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HomeMy WebLinkAboutMiscellaneous - 77 BRIDGES LANE 4/30/2018 (2)N_ pO • W O � 60 G) m W 0) o z o m o r^ 0 PO Box 55098 Boston, MA 02205-5098 617-951-0500 Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS, Ch. 139, Sec. 3B To: Building Commissioner or Board of Health or Inspector of Buildings Board of Selectman City Hall City Hall NORTH ANDOVER, MA 01845 NORTH ANDOVER, MA 01845 RE: Insured: JANICE T PIASECKI Property Address: 77 BRIDGES LANE, NORTH ANDOVER, MA Policy Number: HMA 0363121 Claim Number: BOS00050314 Date of Loss: 2/9/2014 Company: Safety Indemnity Insurance Company Claim has been made involving loss, damage or destruction of the above -captioned property, which may either exceed $1,000.00 or cause Mass. Gen. Laws, Chapter 143, Section 6 to be applicable. If any notice under Mass. Gen. Laws, Chapter 139, Section 3B is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim number. Eric Gill Claim Examiner 8/11/2015 Safety Insurance Company Homeowners Claims Unit P. O. Box 55098 Boston, MA 02205-5098 Phone: (617) 951-0600 EXT 3321 Fax: (617) 531-5774 Email: EricGill@Safetylnsurance.com PO Box 55098 Boston, MA02205-5098- W Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS, Ch. 139, Sec. 3B To: Building Commissioner or Board of Health or Inspector of Buildings Board of Selectman City Hall City Hall NORTH ANDOVER, MA 01845 NORTH ANDOVER, MA 01845 RE: Insured: JANICE T PIASECKI Property Address: 77 BRIDGES LANE, NORTH ANDOVER, MA Policy Number: HMA 0363121 Claim Number: BOS00063089 Date of Loss: 7/5/2015 Company: Safety Indemnity Insurance Company Claim has been made involving loss, damage or destruction of the above -captioned property, which may either exceed $1,000.00 or cause Mass. Gen. Laws, Chapter 143, Section 6 to be applicable. If any notice under Mass. Gen. Laws, Chanter 139, Section 313 is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim number. Allan Leavitt Claim Examiner Safety Insurance Company Homeowners Claims Unit P. O. Box 55098 Boston, MA 02205-5098 Phone: (617) 951-0600 EXT 3213 Fax: (617) 531-8891 Email: AllanLeavitt@Safetylnsurance.com 7/24/2015 J� I 11150 Date... .. //.. c ............ . TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that.... W .....­.. ...jz ............. i***-** has permission to perform .... .�'*x4W .... � plumbingin thn buildings of ........ l_4v .................. Fee,57,Lic. No. ....... Check # /�- ........................... Nodh Andover, Mass. <--) ............................ ........ . ......................... C�OLU�BINIG INSPE -TOR i MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ' CITY . /vv a2 Y��1 _ _ V e MA DATES�/ r /_ s __I PERMIT # 1 I I SZ JOBSITE ADDRESS OWNER'S NAME S I P OWNER ADDRESS ?) !-��`hGC°S L ! TEL — FAX E TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL 0 RESIDENTIAL Z9 PRINT CLEARLY NEW: RENOVATION: E REPLACEMENT:,o PLANS SUBMITTED: YES ® NOQ FIXTURES - FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASl01LISAND SYSTEM -_ f . ,._ ( I _.. I . l —I, DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR( INTERIOR) KITCHEN SINK LAVATORY ! _ f ._..___( 1 � l _._.._..1 ( [ .._..__.1 .:_..___I ___. _f I __...._._! ROOF DRAINwl SHOWER STALL .___.._ SERVICE/MOP SINK ..__J 1 { j I J i TOILET ___-- __I I T_k _ ._., f URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES l NO _l IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY © BOND P 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 F-1 AGENT 10 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 with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME I LICENSE #1 (9; ( SIGNATURE MP [A JP Di CORPORATION k--]]# 33 _f PARTNERSHIPD# _ e LLC COMPANY NAME -k ijADDRESS y CITYNa4--_r►0✓4.. ._ .__ ._.._ .._I) STATE ,A _ ZIP TEL S'7 - ?4 FAX CELL S-_73 Z EMAIL �✓ 1 O rl Z W tii w LL rA 0 0 z z a a i Date.... .............. .... ..... .... .... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ................>... %%4..%��1-..(.......y....�.... .�..