• 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 a ed in a joint enterprise, and including the legal representatives of a deceased employer, or the of the foregoing eng g to a to ees. However the receiver or trustee of ab individual, partnership, association or other legal entity, employing mp y owner of a dwelling house having not more than three apartments and who resides therein, or the occupant el ling the dwelling house of another who employs persons todo notbecause d such employment be deemed to be maintenance, construction or repair work on such an empl Yer house or on the grounds or building appurtenant thereto shall 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." ter 152, 25C 7 states "Neither the commonwealth nor any of its political subdivisions shall Additionally, MGL chap § ( ) f public work until acceptable evidence of compliance with the insurance enter into any contract for the performance o 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) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLQ or Limited Liability Partnerships S IIe. If an LLC or LLP does have employees than the members or partners, are not required to carrycompensation 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: sign and date license is beingthe afridavit. The requested, not the Department oavit should be returned to the city or town that the application for the permit o 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 app applicant Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an app 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 ff @avit is on file for future permits or licenses. A new affidavit must be filled out each applicant as proof that a valid a 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 Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 5-26-05 www.mass-gov/dia A, North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11,S150A. The debris will be disposed of in: C C- to (Location of Facility) 0 V t r Signature Permit Applicant 24=OJ`� Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector