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HomeMy WebLinkAboutMiscellaneous - 71 PLEASANT STREET 4/30/2018North Andover Board of Assessors Public Access q NO RTN Ot 4t`' •1'�'O T F 9 ,SSACMUs�t Click Seal To Return Search for Parcels Search for Sales Summary Residence Detached Structure Condo Commercial n�V" tr `, Page 1 of 1 10126. roperty Record Card Parcel ID :210/055.0-0046-0001.0 FY:2008 Community : North Andover SKETCH PHOTO No Sketch No Picture Available Available ttion:�71 PLEASAN �RIE . I I —pw- ier e ' U ier Address: 71 PLEASANT STREET City: NORTH ANDOVER State: MA Zip: 01845 ,hborhood: 0 Land Area: 0.00 acres Code: 102 -CONDOMINIUM Total Finished Area: 1699 sqft o ASSESSMENTS Total Value: Building Value: Land Value: Market Land Value: Chapter Land Value: CURRENT YEAR 248,800 248,800 0 0 PREVIOUS YEAR 261,900 261,900 0 LATEST SALE Sale Price: 10 Sale Date: 09/27/2006 Arms Length Sale A -NO -FAMILY Grantor: SABET, KAZEM Code: Cert Doc: Book: 10413 Page: 58 http://csc-ma.us/PROPAPP/display.do?linkId=1176986&town=NandoverPubAcc 11/7/2008 i i North Andover Board of Assessors Public Access i NO OTN 1 O� «• H t ,sSACHUSt� Click Seal To Return Search for Parcels Search for Sales Summary Residence Detached Structure Condo Commercial AndoverNorth Page 1 of 1 j�roperty Record Card Parcel ID :210/055.0-0046-0002.0 FY:2008 Community: North Andover SKETCH PHOTO No Sketch No P4dure Available Available Location: 73 PLEASANT STREET Owner Name: NICHOLSON, CHARLES Owner Address: 73 PLEASANT STREET City: NORTH ANDOVER State: MA Zip: 01845 Neighborhood: 0 Land Area: 0.00 acres Use Code: 102 -CONDOMINIUM Total Finished Area: 1699 sqft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 251,900 265,200 Building Value: 251,900 265,200 Land Value: 0 0 Market Land Value: 0 Chapter Land Value: http://csc-ma.us/PROPAPP/display.do?linkld=1176987&town=NandoverPubAcc 11/7/2008 s North Andover Board of Assessors Public Access Page 1 of 2 NORTH North Andover Board of Assessors 3g e•',r, .... • of o• `,r ; MATCHING PARCELS SSS^CM"'°` Click on a column title to sort data by that column Click Seal To Return 93 items found, dis )laying 1 to 50. fmFirst/Prev 1 1 2 Next/Last Fiscal Year Parcel ID St.No. Street Owner Name 2008 210/095.0-0036-0000.0 p PLEASANT COATES, ALBERT G & RUTH COATES, OR STREET KEITH MARTINS 2008 210/037.C-0009-0000.0 p PLEASANT BEAR HILL DEVELOPMENT, INC, Search for Parcels STREET 2008 210/055.0-0053-0000.0 p PLEASANT LANDERS, VINCENT B, STREET Search for Sales 2008 210/055.0-0052-0000.0 p PLEASANT LANDERS, VINCENT B, STREET 2008 210/037.C-0050-0000.0 p PLEASANT TOWN OF NORTH ANDOVER, STREET 2008 210/037.C-0003-0000.0 0 PLEASANT MASS ELECTRIC CO, C/O PROPERTY TAX STREET DEPARTMENT 2008 210/037.C-0004-0000.0 0 PLEASANT TOWN OF NORTH ANDOVER, STREET 2008 210/037.C-0002-0000.0 p PLEASANT TOWN OF NORTH ANDOVER, STREET 2008 210/037.C-0026-0000.0 p PLEASANT PLEASANT TIMES REALTY TRUST, STREET 2008 210/042.0-0034-0000.0 g PLEASANT DEPOLITO, MARK J, ADELE K STREET GAULOCHER 2008 210/055.0-0034-0000.0 14 PLEASANT PROGRESSIVE REAL ESTATE, COMPANY, STREET INC 2008 210/055.0-0021-0000.0 15 PLEASANT WENTWORTH, GARY C, LAURETTA E STREET WENTWORTH 2008 210/055.0-0020-0000.0 19 PLEASANT SCHRUENDER, EDWARD D, STREET 2008 210/055.0-0035-0000.0 20 PLEASANT MAYR, JOSEPH F, CHERYL A MAYR STREET 2008 210/055.0-0039-0000.0 25 PLEASANT WILLIAMS, CHRISTOPHER J., WILLIAMS, STREET HOLLIE A. 2008 210/055.0-0005-0026.0 26 PLEASANT ZAMBE, PRISCILLA, STREET 2008 210/055.0-0005-0028.0 28 PLEASANT BUSH, SUSAN, STREET 2008 210/055.0-0040-0000.0 31 PLEASANT MCGOVERN, DIANE, STREET 2008 210/055.0-0036-0000.0 32 PLEASANT GAMBLE, JAMES & SUZANNE, STREET 2008 210/055.0-0041-0001.0 37 PLEASANT STARKS-SHOTTER, WANETA, STREET 2008 210/055.0-0037-0000.0 38 PLEASANT WALDREP, NEAL A., STREET 2008 210/055.0-0041-0002.0 39 PLEASANT TIBERT, WILLIAM J, III, DEBORAH STREET TIBERT PIAZZA 2008 210/055.0-0042-0000.0 43 PLEASANT GAMBLE, JEFFREY W., GAMBLE, STREET THERESA A. 2008 210/055.0-0038-0000.0 44 PLEASANT LOCKWOOD, PAUL N, LAURIE J STREET LOCKWOOD 2008 210/055.0-0019-0000.0 49 PLEASANT ANDERSON, PETER J, ANN BEVERLY STREET ANDERSON 2008 210/055.0-0014-0000.0 52 PLEASANT SHORT, JAMES EDWARD, LYNN ANN STREET ZLINDRA-SHORT 2008 210/055.0-0043-0000.0 55 PLEASANT WALSH, JUDITH M, STREET 2008 210/055.0-0015-0000.0 60 PLEASANT KLISIEWICZ, TADEUSZ K, EWA B STREET KLISIEWICZ 2008 210/055.0-0044-0000.0 61 PLEASANT PICKLES, WILLIAM J, JANET O PICKLES STREET 2008 1210/055.0-0045-0000.0 C7 PTEASANT DEWHIRST, ALAN W, http://csc-ma.us/PROPAPP/newSearch.do?town=NandoverPubAcc&from=NewSearch 11/7/2008 f North Andover Board of Assessors Public Access Page 2 of 2 http://csc-ma.us/PROPA,PP/newSearch.do?town=NandoverPubAcc&from=NewSearch 11/7/2008 PLEASANT SCHRUENDER, GEORGE H ETUX, 855 2008 210/069.0-0008-0000.0 70 STREET REALTY TRUST 2008 210/055.0-0046-0001.0 71 1 PLEASANT STREET WINFIELD, MARIE, 2008 210/055.0-0046-0002.0 73 PLEASANT NICHOLSON, CHARLES, STREET PLEASANT MARTIN FAMILY REALTY TRUST, PETER 2008 210/055.0-0047-0000.0 77 STREET H MARTIN, TR 2008 210/069.0-0023-0000.0 84 PLEASANT OUELETTE, NANCY, STREET 2008 210/069.0-0024-0000.0 88 PLEASANT ACROPOLIS HOLDINGS, LLC, STREET 2008 210/055.0-0048-0000.0 89 PLEASANT STREET WHITE, BRIAN J, PLEASANT MICHEL, LUCIUS C & MICHELE M MC 2008 210/070.0-0004-0093.0 93 STREET HUGH, 2008 210/070.0-0004-0095.0 95 PLEASANT DORR, STACI & DEBORAH A OLSON, STREET PLEASANT SHEEHAN, CECELIA M LT, J J SHEEHAN 2008 210/069.0-0025-0000.0 98 STREET & J C HARTNETT 2008 210/070.0-0011-0000.0 102 PLEASANT STREET MAKER, THOMAS J, SUE A MAKER 105- PLEASANT ONE HUNDRED FIVE & SEVEN 2008 210/070.0-0005-0000.0 107 STREET PLEASANT ST TR, OR PAWEL LEPICKI 2008 210/070.0-0012-0000.0 106 PLEASANT STREET GIOIA, ALEXANDER P, PLEASANT EVERETT, THOMAS & DRISCOLL, 2008 210/070.0-0013-0000.0 114 STREET MARIANN, 2008 210/070.0-0007-0000.0 115 PLEASANT PHAIR, DONALD J, ALICE B PHAIR STREET 2008 210/070.0-0014-0000.0 122 PLEASANT CRESCIMANO, ANTHONY F, M L & N O STREET CRESCIMANO 2008 210/070.0-0006-0000.0 130 PLEASANT STREET AGEY, SOPHIE D, 2008 210/070.0-0008-0000.0 132 PLEASANT STEINBERG, SCOTT, JENNIFER L STREET STEINBERG 2008 210/070.0-0027-0004.0 133 PLEASANT ROUKES, JEFFREY JR & CONLEY, JOY, STREET 2008 210/070.0-0027-0003.0 133 PLEASANT STREET MCCARTHY, MARIE A, 93 items found, displaying 1 to 50. [First/Prev] 1 1 2 [Next/Last] http://csc-ma.us/PROPA,PP/newSearch.do?town=NandoverPubAcc&from=NewSearch 11/7/2008 INSPECTIONAL SERVICES LOG spection D to 1 res ie ne nit# Office Note Inspection Request: Rough Final DATE: Inspected By: cj Date of Inspection: Pass Fail C10 ther Correction Note/Inspection c ,nts° C/Footing " " ` Foundation" Frame Other( �jrj %— /Q n Time in: Time out: dress p Inspected By: me Date of4n-' ecti one'Pass rmit# Office, Note p G-wCo . ec ' n Nod Inspection Request: ESC/Footing . Foundationi, Frame Rough Final Other. Time Fn: F2il Other nspection comments: Time out: Ins tion Date ction Date J �C/ �a� �'" D Address Z— Inspected By; Name X Phone Date of Inspection: Pass Fail Other i. Permit# _ Office Note __ ,Correction Nnte/Inspection comments: Inspection Request: ESC/Footing Foundation Frame Inspected By: Time in: Time out: Rough Final Other I Address 12 �• ction Date J �C/ �a� �'" D �/"� Inspected Name Address ( i. Date of In ction: Phone Inspected By: Pas Fail Oth Permit# Office Note Correction Note/Insp ction omments: Phone c Inspection Request: ESC/Footing Foundation Frame Office Note Rough Final Other Correction Note/I spection Time in: Time out: Signature "Aw Inspection ate r` �/"� r Address ( i. Inspected By: Name r / Date of Inspection: Phone Pass Fail /0thetr Permit# Office Note Correction Note/I spection co rx%nts: Inspection Request: ESC/Footing Foundation Frame Time in: Time out: Rough 'Final Other Signature "Aw INSPECTIONAL SERVICES LOG VInspection Date ddress�M!