���....: haspermission to perform ................. !...: �T7............................................................. wiringin the building of................................................................................ jot � 1 6&/ North Andover ass. a........................................5....../............../i, .,, 7 .. Fee ...................�.�"Lic. No.�1...�.�?���........�,��.,�.�.....,:..... % qr f ELECTRICAL INSPE� OR Check # / 3O L 133 r,17 r IV Commonwealth o f Mamac"tb Official Use Only cc�� cc77 Permit No. 13 JZ. 5f aL.JeParfinent o�.}ire �ervicea Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (ieaveblank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MPC),27 CMR 12.00 (PLEASE PRINTININK ORTYPEALL INFORrTION) Date: 6-1d)115 City or Town of:O cl- ,�� To the Inspector of Wires: By this application the undersigned gives notice of his or -her intention to perform the electrical work described below. Location (Street & Number) % ?�rl�l Owner or Tenants Owner's Address t Is this permit in conjunction with a building permit? Telephone No. No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps 1 Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion of the following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. of Tota 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 ALAR IS 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 b No. of Waste Disposers Heat Pump Totals: ._,gm_er'"on's J.KW' o. o Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW ecurity Systems:* No. of Devices or Equivalent No. of Water Heaters KW No. o 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 glVires. Estimated Value of lec cal Work: %�'''J a (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE C VE GE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties ofperjury, that te tnf rn/ation on this application is true and complete FIRM NAME: c0J Z, � .:%/ �%c G i ��G�ii� ��it kkl/J15 ZL� LIC. NO.: Off% -20Y- Licensee: �,/ri '� Sms%� Signature LIC. NO.: -2J 205— A (If applicable, enter "exempt" in the license number line.) Bus. Tel. No.: Address: Alt. Tel. No.: *Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's a est. Owner/Agent Signature Telephone No. PERMIT FEE: $ V The Commonwealth of Massachusetts Department of Industrial Accidents Office of Invesdgations 600 Washington Street Boston, MA 02111 www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (BusinesstOrganization/Individual): Address: v Phone #: Are you an employer? Check the appropriate box: 1 I am a employer with 4. ❑ 1 am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ 1 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. employees and have workers' [No workers' comp. insurance comp. insurance.$ 5. ❑ We are a corporation and its required.] 3. ❑ 1 am a homeowner doing all work officers have exercised their myself. [No workers' comp. right of exemption per MGL insurance required.] t c. 152, §1(4), and we have no employees. [No workers' comm insurance required.l LZ C. —61V7,�P% 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. 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 state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employeex Below is the policy and job site reformation. ; ) 171 Insurance Company Policy # or Self -ins. Lic. M AILAIeI fir' 6 ZZ Expiration Date:L,C.� J ' r Job Site Address: // `�, City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the p ' penal ' s of perjury that the information provided above is true and correct Rionatnre- Date: Phone M ��2Y _ 4-19--&"10 7 Official use only. Do not write in this area, to be completed by city or town officiat City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: r �.10RTy O�tt`eO �6gti0 L y b yyT O cun�cwiw�c• ��' '�p4A�RATED I.PPi'(�/ CONSERVATION DEPARTMENT Community Development Division May 31, 2011 Janice Piasecki 77 Bridges Lane North Andover, MA 01845 RE: Selective cutting of two trees and pruning/limbing of several other trees within the buffer zone of a wetland resource area. This is a follow up letter pertaining to your request to remove two (2) trees in close proximity