HomeMy WebLinkAboutMiscellaneous - 73 HOLLY RIDGE ROAD 4/30/2018d..: suis<:1FKk«Yi!� 1 9800 Fredericksburg Road San Antonio, TX 78288 USAW 04664.1W3WK.JSS1043067285.01.01.780 CITY OF NORTH ANDOVER 120 MAIN STREET NORTH ANDOVER,MA 01845-2420 Reference: MASSACHUSETTS GENERAL LAWS, CHAPTER 139, SECTION 3B Attention Building Commissioner, I am writing regarding the claim referenced below. Policyholder: Michael J Schiff Reference #: 004911513-17 Date of loss: February 15, 2015 Location of loss: North Andover, Massachusetts Address: 73 Holly Ridge RD, 01845 May 1, 2015 A claim has been made involving loss, damage or destruction of the property referenced above, which may either exceed $1000.00 or cause MASSACHUSETTS GENERAL LAWS, CHAPTER 143, SECTION 6, to be applicable. If any notice under MASSACHUSETTS GENERAL LAWS, CHAPTER 139, SECTION 3B is appropriate, please direct it to my attention and include the reference #. You may submit correspondence or questions to me. My contact information is: Address: P.O. BOX 33490 SAN ANTONIO, TEXAS 78265 Fax: 800-531-8669 Phone: 800-531-8722, ext 61266 Sincerely, , - Cindy L. Otte Property -SAT -E Unit 9 USAA Casualty Insurance Company P.O Box 33490 San Antonio, TX 78265 Phone: 800-531-8722, ext 61266 Fax: 800-531-8669 CMG/CLO 004911513 - DM -04664 - 17 7357- 59 54577-0914 Page 1 of 1 Date .. //-/�` _ TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ...... G- ?t ..G ...... . has permission to perform .. � 0 /C Lk')... !�/� F/C..... , wiring in the building of ..... Sc- h .' ................. . at . © 1... ��1� .. '? ......... , North An over, Mass. Fee ......... Lic. Not fx Gr.,e.............. 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D Ismagaaaadco■ammomdI hwehbdtw PROs �. Qrtew }s 2.0 ,or = 7 13Ramieftg formiay 9 D D � comp. Rd"s rg=wadrdmS.Oweaesia" nq*a&l 3.L7lmabdmoomadaimgAvxmk s&af�e ILE3PimbbgnpdmQradM= mam Db amp- C.MM=dweliawjw Pb :��9reatieabeo�#1 moscaba �aeissoe�iodbeioa.stio.r�g9�rwo�' aor�pam�od�o6q �iam�. tHoaeo�e�aswm�c�isa�dav�s�o���a�sag.�art�estmeae�aeeaoam.�7oe:�csd+micsaaw�eio�e�eilgse�h . �Ccaewu�o�slrtaiedc8isba��sau�ct�ed�ad�aad �eet�� �maat9�eaoda�sdhed�eracaOttLo'eaatieir�Lae eapio�oeR �ioaebooaaaau�ir�empioyeer,�9�P�°� �10d0�C°�`�10i�D=�� - — Ia:#cas AWit s' a9 Beilona�atlageyewi�oisg+e T� M, -I rINYMMAHUMMU& ►arse WGoaiK3o53 dmw AtmdtaaWotd ew s' pdkypop(dmft*gpdiLymdd84 pa&wlbm.p e a as aeaa 2SAofMM a. Li2 cmiMdlDdro cf Ofa fe�eng�oSi,'�Q:� eadra�rco�►ear as�as ci�p��e � afa Sinl'a�d a5ee afapllaSMMad®y dWvidNor B*s*dwddW&QWsfV*dMmmW=Wbcfmaasr3edto�eo lioecf doom a£do Du for im m cmarvedfiedick This certifies that . �(7!'1rJ.. r`? .............. + has permission for gas 'nstallation ..off.1 Q , in the buildings of ... f . .v... ..................... . at ....-�.-1" t��k North Andover, Mass. Utz. �. Fee �. ..... Lic. No. .. .� ....... GASINSPECTOR Check # r � s MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY�-��1—m-- oee— MA DATE c PERMIT# -� - JOBSITE ADDRESS c� � c.OWNER'S NAME t �r GOWNER ADDRESS '7 TEL TYPE OR PRINT OCCUPANCY TYPE COMM CIAL D EDUCATIONAL ® RESIDENTIAL - CLEARLY NEW: RENOVATION: Q REPLACEMENT: Fj PLANS SUBMITTED: YES Q •"N0o APPLIANCES 7 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER �...._� _. _- _( __. i _ _ J __ 3-31 CONVERSION BURNER COOK STOVE l a J -.. _ . mJ -._ _.I DIRECT VENT HEATER DRYER FIREPLACE _. _ _I lJ^� I .. - �1 w� FRYOLATOR FURNACE GENERATOR T . ji (_ r_ I _rte . i ^ (�-- --__-- (..__-t( —AL GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT �_.._ 1-i = TEST UNIT HEATER UNVENTED ROOM HEATER( - WATER HEATER OTHER I INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES 10 _[l_I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICYOTHER TYPE INDEMNITY BOND (4 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 - 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 all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUM BER-GASFITTER NAME ��di��LICENSE # 3.4 SIGNATURE MP MGF JP 0 JGF __.( LPGI --� l [� CORPORATION�j #� PARTNERSHIP 0#==.r -----_-_II LLC ]# COMPANY NAME:,_ ADDRESSC.,( 1 CITY ---. _ �._ f _ ._.... -I STATE .- --- _ZIP CJS, _�_ (TEL FAX CELL, C _ � S S � AEMAIL-�� ..._.. - cl 1 k 1 OR Z U W w ~ ft � cn a a co �.