� ame hone Permit# Office Note Inspection Request:_ ESC/Footing Fou Rough Final Other DATE: Inspected By: Date of Inspection: Pass Fail Other Correction Note/Inspection comment A K n: r Time out: Inspection Date Address Inspected By: Name Date of Inspection: Phone , .-Pass Fail Other Permit# Office. Note Correction Note/Inspection comments: Inspection Request: ESC/Footing Foundation Frame Rough Final Other Time in: Time out: Inspection Date Address Inspected By: Name Date of Inspection: Phone Pass Fail Other t Permit# Office Note Correction Npte/Inspection comments: Inspection Request: ESC/Footing Foundation Frame Rough Final Other Time in: Time out: Inspection Date Address Inspected By: Name Date of Inspection: Phone Pass Fail Other Permit# Office Note Correction Note/Inspection comments: Inspection Request: ESC/Footing Foundation Frame Rough Final Other Time in: Time out: Inspection Date Address Inspected By: Name Date of Inspection: Phone Pass Fail Other Permit# Office Note Correction Note/Inspection comments: Inspection Request: ESC/Footing Foundation Frame Time in: Time out: Rough Final Other Signature Bk 10620 Pg 189 #4088 BK 10413.P6. 58 QUITCLAIM DEED I, xmm Sabet of Andover, Essex County, Massachusetts for consideration of Ten ($10) Dollars and other good and valuable consideration; grant to Marie Winfield, Individually, of 71 Pleasant Street, North Andover, Essex County, Massachusetts, with Quitclaim Covenants, Unit 71 of Seventy -One -- Seventy =Three Pleasant Street Condominium, having an address of 71 Pleasant Street, N. Andover, MA; a condominium established pursuant to ti Massachusetts General Laws, Chapter 183A, by Master Deed dated January 11, 2002, (The "Master Deed') and recorded January 15, 2002 at Essex North District Registry of a Deeds, at Book 6610, Page 37. Said unit contains the number of square feet, more or v A less, and is laid out as shown on a portion of a plan filed herewith, to which is affixed a; y verified statement in the form provided for in Massachusetts General Laws chapter 183A,,r< section 9, certifying that the plan _ fully and accurately depicts the layout of the unit, ii location, dimensions, approximate area, main entrance, and immediate common area to -v`, which it has access, and which plan is a copy of a portion of the plan's recorded with sail Master Deed. MCD Said dwelling is hereby conveyed together with: o L An undivided % interest in the common areas and common elements of the condominium pursuant to the provisions of the Master Deed; 2. All other rights, easements, agreements, interests and provisions contained in the Master Deed, and the Rules and Regulations adopted pursuant thereto (the "Rules and Regulations!% as. any of the same may be amended from time to time pursuant to the provisions thereof; 3. Said dwelling is conveyed subject to and with the benefit of:. a. The provisions of chapter 183A as the same may be amended from time to time; b. The provisions of the Master Deal, including, without limitation, the title matters set forth in "Exhibit A" to the Master Deed; C. Declarant's reserved rights as set forth in the Master Dead; d. Real estate taxes assessed against the unit and the common areas and facilities which are not yet due and payable; and e. Provisions of existing building and zoning laws. 4. The right, agreements, easements, restrictions, provisions and interests set forth herein, together with many amendments thereto, shall constitute convenants Bk 10620 Pg 190 #4088 BK -10413 PG 59 ruining with the unit and shall inure to the benefit ofi and bind, as the case may be; any employees, licenses, visitors and lessees as though the same were fully set forth herein, and 5. The dwelling may be used only for residential purposes and accessory use as permitted by the Zoning.By-Laws of the City of North Andover and the Master Deed. By execution hereof, the undersigned certified that he is authorized to make this conveyance on the. terms and conditions contained herein, and that neither this instrument nor any other record at the Registry of Deeds discloses anything in contravention of MGL c. 156c,* section 66 as amended. Being the same premises conveyed to me by deed. dated November 3, 2005 and recorded at said Registry at Book 9872, Page 28. Grantee agrees to assume and pay the existing first mortgage on said premises in the- principal heprincipal amount of 82249000 and recorded in said Registry at Book 98729 Page 30; and existing secondmortgage on said premises in the �riucip s amount of 56,000 and recorded in said Registry at Book 872, Page 51. . . rj'Jttr; a4 rd •oris nt%, Fos AN ` yO-e Witness my hand and seal this 13x' day of September, 2006. Commonwealth of Massachusetts Middlesexy ss. September. 13, 2006 Then personally appeared Kazem Sabet, proved to me through satisfactory evidence of identification, which was a Massachusetts driver's license, and acknowledged the foregoing instrument to be lois free act and deed, before me. 1�S► C '0 pUBI�: c�:MEX VAsEM�rOOMMI8tOg: BK 10413 FSG 60 MORTGAGE I, Marie Winfield, of 71 Pleasant Street, North Andover, Essex County, Massachusetts, for consideration paid, grant to AM-POL Nominee Trust, under a Declaration of Trust dated September 19, 1994 and recorded at Middlesex North District Registry of Deeds at Book 7267, Page 185 With Mortgage Covenants, to secure the payment of Twenty -Five Thousand ($25,000) Dollars as provided in a Promissory Note dated September 13, 2006. See Exhibit "A' Attached Hereto Middlesex, ss. September 13, 2006 0 Then personally appeared MarieWinfield, proved to me through satisfactory w evidence of identification, which was a Massachusetts drivers license, and acknowledged o the foregoing instrument to be her free act and deed, before me. cr- Locus: 71 Pleasant Street, North Andover, MA This mortgage is upon the statutory condition, for any breach of which the mortgagee C. Q shall have the statutory power of sale. C^ H Executed as a sealed instrument this 13th day of eptember, 2006. mr, rn $ xU N 00 mc) ,A MiAe Winfield „io o N W N Commonwealth of Massachusetts Middlesex, ss. September 13, 2006 0 Then personally appeared MarieWinfield, proved to me through satisfactory w evidence of identification, which was a Massachusetts drivers license, and acknowledged o the foregoing instrument to be her free act and deed, before me. cr- BK 10413 PG 61 Exhibit "A" Unit 71 of Seventy -One — Seventy -Three Pleasant Street Condominium, having an address of 71 Pleasant Street, N. Andover, MA; a condominium established pursuant to Massachusetts General Laws, Chapter 183A, by Master Deed dated January 11, 2002, (The "Master Deed') and recorded January 15, 2002 at Essex North District Registry of Deeds, at Book 6610, Page 37. Said unit contains the number of square feet, more or less, and is laid out as shown on a portion of a plan filed herewith, to which is affixed a verified statement in the form provided for in Massachusetts General Laws chapter 183A, section 9, certifying that the plan fully and accurately depicts the layout of the unit, its location, dimensions, approximate area, main entrance, and immediate common area to which it has access, and which plan is a copy of a portion of the plans recorded with said Master Deed. Said dwelling is hereby conveyed together with. i . An undivided %z interest in the common areas and common elements of the