to your home at 77 Bridges Lane. The trees were identified by Ms. Piasecki during the site inspection conducted by the conservation department on May 26, 2011 to review the location of the trees to be cut and/or limbed and their distances to the wetland resource area. Upon review of the site, it was determined that one large dying oak tree and several healthy birch saplings are located within or just bordering the 25' No -Disturbance Zone pursuant to the North Andover Wetlands Protection Bylaw (C. 178 of the Code of North Andover). A large white pine tree with the top of the tree broken off is located outside of the 25' No -Disturbance Zone. Removal of vegetation, including pruning and cutting, is prohibited within the No -Disturbance Zone except in rare circumstances, such as safety. Two trees were observed to be in close proximity to the house and are both in the process of dying. Due to the potential danger imposed by the two dying trees, the Conservation Department will permit their removal to prevent possible injury or property damage. The large oak tree and the large white pine tree are both permitted to be removed. The birch saplings may be gently pruned/ limbed, but are not permitted to be removed. These cutting activities shall be limited to the two trees identified and photographed during the site inspection. The approved cutting will be subject to the following conditions: ❖ Please notify the conservation department of when the tree cutting and pruning activities will occur. ❖ No machinery shall enter the 25' No -Disturb Zone which occurs approximately at the stone wall. ❖ No work shall occur in resource areas. ❖ All tree limbs, brush, and other debris materials shall be taken off site and disposed of properly. 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 918.688.9530 Fax 918.688.9542 Web www.townofnorthandover.com er-ti' �',�,t5q _f.A +••Ar �,,,, ,� 'K.r +sem{ A "iT'4 f. 1p Y w t" 't i r•T`. +. r *s •`"" r I��Tr .t ff,,,' •.y'e dt�.vayl i'a'�ir' ° dr S �,•. f X`,. «a'�h. f -,•-•'.it r�' `, ci .fir • 9,a- '` +.y �,s• �4 r i r•''r1`,:teu Sia r•s b+'�i r G�+`Fa t t?P *•• $'4r ,. tt-✓+Ap'� t,• 'trr� h fi•�q,5 t kgd ,t ?. �'ay ''r .I' '�" '' k ftf4 . °x �y �c.�•`. r s KMy�tt�f� +� fi .+ lid '1 y'Y• S� !' r `ti'E' S ,,}y W1% yt f 'tr 5 Y +r �"Y t 4^° N /v aY r" r�' Y• '.,i'ufi^.' •Y•:,I'.'{," •fi` >a+•,t Y fi•f•'"y a s �'c'• •J �` t $ +Ar'•� `» F g r fP•� �Ai,�'F ,�+� � '• ti"1F � v tr` ►• °! ,r .,. :y, ` ,ag7F,, t . �*r 4 r ai• .+ji�E?.!'+c'It" .� ,. t, G ,. .,k'g � 4r`� � " t of •r } ,� r. -c'3� � � ���� v':{ 4",.I�g� ��_ int' �a sltf•. r4. ��, •r� �`+ 5��'y� � 's'�rb =t� F��(,.��'ll, "�a .��t All, w y',r ki, d.a f f ,a�•" it�+i jt j ' r .t lr"r"` � ,�- '� :' .y.;.Y� f°r s c4. 3+ ta� • � •,x#"77' -: �•�F' * # #. y'rh. _'; � � .J� .� ty., .;°,�, Mfr � i* X° .tii. a x. � -a tee^ ��'�t >✓� 1 I '4 I(,yte tel: qqs +A � f � r-, 9r� t Tfdy' '��• r f` ,�,� !� �' C` a � <° +� t'ia r"., t >rf r'.I4 ;•« o _ + h r �i(, ' '4g -,R x+ ~{ �,e,r.•�f 4` �.�- _, r "y# c a. y' ° i h �'�f"t•� AMA 3rys k. f+vlbr t �i S y k 1s � � '`Yq � •ate r.. 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Sec. 3B To: Building Commissioner or Board of Health or Inspector of Buildings Board of Selectman City Hall City Hall NORTH ANDOVER, MA 01845 NORTH ANDOVER, MA 01845 RE: Insured: JANICE T PIASECKI Property Address: 77 BRIDGES LANE, NORTH ANDOVER, MA Policy Number: HMA 0363121 Claim Number: BOS00050314 Date of Loss: 2/9/2014 Company: Safety Indemnity Insurance Company Claim has been made involving loss, damage or destruction of the above -captioned property, which may either exceed $1,000.00 or cause Mass. Gen. Laws, Chapter 143, Section 6 to be applicable. _If any notice under Mass. Gen. Laws, Chapter 139, Section 3B is appropriate, please direct it to the'attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim number. Eric Gill Claim Examiner 2/23/2015 Safety Insurance Company Homeowners Claims Unit P. O. Box 55098 Boston, MA 02205-5098 Phone: (617) 951-0600 EXT 3321 Fax: (617) 531-5774 Email: EricGill@Safetylnsurance:com-