® W Iii LU U- tki The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information A Please Print Letsibly L Name (Business/Organization/Individual): vy tool j f LY/ Address: City/State/Zip: Phone #: !o 63 � :� --S-5 tj 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).* 6 have hired the sub -contractors 2. [ am a sole proprietor or partner- listed on the attached sheet. I _ 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 12.0 Roof repairs 13.❑ Other *Any applicant that checks box #I must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #: lob Site Expiration Date: City/State/Zip: kttach 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 ine 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 if up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of nvestigations of the DIA for insurance coverage verification. do hereby certify under the pains an nalties of perjury that the information provided above is true and correct 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 #: ky- Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or" renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should -be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www,mass.gov/dia Ai-ol GENERATOR APPLICATMN DATE: fa�"jVej pilt'�UY��e.[v� �✓M�' �`� �J�� Jam- ��hl\Z LOCATION: 14)�I1 OWNERS NAME: GENERATOR kw 2--o NO INSTALLATION OR GROUND DISTURBANCE BEFORE APPROVALS* CONTRACTOR:. �UIeIMG�..i Lly�v� � Po-lim LLL PHONE NUMBER: ISI ELECTRICAL IDENTIAL GAS 9 COMMERCIAL TEMPORARY LOCATION OF GENERATOR: "'ZONING DISTRICT: CAI V)A5 KA - till "'CONSERVATION APPROVAL 'town of North Andover 411,f Page 1 of 1 SelectionI Legend- Location- M Select _ ........... (show all) 1 selected To Mailing Labels To Spree Property 1Building Permits Pia Owned SCHIFF, MICHAEL) Owner2 DONNA I SCHIFF Address 73 HOLLY RIDGE ROAD PropertyID 098.B-0017-0000.0 Lot Size 1.08 A Fiscal Year 2013 Land Use 101 Code Last Sale 08/23/1993 Date Book/Page 3813 Total $673800 Valuation Building CL Type Year Built 1989 ..� '--- . 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MICHAEL 098.8-0017-0000.0 1 selected To Mailing Labels To Spre; Pro oertvBuilding Permits Pia Ownerl SCHIFF, MICHAEL owner2 DONNA J SCHIFF Address 73 HOLLY RIDGE ROAD PropertyID 098.6-0017-0000.0 Lot Size 1.08 A Fiscal Year 2013 Land Use- 161 Code Last Sale 08/23/1993 Date Book/Page 3813 Total $673800 Valuation - Building CL Type Year Built 1989 http://mimap.mvpc.org/NorthAndovermimapNiewer.aspx 11/7/2012 Division of Professional Licensure: License Search Page 1 of 1 The Official Website of the Office of Consumer Affairs and Business Regulation (OCABR) Division of Professional Licensure Mass.Gov Mass.Gov Home 'State Agencies A -Z Topics Home > Division of Professional Licensure > ONLINESERVICES ....._.... .......... ....................._....._.__.................................. ... ..... ..................... ...... .......__.. Check a License Cheek A Professional License Locate a Licensed Professional By the Division of Professional Licensure Online Address Change Contact the Agency. SEARCH CRITERIA More " Profession: Plumber REFERENCES & Last Name: beginning with Leonard RELATED INFO City: amherst Zip Code: 03031 Disclaimer Regarding Website License Searches Enforcement Process LIC. BOARD LIC. TYPE NUMBER NAME CITY/STATE STATUS Glossal} Plumbers Ft Master Plumber 13248 JOHN A. AMHERST, Current Glossary of License Status Gasfitters --- LEONARD ;NH Codes Plumbers Ft Journeyman 25690 JOHN A. AMHERST, Current Gasfitters Plumber LEONARD NH MOTe... Your search has resulted in 2 licenses Note: If the licensee cannot be found by name and the name typically has apostrophes, spaces, hyphens or periods try doing the search again without these characters. Examples: If the last name is "O'Donnell", try searching for "ODonnett" or "0 Donnell" If the last name is "McDonald", try searching for "Mc Donaid" If the last name is "St. Helens", try searching for "SfHelens" or "St Helens" If the last name is "Jones -Doe', try searching for "JonesDoe" or "Jones Doe" The page above has been generated by the Division of Professional Licensure web server on Friday, November 16, 201,2 at 7:33:35 AM. © 2007-2011 Commonwealth of Massachusetts Site Policies Contact Us http://license.reg. state.ma.us/public/pubLicRange.asp?profession=Plumber&lName=leon•.. 11/16/2012