condominium pursuant to the provisions of the Master Deed; 2. All other rights, easements, agreements, interests and provisions contained in the Master Deed, and the Rules and Regulations adopted pursuant thereto (the "Rules and Regulations"), as any of the same may be amended from time to time pursuant to the provisions thereof; 3. Said dwelling is conveyed subject to and with the benefit of: a. The provisions of chapter 183A as the same may be amended from time to time; b. The provisions of the Master Deed, including, without limitation, the title matters set forth in "Exhibit A" to the Master Deed; C. Declarant's reserved rights as set forth in the Master Deed; d. Real estate taxes assessed against the unit and the common areas and facilities which are not yet due and payable; and e. Provisions of existing building and zoning laws. 4. The right, agreements, easements, restrictions, provisions and interests set forth herein, together with many amendments thereto, shall constitute convenants running with the unit and shall inure to the benefit of, and bind, as the case may be, any employees, licenses; visitors and lessees as though the same were fully set forth herein, and 5. The dwelling may be used only for residential purposes and accessory use as permitted by the Zoning By -Laws of the City of North Andover and the Master Deed. For my title, see deed dated November 4, 2005 and recorded at Essex North District Registry of Deeds as Document No. 42939. Bk 10764 Ps264 -015999 05-2S-2007 a 08329a ' COMMONWEALTH OF MASSACHUSETTS (SEAL) LAND COURT DEPARTMENT OF THE TRIAL COURT To: 07 MISC 346382 Marie Winfield and to all persons entitled to the benefit of the Servicemembers Civil Relief Act. HSBC Bank USA, National Association, as Trustee, on behalf of the holders of ACE Securities Corp., Home Equity Loan Trust, Series 2006-SD3 Asset Backed Pass -Through Certificates claiming to be the holder of Mortgage covering real property in North Andover, numbered 71 Pleasant Street, Unit 71 of the 71-73 Pleasant Street Condominium given by Kazem Sabet to Long Beach Mortgage Company d aced November 3, 2005, and recorded with the Essex County (43ftmDisftict) Registry of Deeds at Book W72, Page 30, and now held by Plaintiff by assignment has/have fled with said court a complaint for authority to foreclose said mortgage in the manner following: by entry and possession and exercise of power of sale,. If you are entitled to the benefits of the Servicemembers Civil Relief Act and you object to such foreclosure you or your attorney s file a written appearancend answer in said court at Boston on or before the �S day of 20&-h or you may be forever barred from claiming that such foreclosu is invalid under said act. Witness, KARYN F. SCHEIER Chief Justice of said Court this j, day of 2001L. Attest: ABLi1T & WLi01V, P.C. 92MONTVALE2950 SSTONEMK MA 02164 81.0896/ sabot UP -I1-9/0 A TRUE COPY ATrW. %0080r- RESORDER DEBORAH J. PATTERSON RECORDER THIS INSTRUMENT SHOULD BE FILED AT ONCE FOR RECORD OR REGISTRATION. STATE TAX FORM 441 INSTRUMENT OF REDEMPTION TITLE IN MUNICIPALITY THE COMMONWEALTH OF MASSACHUSETTTS Town of North Andover OFFICE OF THE TREASURER The Town of North Andover, holder of a tax title under a taking for non-payment of the 2006 taxes assessed to WINFIELD, MARIE on land described in the instrument of taking deed conveying said title, dated 3/23/2007, and recorded with No Essex Registry of Deeds, Book ..., Page ..., Document No.... , Certificate of Title No.... , does hereby, pursuant to General Laws, Chapter 60, Section 62, acknowledge satisfaction of the tax title account secured by such instrument of taking. Bk 1081,6 P:9347 :20010 08-29-20017 & 09 a 57aL DESCRIPTION OF LAND [The description rust be sufficiently accurate to identify the promises and must agree with the notice of taking. In the case of registered land, the Certificate of Title Number and the Registry Volume and Page must be giv-1 A parcel of Land with buildings thereon, located at 71 PLEASANT STREET UNIT 10, said to contain 0.00 acres, more or less, described as Tax/Map Number 210-055.0-0046-0001.0 in the Assessor's office, recorded as Book 10413 Page 58, at North Essex Registry of Deeds. .......... NAME OF PERSON OTHER THAN THE OWNER OF THE FEE RIGHTFULLY REDEEMING AND REQUESTING TO BE NAMED IN THIS INSTRUMENT Witness the execution of this instrument this.......... tt l...day of....J.C1.viP.�.., ..�� Town of North Andoyer By ................ ....... ....,Treasurer THE COMMONWEALTH OF MASaCHUSSETTS No Essex, Tuesday, June 19, 2007 /+� �� Va. Then personally appeared the aboved-named.....JtJ4 I{ .....�.� .................... Treasurer of the Town of North Andover and acknowledged the foregoing instrument to be free act and deed of said Town. My commission expires .... .•9 20 t i Before me, ............ ...... -..1.................... ::................................. THIS FORM APPROVED BY COMMISSIONER OF REVENUE NOT C -JUSTICE OF THE FFACE Wdf. Form DQ115 AR4-76 (90111Ui[i1IU1�Pi of,�> tti usPf#s 4SSF�K , as V. rIQ/L:t_� �htNF.�cJ 13 S Civil Action No. 66.18 C,V _WRIT OF ATTACHMENT (Rule 4.1) TRUE A7TE� DEPUTY SHERIFF To the Sheriffs of our several counties or their deputies, or a constable of any City or Town within the Commonwealth: We command you to attach the goods or estate of defendant '/Z21 �/tJ ' of L U to the value of $ nQ the amount authorized, as prayed for by plaintiff iy nrt 2,U 40Wi�£AK�'}�' OA MA whose attorney is T of + ' in an action brought by said plaintiff against said defendant in this court, and make due return of this writ with your doings thereon. The compla'nt in this case was filed on %O /O f'0 % Thi a taQhment waa approved on by (date) (signature of judge) S!?o o =� is the amount of $ Thomas M. Brennan Presiding Justic"On�Z WIT NESS (SEAL) _` PROOF OF ATTACHMENT' _.:._.... �V1 ....- #3k ' 10479 PO1-a4---•'037900 11-06-2006 a'1 03 0 20P Essex, SS By virtue of this Writ, on 11/6/2006 at in the 1:52 pm I attached all the right, title and interest that the within named defendant(s), Marie Winfield has/have in and to any and all real estate in the County of Essex. Later, on 11/6/2006 1 deposited at the Registry of Deeds of said County of Essex, -an attested copy of the within writ together with so much of my return as relates to the attachment of said real estate. Deputy Sheriff Later, on 11/6/2006 1 notified the defendants) by mailing to his/her/their last known address an attested copy of the within writ together with so much 'of my return as relates to the attachment of said real estate and Its recording at 'the Essex County Registry of Deeds to wit: 71 Pleasant Street ,North Andover, MA 01845 Deputy Sheriff EXECUTION OOCKETNUMBER 200618CV001365- CASE NAME KENNETH H. POLLARD FUNERAL HOME, INC. vs. MARIE WINFI.ELD DGMENT CREDITOR(S) IN WHOSE FAVOR EXECUTION 1S ISSUED P01 KENNETH H. POLLARD FUNERAL HOME, INC. s . DGMENT CREDITOR (OR CREOITOR'S ATTORNEY) WHO MUST ARRANGE SERVICE OF EXEC61W 1 P01 MATTHEW A. CAFFREY 42—I<J CAFFREY & SMITH, P.C. 300 ESSEX STREET LAWRENCE, MA 01842 JUDGMENT DEBTOR AGAINST WHOM EXECUTION IS ISSUED D01 MARIE WINFIELD 71 PLEASANT ST. N ANDOVER, MA 01845 Trial Court of Massachusetts'. a\ 6.. District Court Department t'l . CURRENTCOURT ,Lawrence District Court 2 Appleton Street Fenton Judicial Center Lawrence, MA 01840-1525 (978) 687-7184 g DORY 9 1 ?SOURTT 4t S H —2407 & TR DEPUTY SHERIFF TO THE SHERIFFS OF THE SEVERAL COUNTIES OR THEIR DEPUTIES, OR (SUBJECT TO THE LIMITATIONS OF G.L. C. 41 § 92) ANY CONSTABLE OF ANY CITY OR TOWN WITHIN THE COMMONWEALTH: The judgment creditor(s) named above has recovered.judgment against th•a judgment debtor named above in the amount shown below. WE COMMAND YOU,therefore, from out of the value of any real or personal property of such judgment debtor -found within your territorial jurisdiction, to cause payment to be made to the judgment creditor(s) in the amount of the "Execution Total" shown below, plus additional postjudgment interest as provided by G.L. c. 235 § 8 on the "Judgment Total" shown below commencing from the "Date Execution Issued" shown below at the "Annual Postjudgment Interest Rate" shown below, and to collect your own fees, as provided by law. This Writ of Execution is valid for twenty years from the "Date Judgment Entered" shown below.'lt must be returned to the court, along with your return of service. within ten days after -this judgment has been satisfied or discharged, or after twenty years if this judgment remains unsatisfied or undischarged.. $4,915.44 1. Judgment Total 12i0512G06 2. Date Judgment Entered 12/05/2006 3. Date Execution Issued . 4. Number of Days from Judgment to Execution (Line 3 - Line 2) 0 5. Annual Postjudgment Interest Rate of 12.00%/ 365 = Daily Interest Rate 0.032877% 6..Posqudgment Interest from Judgment to Execution (Lines 1x4x5) $0.00 7. Postjudgment Costs (if any) $0.00 $0.00 8. Credits (if any) 9• EXECUTION TOTAL ( Lines 1 + 6 + 7, minus Line 8) $4,915.44 LEVYING OFFICER: (a) Add daily interest from date execution issued. (b) Add your.fees as provided by law: TESTE OF FIRST JUSTICE DATE EXECUTION ISSUED CLERK. I WITNESS: Hon. Thomas M. Brennan 12/05/2006 X OR .. Datelrime Printed: 12!05/2006 0245 PM Bk 10620 Tssex County Sheriff's Department Z L Division of Civic Process 381 Common Street 3rd Floor Frank G. Cousins, Jr. Lawrence, MA 01840 Sheriff Richard J. Roaf, Jr. Director Robyn Clarke Office Manager Date: 2/5/2007 Time: 11:43 am Plaintiff: KENNETH H. POLLARD FUNERAL HOME, INC. Plaintiffs Attorney: Caffrey & Smith, P.C. Attorney's telephone number: (978)686-6151 Defendant: MARIE WINFIELD Book: 10413 Page: 58 & 59 Pg 188 #4088 Telephone: (978) 683-7810 Fax: (978) 683-8205 www.eccf.com Court of Issue: Lawrence District (Essex) Execution # 200618CV001365 By virtue of the attached execution, the original of which is in my hands for the purpose of taking the above described real estate, I have this day levied upon, seized and taken all right, title and interest that the within named Judgment Debtor had in such real estate in Essex County when it was attached on mesne process on 11/06/06. Attached is a true copy of- this execution on the above so much of my return as relates to the levying upon, seizure, and taking of this real estate on the execution. And immediately afterward, I suspended the further levy on this execution upon the above described real estate by written request of the attorney for the with.ki named judgment creditor. kp%MWn AMESBURY - ANDOVER - BEVERLY •BoxFORD - DANVERS - ESSEX - GEORGETOWN - GLOUCESTER • GROVELAND - HAMILTON - HAVERHILL IPSWICH - LAWRENCE • LYNN - LYNNFIELD - MANCHESTER • MARBLEHEA0 - MERRIMAC - METHUEN - MIDDLETON - NAHANT - NEWBURY - NEWBURYPORT NORTH ANDOVER - PEABODY - ROCKPORT - ROWLEY - SALEM . SALISBURY - SAUGUS . SWAMPSCOTT - TOPSFIELD - WENHAM -WEST NEWBURY Opv�F; IY pN Of NoFt'� VV,R�NG To�N MST FoR PER .... p ? ...................... Mass. ifies mat .........:....... G L........ ao�ez, ,mss �e on to peotm ...... ......{ ��o ssi....... R ...• ras 4e"� bu>>aing of .......... 7• ..... �a...........T .• ^s� 1r}seE r v ng"'fie Lf� S/.y�t:................ • .� .................14oJR dee r` ...•••;• .J� k# Ghee Commonwealth o� Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS offi�� "J �,O (ly Permit No. Occupancy and Fee Checked [Rev. 1/071 (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEQ, 527 CMR 12.00 (PLEASE PRINT WINK OR TYPE ALL INFORMATION) Date: 6 - //71 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. lOwneLocation (Street & Number) 6-/ 17 -- Owner r or Tenant MAI Mal -/p ff4 Telehone No. Owner's Address Is this permit in conjunction with a building permit? Yes Vr No ❑ (Check Appropriate Box) Purpose of Building „2 FAmi t h y byl'9i-f-X _ Utility Authorization No. - Existing Service 100 Amps ld'- /00 Volts Overhead1� 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: Comnletinn nfthe fallowing tahle may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- ❑ rnd. grnd. o. of Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers p Heat Pump Totals: N_ umber Tons ­ *.......... KW No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KW Heaters No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of *rhes. Estimated Value of Electrical Work: ,� 0 m 0. aa (When required by municipal policy.) Work to Start: G - I{ - 1y 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 e is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE [BOND ❑ OTHER ❑ (Specify:) X certify, antler the pains and penalties ofperjury, that the information on this application is true and complete. FIRM NAME: _ ToH,-- CAJAIY— �p/ cjdL�L LIC. NO.: -- Licensee: 7oHr,/ CM0-; Signature LIC. NO.: ble, enter�`empt"alinmr line) 7 Bus Tel. . Address:�9� A& S'y Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires hepartment bf P blic 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 PERMIT FEE. $ Seo D Signature Telephone No. S -L 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance -with the provisions of M.G.L. c. 143, § 3L, the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed electrical permit shall be issued to the person, on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an firm or corporation stated on the permit application. Such entity shall be responsible for the M notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shall. be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. The Permit Extension Act was created by Section 173 of Chanter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Actfurthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, 2008 and extending -through August 15, 2012. ❑ Rule 8 — Permit/Date Closed: 'Note: Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: :B WEINHOLD ... TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com The Commonwealth of Massachusetts Department of Industrial Accidents Office offnvesfigations 600 Washington Street .Foston, MA 02111 www.mass.govIdla Workers' Compensation Twurance Affidavit: Bui tiers/Contractors/Blectri.ciansJPliibabers Applicant Information Please Print Legibly Name (Business/Oxganizailon/tudividual): J-011AI r Address: P-0 ® / City/State/Zip: �li�Y �!7 l - 03'76 —Phone #: Are you an employer? Check the appropriate box: 1. Q I am a employer with 4. 0 I am a general contractor and I 2. Vemployees (full and/or part-time)-* I am a sole proprietor or partner- ship and'haveno.employees working forme is any capacity. [No workers' comp. insurance xequ9red.] 3. ❑ 1 am a homeowner doing all work myself EEO workers' comp. insurancerequired.] Ti have hired the sub -contractors listed on the attached sheet. t These sub -contractors have workers' comp. insurance. 5, ❑ We are a corporation and its officers have exercised.their right of exemption p or MGL c. 152, §1(4), andwe have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. [] Demolition 9. ❑ Building addition 10. Electrical repairs or additions 11.[] plumbing repairs or additions 12.❑ Roofrepairs 13.❑ Other 'Any applicant that checks box#I must also fill out the section below showingtheirwbrkers' compensation policy information. i -Homeowners who submitthis affidavit indicating they Are d9ing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors that checkthis boar must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am are employer that is providing workers' compensation insurance for my employees Below is the policy and'job site information. Insurance Company Name;AlAUT-a 0-5 Policy # or Self -ins. Lic. #: �� - 3Expiration Date: Job Site Address; 71 J �f7��T jr City1State/2ip:jV0.. 6-kaK M-4,45 Attach a copy o#tie workers' compensation -policy declaration page (showing the policy number and expiration date). Failure to secure coverage as req A dunder Section 25A ofMGL o.152 can lead to the imposition of criminal penalties of a flue 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. X do ]iereby c ti under the p ' ncipenalties ofpeyjury that file information provided aboov/e is true and correct. - Simature• Data: (O ^ -7 �lf Phone #: - r9-76- 3? - //3 54( Official use oBly..Do not write in this area, to be completed by city or town official. City or Town: Permit/License 0 Issuing Authority (circle ane): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - - Contact Person: Phone #: Information and Instrnctions 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 tri the service of another under any coriiract ofhire, express or implied, oral or written." An employei is defined as "an individual, partnership, association, corporation, ox 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, employingemployees. Iyowever 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 lie -ening 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 ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapter have beenpresentedto the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necegsary, supply sub -contractors) name(s), address(es) and phone number(s) along with. their certificates) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees oilier than the members or partners, are not required to carry workers' compensation insurance. If au LLC or LLP does have employees, a policy is required. Be advised that this affidavit maybe 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 Iaw or if you are xequired 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 permi-t/Iicense 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. of the affidavit that has been officially stamped or marked by the city or town maybe provided to the applicant as pz oof that a valid affidavit is on file for future permits or licenses..A. new affidavit must be filled out each year. Where a homeowner or citizen is obtaining a license or p eimit not related to any business or commercial venture (i.e. a dog license orpermit 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 Wad fax number: The Co ou—maltbLofMassarhUsPtts Depaidment ofTudustdal .Accidonta Qfrtee QuAvestigatiom 600 Wasbiggtm Slxeet Boston. MA 021. It Tei, # 617-72'4-4900 -4900 sit 406 ox 1-877-MASS.AFE Revised 5-26-05 `ax, 0 617-727-7749 wt�w.�ass,gov�d�a \1 . 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance -with the provisions of M.G.L. c. 1433L the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an electrical permit shall he issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shall -be limited as to the time ofongoing constriction activity, and maybe_deemed-by-the , Inspector_of_Wires abandoned_and_invalid.ifhe—.. _ or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written ap ' t of an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written equesof either the owner or -the installing entity stated on the permit application. The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections.74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence' during the qualifying period beginning on August 15, 2008 and extending"through August 15, 2012. i — Permit/Date Closed: ` *** Dote: Reapply for new ExtensionA c — Permit/Date Closed:l��"e' Date`'...:.... .. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .......j ...............C.......k ..fi... .......................... .... ... has permission to performAto ... )�*iK .... 6�, 7 .. ........ wiring in the building of ...... ...1-h/// ......................................... at..� . .............................. ....... ........ ................... PNorth Andover, Mass. ti - 7 Fee.3P ... . .... Lic. No. .......... Ei, ICAL INs S� ECTO Check # W 9'1 43 Commonwealth of Massachusetts Official Use Only Department of Fire services Permit No. BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked X [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 PRINT WINK OR TYPE ALL INFORMATION) Date: J 'j City or Town of: NORTH ANDOVER To .the Inspector of Wires: By this application the undersigned gives notice of his or her intention to Location (Street &Number) perform the electrical work described below. l Perform Owner or Tenant M.�D Telephone No. a i(�. Owner's Address _ � Is this permit in conjunction with a building permit? Purpose of Building �,,�.,�' r.� Yes NO E] (Check Appropriate Box) � Utihtv Authorization No. Existing Service Amps ItoIli Volts Overhead Und rd g ❑ No. of Meters New Service ❑ Amps / Volts Overhead Undgrd ❑ No. of Meters d. A Number of Feeders and (J I lJLr — 14 O PC. Location and Nature of Proposed Electrical Work. Com letion o the ollowin table may be waived hv the Inv--,— -r Wires. No. of Recessed Luminaires No. of Ceil.-Sus No. of Total . p. (Paddle) Fans Transformers No. of Luminaire Outlets No. of Hot Tubs ICVAGenerators KVA No. of Luminaires Swimming Pool Above ❑ In_ o. o mergency lg g d. d• Battery Units No. of Receptacle Outlets No. of Oil Burners FT,ItE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and No. of Ranges No. of Air Cond. Total InitiatinLy Devices Tons No. of Alerting Devices No. of Waste Disposers eat Pump Number Tons KW p Totals: - -- __.._. o. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ConnEl ection No. of Dryers Heating Appliances K -W Security Systems: No. of Water No. of No. of Devices or Equivalent Heaters KW No. of Data Wiring: t Si s Ballasts . No. of evices or Equivalent 1 No. Hydromassage Bathtubs No. of Motors Telecommunications firing: Total HP OTHER: No, of Devices or E uivalent Attach additional detail tf desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: 42 �� (When required by municipal policy Work to Start 10 - 0Inspections to be requested in accordance with MEC Mule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electric work may issue unless the a signed provides proof suof ch insurance including "completed operation" coverage or its subs tial equivalent. The undersigned certifies that such cov ge is in force, and has exhibited proof of same to the permit issu' office. CHECK ONE: INSURANCE P BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete- Licensee: ompletes / FIRM NAME: �0 /V /�,/t'�1 rG G .. �• �.S l� Licensee:�� ('/�� `�'T— LIC. NO.: Signature LIC. NO.: (Ifapplicable, entt"in the License-numberline.) Address: „ � P` p N 0 30`7 Bus. Tel. No.:S *Per M.G.L c. 47, s. 57-61, security work requires D ty „ „ C �t Tel. No.: OWNER'S INSURANCE WAIVEA: I am aware that the Licensee does not Safehave the l abili Lic. No. required by Iaw. By my signature , ally I hereby waive this requirement I am the (check one) owner rance coverage owner's�agent Owner/Agent Signature Telephone No. �P"�UFEE. S �ti oK �-z�-��, The Commonwealth of Massachusetts Department ofIndustrial Accidents. Office oflnvestigations • 600 Washington Street Boston, 1tA-02111 www.massgovldia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/PlumberIs Applicant Information Please Print Legibly Name (Business/Organization/Individual):�����` Address: P-D- City/State/Zip:....FiLPAY1 kl eD Phone #: Type of project (required): 6. ❑ New construction 7. Q emodeling 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other ow s owing thea workers compensation policy information 1 Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 2Contractors 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 isproviding workers' compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name: C Policy # or Self -ins. Lic. #: Expiration Date: Date: -- of -0/ Job Site Address - --7 % p �, "A / J� / f City/State/Zip:�/� X955 Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration e . ) 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 mprisonment, 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�ertify under the pains and penalties of perjury that the information provided above is true and correct n n_ -,)o Official use only. Do not write in this area, to be completed by city or town official City or Town: Issuing Authority (circle one): 1. Board of Health 2. Building Department 6. Other Permit/License # 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector Contact Person: Phone 4: Are you an employer? Check the appropriate bog: 1. ❑ I am a employer with d 4. ❑ I am a general contractor and I mployees (full and/or part-time).* have hired the sub -contractors 2. I am a sole proprietor or partner- listed on the attached sheet 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 3.0 I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, §,l (4), and we have no insurance required.] t employees. No workers' comp. insurance required.]. *ny applicant that checks box 41 m wsc 81l out the se -h on bel b Type of project (required): 6. ❑ New construction 7. Q emodeling 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other ow s owing thea workers compensation policy information 1 Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 2Contractors 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 isproviding workers' compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name: C Policy # or Self -ins. Lic. #: Expiration Date: Date: -- of -0/ Job Site Address - --7 % p �, "A / J� / f City/State/Zip:�/� X955 Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration e . ) 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 mprisonment, 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�ertify under the pains and penalties of perjury that the information provided above is true and correct n n_ -,)o Official use only. Do not write in this area, to be completed by city or town official City or Town: Issuing Authority (circle one): 1. Board of Health 2. Building Department 6. Other Permit/License # 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector Contact Person: Phone 4: Information and Instructions Massachusetts General Laws chapter 152 requires all employers toprovide workers' compensation for their employees ' 16 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 Iocal 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) 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 Depart crit 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 Roston, MA. 0.2111 Tel. 4 617-7274-900 ext 406 or 1-877-NIAS:SAFE Fax 4 617-72.7-7749 Revised 5 -26 -OS NAr"—w.mass..govfdia 2ao ...................... ................ TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION Thiscertifies that ......................................... .......................... I .. .............................. has permission for gas install tion .................. / .... e .............. !.A4 .............. inthe buildings of ............................... . .................................................................................. at .....7.J. .... . ... A .... V1.0. ... 5/YZO� ........... North Andover, Mass. Feel,4A ............... ..... Lic. No . .......................... . .. ........................................................ Check #IA12— 16-657 GAS INSPECTOR V A�Jji I MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY f%(6L___ MA DATE/ PERMIT# 4/-��__..,.WNER'S NAMEJOBSITE ADDRESS CLIJ� GOWNER ADDRESS _ TE _ FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ® RESIDENTIALO PRINT _ CLEARLY NEW: F-1 RENOVATION, -11 REPLACEMENT: 13 PLANS SUBMITTED: YES E] NO APPLIANCES 1 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILERLXJ L ..: .._ ._. __ ._ . � . _. - . I I...._. BOOSTER _ CONVERSION BURNER _ =D ^_( COOK STOVE (- a ....... DIRECT VENT HEATER DRYER FIREPLACE_..-- FRYOLATOR FURNACE GENERATOR_. -- .__I. _- _I _ _ _. I GRILLE INFRARED HEATER LABORATORY COCKS I I� _- j-1 -1 f _-_ �- _ r�_. r:._--Jj jMAKEUP AIR UNIT OVEN _ _ _I L POOL HEATER ROOM / SPACE HEATER _ ROOF TOP UNIT I TEST UNIT HEATER UNVENTED ROOM HEATER z� WATER HEATER OTHER I r I - -^ --^------ .-INSURANCE COVERAGE have liability insurance its the MGL. Ch. 142 YES10 a current policy or substantial equivalent which meets requirements of I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLIC OTHER TYPE INDEMNITY © BOND OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNERt 0 AGENT SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this 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 will be in compliance with nt provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUM BER-GASFITTER NAME LICENSE # 5 TURE MP -RrtGF EjI JP ® JGF LPG[ © CORPORATION ©# PARTNERSHIP DI#L_ LLC E#= COMPANY NAME: ADDRESS , /cam 2Lf41/I S� CITY _� STATE ZIP (J TEL FAX CELL - - - EMAIL _ V A�Jji I W H O Z O U W a W i o El a z C)yF] W r F- W ° °z a LU En CO w W a W LLI O > �+ w CO 0 a a a U J LL CL < � w = w H LL Ln H z 0 H U P-4 U L�7 O -of = The Commonwealth of Massachusetts Department ofIndustrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 UV. www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: Phone #: Are you an employer? Check the appropriate box: 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 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. - 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 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12. ❑ Roof repairs 13.❑ Other *Any applicant that checks box#1 must also fill out the section below showing their workers' compensation policy information. i Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. $Contractors that checkthis box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. lam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Policy # or Self -ins. Lic. #: Job Site Expiration Date: 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 requiredunder 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 certtry under the pains and penalties ofperjury 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 Information and Instruction' s 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 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 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 ofzndustrial Accidents Office of Investigations 600 Washington Street Boston, M,A. 02111 TeX. # 617-7274900 ext 406 or 1-877rMASSAFB Revised 5-26-05 `ay, # 617-727;7749 www.naass.govfdaa Division of Professional Licensure: License Search w The Official Website of the Office of Consumer Affairs and Business Regulation (OCABR) Division of Professional Licensure Mass.Gov Home State Agencies A -Z Topics Home > Division of Professional Licensure > Check A Professional License By the Division of Professional Licensure LICENSEE Name:MICHAEL N. CAPELESS METHUEN, MA ..This Licensee has additional Licenses, click here to view them." Licensing Board: PLUMBERS li GASFITTERS License Type: MASTER PLUMBER License Number: 15851 Status: CURRENT. THE LICENSE IS WITHIN ITS RENEWAL PERIOD Expiration Date: 5/1/2014 Issue Date: 9/16/2011 Exam Date: 9/16/2011 School: This web site displays disciplinary actions dating back to 1993. This license has had no disciplinary actions taken during this time. The page above has been generated by the Division of Professional Licensure web server on Wednesday, April 09, 2014 at 9:16:51 AM. © 2007-2011 Commonwealth of Massachusetts Page 1 of 1 Mass.Gov ONLINE SERVICES Check a License Locate a Licensed Professional Online Address Change Contact the Agency More... REFERENCES & RELATEDINFO Disclaimer Regarding Website License Searches Glossary of License Status Codes More... Site Policies Contact Us http://license.reg. state.ma.us/publiclpubLicenseQ. asp?board_code=PL&type_Class=_M&Iic... 4/9/2014 9340 Date . l .l3// Z.. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING SSA�MU`�� y This certifies that ..� /!�...QJ-�. .. ' ..... has permission to perform plumbing in the buildings of.../?.!LL�.!�.................... . at .... �..�E'�4's? T / .. , �jorth And/ et, Mass. Fee . J��Z, 7a. Lic. No. IS. 8S/ 4-,A. - � %�H. ` r ..... PLUMBING INSPECTOR Check # O -qi: MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ., C� I y CITY (, . MA DATE - O j PERMIT # 1 12"' o JOBSITE ADDRESS / "rT'_ OWNER'S NAME r) m ] `-L P OWNER ADDRESS M O TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIALE] EDUCATIONAL ❑ RESIDENTIALA PRINT CLEARLY NEW: El' RENOVATION: P�, REPLACEMENT:[-] PLANS SUBMITTED: YESE] N00 FIXTURES Z FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB LI- _-- CROSS CONNECTION DEVICE { {I I, f - (�-j�-{ (-- DEDICATED SPECIAL SPECIAL WASTE SYSTEM �� .. II j j(� :jam—�� �� —��-- DEDICATED GAS/OIL/SAND SYSTEM�� _1 1 DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM =71 DISHWASHER =I DRINKING FOUNTAIN =IE7� FOOD DISPOSER FLOOR /AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK LAVATORY _ ... ROOF DRAIN ( SHOWER STALL SERVICE / MOP SINK TOILET f URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES { WATER PIPING -- OTHER -1I1L� INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YESF-1 NO 0 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAM: Rar-rNrrrKiN.r_, THF APPROPRIATE_B.OXBELOW LIABILITY INSURANCE POLICY N- OTHER T OWNER'S INSURANCE WAIVER: I am aware that the license( + ter 142 of the Massachusetts General Laws, and that my signature on this G� � C '� C� ,1,/, INER [:]AGENT SIGNATURE OF OWNER OR AGENT 1 hereby certify that all of the details and information I have submitf 1I_ ;the best of my knowledge and that all plumbing work and installations performed under the p( L^ �2•�T ;tinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the Gene PLUMBER'S NAME 4)1 t9 4E GS fid' ATURE MP&—JP[--1 CORPORATION' U ► /� — 4- 1 L COMPANY NAME i L CITY STATE ` w FAX CELL MAILF7 o z!D LU IL w w LL AV+ 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 shallnot 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 ur renewal of a Iicense 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 PIease 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 phonenumber(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 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 ofinsurance 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 theapplicant. 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 (ifnecessary) 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 by 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 notrelated 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 affiddvit. 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: Ahe CorrjimortweEaU-- of Aflassaeatlsetts Depar`ment of ladustrial Accidents Office of Investigattons 600 Washiugton Street Boston. MA 4211 X Tot. # 617-727-4900 ext 406 ox 1-877 M-ASSA.FE Revised 5 26-05 Fax #61.7-727-7749 www.mass.l;ovMa P TYPE OR PRINT CLEARLY FIXTURES Z MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY MA DATE j PERMIT # 1 C�20 JOBSITE ADDRESSL.- OWNER ADDRESS M > (J TEL FAX OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL ❑ RESIDENTIAL, NEW: F- RENOVATION: K., REPLACEMENT: F-1 PLANS SUBMITTED: YESFJ NO[] FLOOR BSM 1 1 7 1 3 1 d 1 F 1 R 1 7 1 Q 1n an en BATHTUB _ T CROSS CONNECTION DEVICE I—��-(� DEDICATED SPECIAL WASTE SYSTEM _ C —(�j DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM 0 DISHWASHERI—.__I� DRINKING FOUNTAIN' FOOD DISPOSER FLOOR / AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK LAVATORY --I �� I --I . _.. I --I ROOF DRAIN SHOWER STALL SERVICE /MOP SINK TOILET URINAL —,1 WASHING MACHINE CONNECTION - - - WATER HEATER ALL TYPES _ ....... ... WATER PIPING I—� OTHER INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES F -j NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY ❑ BONDF71 OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT Q SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this 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 will be in compliance w' al ertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME I rhi 6- LS LICENSE # SI ATURE MP& JP El CORPORATIONE]# �PARTNERSHIPF�#[�LLCQ#� COMPANY NAME 1 L oi�ADDS FJ-0e--'PL�11Ca CITYLM STATE ZIP TEL FAXI CELL C MAIL A.+ pc N� El � w w O a � z w � a � W w w Q N Z O � H Q U J a a Q vv N 2 H li! W LL h The Commonwealth ofMassachusetts Department oflndustrialAccidents Office oflnvestigations' 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/•PIumbers )nlicarit Tnfnrm�f;�„ Name (Business/Organization/Individual): Address: City/State/Zip: %}� ��, i ©icy Phone It: Ar you an employer? Check the appropriate box: a employer with 4. g ` ❑ I am a general contractor and I employees (full and/or part-time).* 2. ❑ I am a sole proprietor or have hired the sub -contractors listed partner- on the attached sheet. ; ship and have no employees These sub -contractors have working for mein any capacity, [No workers' comp, insurance workers' comp. insurance. 5. ❑ We are a corporation and its required.] 3. ❑ I am a homeowner doing officers have exercised their all work right of exemption per MaL myself. [No workers' comp, c. 152, §1(4), and we have no insurance required.] f employees. [No workers' comp, insurance required ] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. [J Demblition 9. D Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roofrepairs I3.[] Other r *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. I f Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 'Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp, policy information. lam an employer that isproviding workers' compensation insurancefor my employees. Below is fiiepolicy andjob site Insurance Company Policy # or Self -ins, Lie. #: (9 q0 t Expiration Date: ` GJ It Job Site Address - 7t o AM.6(22,2T� 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 maybe forwarded to the Office of Investigations of the DIA, for insurance coverage verif cation. I do hereby certify under fite/�jcii mandpenalties ofperjury that the information provide f above is true and correct. i it t/1 , l �� vfficaai use only. Do not write in fills area, to be completed by city or town official. City or Town: Fermit/License # Issuing Authority (circle one): I. Board of Health 2. Building Department 3. City/Town Clerk 4.EIectrical In 5. PIumbing 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 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 "everystate or local licensing agency shall'wxthhold 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 -contractors) name(s), address(es) andphone number(s) along with their cerocate(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 ofiusurance 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 permitllicense number which will be used as a reference number. In addition, an applicant that must submit multiple permit/licerise applications in any given year, need only submit one affidavit indicating current policy information (ifnecessary) 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 ba filled out each year. Where a homeowner 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: Tke O01j)MAO) health Of V14,9sachusetts Department of kdustrzal Accidents Of ce ollnvestigations 600 Washingi<on Street Boston; MFA. 02111, Tot. # 61.7-727-4900 ext 4406 ox i-s77-m-AsSAFR Revised 5-26-'05 Fax # 617-727-7749 wwwaaass.g-ovfdia Page 1 of 2 DelleChiaie Pamela From: Sawyer, Susan Sent: Wed 11/5/2008 4:28 PM To: Melnikas, Andrew; Grant, Michele; Brown, Gerald Cc: DelleChiaie, Pamela Subject: 73 Pleasant Attachments: I spoke with Pam Patrowski 683-1260 today. Owner of 71 Pleasant Street She said she has not called me before, but I believe she had as it was very familiar to me. Anyway, I told her we understand her concerns and listened to her multiple issues. She has spoken to police as most of the real issue is her family's safety. I also said we would use our resources to help locate the best party to contact. This is an unusual situation as the defaulted owner of the condo is apparently still allowed in the house and is possibly damaging the home when she returns. As this is a two condo home it affects the caller as well. We will not be going in the property however we will do our best to determine the entity to contact about this property. I recommended she draft a letter to the current owner explaining the damage being done and requesting they secure the property from her entry noting she has been to the police for advice. Also I recommended legal counsel as this will end up being a legal issue if damage is done to her own home by the neighbor's actions. Susan Pam, we need your help on this. Can you get any info you can find on it? Thx From: Melnikas, Andrew Sent: Tuesday, November 04, 2008 8:36 AM To: Grant, Michele; Sawyer, Susan Subject: FW: From: McCarthy, William Sent: Monday, November 03, 2008 7:27 AM To: Fire Department http://exchange2003.town.north-andover.ma.us/exchangelpdellechiaiellnboxl73 %20Pleasa... 11/6/2008 Page 2 of 2 Subject: DEPUTY, ENGINE 1 UNIT 4 WENT TO 73 PLEASANT STREET FOR A WATER PROBLEM. THEY FOUND THAT WATER DAMAGE HAS DAMAGED THE FLOOR IN THE DUPLEX NUMBER 73. THEY FEEL THE FLOOR COULD BE DANGEROUS IN THE EVENT OF A FIRE. UNIT 3 A-1 WENT TO 135 MASS AVE FOR A MEDICAL AND INFORMED ME THAT THE OWNER IS A PACK RAT AND THIS HOUSE COULD BE DANGEROUS IN THE EVENT OF A FIRE. I WILL INFORM THE ON COMING LT TO FOLLOW UP WITH BUILDING DEPARTMENT AND FIRE PREVENTION. LT.W.MCC 0 http: //exchange2003 .town.north-andover.ma.us/exchangelpdellechiaielInboxl73 %20Pleasa... 11/6/2008 Location #r/// l PA Ul `,� No. 29"5-- Date l%d'�Oc7 TOWN OF NORTH ANDOVER Vol Certificate of Occupancy $ Building/Frame Permit Fee $— sACMUs y Foundation Permit Fee $ Other Permit Fee $ _ TOTAL $ S� Check # (Call - 14 C 2 6 14026 % Building Inspector 4�N' . 'qt ,i TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAI RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: DATE ISSUED: �7—c�CF.---ev _CD SIGNATURE: Building CommissioZmEjector of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: X Map Number Parcel Number �- 1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: Lot Area Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided 1.7 Water. Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: Public ❑ Private 0 Zone Outside Flood Zone ❑ 1.8 Sewerage Disposal System: Municipal 0 On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record Name (Print) Address for Service: 19vvp-- !L� co f AinaturV Telephone 2.2 Owner of 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 ❑ License Number Expiration Date 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name Registration Number Address Expiration Date Signature Telephone c'a �� X f �It SECTION 4 - WORKERS COMPENSATION (M.G.L C 152 § 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 permit. Signed affidavit Attached Yes .......❑ No ....... ❑ SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by permit applicant QFFICIALUSEQNLY , uBuilding 1. Building - yy UJ (a) Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (e) X (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, 0, S !� Q s Owner/ thorized Agent of subject property Hereby authorize to act on My beha in all matters relative, o rk authorized by this building permit application. Si nature of er X 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/Aent 1 1111111 NO. OF STORIES Date 113MM lull SIZE BASEMENT OR SLAB SIZE OF FLOOR TEVIBERS 1ST 2 ND3RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE D. Robert Nicetta Building Commissioner (978) 688-9545 (978) 688-9542 Fax HOMEOWNER LICENSE EXEMPTION Please print DATE '�I JOB LOCATION Number Street -HOMEOWNER G Zq/v-,^ Name PRESENT MAILING ADDRESS City Town �7 � r � i --T I d- C j Home Phone State Map / lot Work Phone Zip Code The current exemption for "homeowners" was extended to include owner -occupied dwellings of two units or less and to allow such homeowners to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor. (State Building Code Section 108.3.5. 1) DEFINITION OF HOMEWOWNER: Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one or two family dwelling, attached or detached structures ac- cessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shalt not be considered a homeowner. The undersigned "homeowner" assumes responsibility for compliance with the State Building Code and other Applicable codes, by-laws, rules and regulations, The undersigned "homeowner" certifies that he/she understands the Town of No. Andover Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. A HOMEOWNER'S SiGNA APPROVAL OF BUILDING OFFICIAL t NORT" Town of North Andover Building Department 27 Charles Street North Andover, MA. 01,845 D. Robert Nicetta Building Commissioner (978) 688-9545 (978) 688-9542 Fax HOMEOWNER LICENSE EXEMPTION Please print DATE '�I JOB LOCATION Number Street -HOMEOWNER G Zq/v-,^ Name PRESENT MAILING ADDRESS City Town �7 � r � i --T I d- C j Home Phone State Map / lot Work Phone Zip Code The current exemption for "homeowners" was extended to include owner -occupied dwellings of two units or less and to allow such homeowners to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor. (State Building Code Section 108.3.5. 1) DEFINITION OF HOMEWOWNER: Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one or two family dwelling, attached or detached structures ac- cessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shalt not be considered a homeowner. The undersigned "homeowner" assumes responsibility for compliance with the State Building Code and other Applicable codes, by-laws, rules and regulations, The undersigned "homeowner" certifies that he/she understands the Town of No. Andover Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. A HOMEOWNER'S SiGNA APPROVAL OF BUILDING OFFICIAL Town of North Andover a* "a RTH qti 671 6i 0 o Building Department ti 27 Charles Street North Andover, Massachusetts 01845 ?, e (978) 688-9545 Fax (978) 688-9542 �4�°co 11 R,Too ,PP`��y VS CH DEBRIS DISPOSAL FORM In accordance with the provisions of MGL c 40 s 54, and a condition of Building permit # the debris resulting from the work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL cl 1, s150a. 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