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HomeMy WebLinkAboutMiscellaneous - 83 HUCKLEBERRY LANE 4/30/2018Po Box 55098 Boston, MA 02205-5098 617-951-0600 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: CINDY TRAVERSO and MICHAEL TRAVERSO Property Address: 83 HUCKLEBERRY LN, NORTH ANDOVER, MA Policy Number: HMA 0352755 Claim Number: BOS00057864 Date of Loss: 3/31/2015 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, 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. Jedd Canane Claim Examiner Safety Insurance Company Homeowners Claims Unit P. O. Box 55098 Boston, MA 02205-5098 Phone: (617) 951-0600 EXT 3524 Fax: (6 17) 531=8897 Email: JeddCanane@Safetylnsurance.com 4/1/2015 .. N- " i j 6 .-Y7 TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ... . ....... rk�cze'.K.--Q .............. has permission to perform ........ N-::�� .... . .......................... wiring in the building of ...... .................. at ...... 4�')tJ ....... 4,41, , North Andover, Mass. FeegJ. ....... Lic. No. .......................................................... ELECTRICAL INSPECTOR ( "I tr e06 3 41 WHITE: Applicant CANARY: Building Dept. PINK: Treasurer 011e CJuuununwPttltll of .4&13Btte1lu1Rtt15 13cpartment of Ilublic fttft:tg BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 Office Use Only Permit No. Occupancy A Fee Checked 3/90 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date 4,2 —17-7-7 City or Town of NORTH ANDOVER To the Inspector of Wires: The udersigned applies for a permit to perform the electrical work described below. Location (Street &Number —_d1L 7 y 3/-`'k Cftle�e"14 (Qi1,<_ Owner or Tenant 1Ajq tJbO _ bow. Owner's Address Is this permit in conjunction with $ building permit: Yesf No ❑ (Check Appropriate Box) Purpose of Building s7r4a (t OoIfil)tit' )J Utility Authorization No. V-0 Z33 Existing Service Amps _J Volts Overhead ❑ Undgrnd ❑ No. of Meters New Service Z400 Amps /2,01 ZYb Volts Overhead ❑ Undgrnd No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work A /?.f.c ) <VLc )o // No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures Swimming Pool Above In- ❑ ❑ grnd. grnd. Generators KVA No. of Emergency Lighting No. of Receptacle Outlets No. of Oil Burners - Battery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Detection and No. of Ranges No. of Air Cond. Total tons Initiating Devices No. of Disposals No.of Heat Total Total Pumps Tons KW No. of Sounding Devices No. of Self Contained No. of Dishwashers Space/Area Heating KW Detection/Sounding Devices Local Municipal El Other ❑ No. of Dryers Heating Devices KW Connection No. of No. of Low Voltage No. of Water Heaters KW Signs Ballasts Wiring No. Hydro Massage Tubs No. of Motors Total HP ...OTHER: INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts general Laws 1 have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent. YES X NO ❑ 1 have submitted valid proof of same to the Office. YES f& NO O If you have checked YES, please indicate the type of coverage by checking theapP �r°priate box. INSURANCE YJ BOND ❑ OTHER ❑ (Please Specify) �` (Expiration Date) Estimated Value f Electrical Work $ Work to Start _�2 ,1'7=f 7 -- Signed Signed ui FIRM NA Licensee Add Inspection Date Requested: Rough Gtirl� Ca.� Final No / NO. Bus. Tel. No. y'i8 ^ d&r —6zyc Alt. Tel. No. OWNER'S INSURANCE WXIVER: I am aware that the Licensee does not have the insurance coverage or its substantial equivalent as re- quired by Massachusetts General Laws, and that my signature on this permit application waives this requirement. Owner Agen (Please check one) 5-� 1� Telephone No. PERMIT FEE $ lVi (Signature of Owner or Agent) x•6565 Location— No. Date OOtTol TOWN OF NORTH ANDOVER Certificate of Occupancy $ CHU Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 4, Building Inspe4e, TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAI RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: DATE ISSUED: 314; of hpv SIGNATURE: Buil n Co missioner/I for of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map Map Number and Parcel Number: Parcel Number 1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: -5-S Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard ReqWred Provide RegWred Provided Reqtfired Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: Public ❑ Private ❑ Zone Outside Flood Zone ❑ 1.8 Sewerage Disposal System: Municipal 0 On Site Disposal System 0 SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record I �,, ff ShQhYl0iYt .0 WPTNEWC Name (Print) Address for Service Signature Telephone 2.2 Owner of Record: Name Print i Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Licensed Construction Supervisor: Address Signatu n � Telephone Not Applicable ❑ License Number Expiration Date 3.2 Registered Home Improvement Contras Not Applicable ❑ Company Na susRegistration L Number ti 3J a pal L Address / -5 �! Expiration DateQ signature- IV Telephone 1 L 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) V Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: PAK SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by permit applicant OFFICIAL USE ONLY 1. Building �d© 0 (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) x (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, as Owner/Authorized Agent of subject property .Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief Print Naniei L / b el J Signature of Owner/A ent Date NO. OF STORIES SIZE r BASEMENT OR SLAB SIZE OF FLOOR TIMBERS r G c r 1 2 3 RD SPAIN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS IVY /11 HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING /;p diA X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND ° i IS BUILDING CONNECTED TO NATURAL GAS LINE ,j r o— � gs0-57t7 ,oc. QF aA.0 JEFFAEY� HOFMANN R PAI I�Z� W. ' CPO T /dj�VC /Nt7��i ��fll.ft� � ��E �vtario,v ,Qv /LOT VAI b IAI ' O.!'.Ili✓N Foe' o 1 it Seer. io' isy7 ,KE.E!'/.«GIGS' �•Vati2rG�.��K� J' .LvoOv6.� .i�GISS�tva^S�TT.S oisio ■ 4- 4165 � c F- lG�-� `fes.-�.. -7N--* _(�N BUILDING DEPARTMENT DEBRIS DISPOSAL FORM In accordance with the provisions of MGL c 40 S 54, a condition of Building Permit Number Is that the debris resulting form this work shall be disposed of in a property licensed solid waste disposal facility as defined by MGL c 11, S 150A The debris will be disposed of in: Location of Facility Signature of PeripW Applicant 00 i Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS 026641 Birthdate: 01/19/1933 Expires: 01/19/2002 Tr. no: 13569 - Restricted To: 00 ALBERT J LANZO 14 REYNOLDS RD WAKEFIELD, MA 01880 —i? Administrator T � u HOME IMPROVEMENT CONTRACTOR J Registration 123113 . Type - PARTNERSHIP Expiration 03/28/01 On Top Builders Albert J. Lanzo :Z-Z,,.,2�eynolds Rd ADMINISTRATOR - Wakefield MA 01880 The Commonwealth Of Massachusetts Department of Industrial -Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance .Afdavit dame Please Print J 1 �V;:;me Lccaticn' e ��r )� QIo t�y Phone Cam I am a homeowner performing all work myself. am a sole prcprie!er and have no one vicrkine in any capacity I am an employer providing workers' compens2tion for my employees working on this job. f Cihr Fr Phone e ( �S �?0 1-3 Insuranceo �•G���-G�y1��-t�O�uli. ��olic, T � Z'st1'.�--L�o��xg��—/�' -%� Co. 1 Comcanv name: Address Cih/: Phone T* Insurance Cc. Polio Y Failure to secure ccverage as recuirac uncer Secticn 25A or 152 can lead to the imposition cr criminal penalties cf a fine up to 51.9u0.00 and/or one years' imoriscrment as 'Neil as c:vii penalties in the form of a STCP'P/CRK ORCER and a Fine cf (51,00.00) a day against me. 1 understand that a c ray of ;`tis statement may to fcrNarced to the Office cf investigations cf the GIA fcr coverage verification. I do hereby certify undar the pains and penalties of perjury Sicnatu Print nam the information provided accve is !rue and ccrrec:. Date 3 /�d �7el Phone;P Official use only ce not write in this area to to completed ty city cr town cmc:a( Cty or TcNn P=rmit/Ucensire [Check if immediate response is required C.:ntact person: Phcre T' Euildirg Cept Licensing Board [j Selectman's Office health Department ❑ Other NOTICE ,.TO EMPLOYEES NOTICE TO EMPLOYEES The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston, Massachusetts 02111 617-721-4900 As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will give you notice that I (we) have provided for payment to our Injured employees under the above mentioned chapter by Insuring with: ZURICH -AMERICAN INSURANCE GROUP -------------------------------------=---------------------------- NAME OF I INSURANCE COMPANY ONE TOWER SQUARE HARTFORD, CT 06183 -------------- ------- 7---------- ADDRESS OF INSURANCE COMPANY (6ZSUB-422X849-A-98) .052098 TO 052099 ---------------------------------------------------- POLICY EFFECTIVE BOYLE INSURANCE AGENCY 445 MAIN STREET WOBURN MA 01801 Mom ----------------------- -------------------- -------------- NAME OF INSURANCE AGENT ADDRESS PHONE LANZO, ALBERT J SR & 14 REYNOLDS. ROAD LANZO, ALBERT 4 JR WAKEFIELD M MA 01880 M------------------------------------------------------------------- -EMPLOYER ADDRESS tM0I:6V_E_R%__WdRkERS COMPENSATION OFFICER (IF ANY) DATE MEDICAL TREATMENT 'The above named Insurer is required In cases of personal Injuries arising out of and In the course of employment to furnish adequate and reasonable hospital and medical services In accordance wfth*the provislonsof the Workers CompensetlonAct. A copy of the First Report ofInjury must. be given to the Injured employee. The employee may select his or her own physician. The reasonable cost of. the services provided by the treating physician will be paid by the Insurer, If the treatment is necessary and reasonably connected to the work related, Injury. In cases requiring hospital attention, employees are hereby notified that the Insurer has arranged for such attention at the gr�-, fi Of ux) FORM U - LOT RELEASE FORA SUW1vv61K INST�UC T IONS: This form is used to verify that all necessary approvals/permits from Ecards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. k**'�'****-.t****"*APFLICAiNT FILLS OUT THIS APFLICA�4 T C� ���v 7" PHONE 1-- 197J'���=��f/ LOCATION: Assessors Niao Number !Y PARCEL SUEDIVISION LOT (S)` STREET / . lloc le kei'� ST. NUMEER *�* OFFICIAL USE ONLY ...rte REC ENDATIONS OFT WN A-EiNTS: CONSERVATION ADMINISTRATOR DATE APPROVED 3 DATE REJECTED COMMENTs N 6(� v In S I (, a o wt COMMENTSI 0D, 6-� nl\bpig-e� Nip FOOD INSPECTOR -HEALTH SEPTIC INSPECTOR -HEALTH COMMENTS DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED PUELIC WORKS - Si=YVERIWA T ER CONNECTIONS DRIVEWAY PERMIT FIRE DEPAR T 7MENT RECEiVED EY EUILDING iNSPECTCR Revised 5�.-1 im DATE Cl) m m m C/) Cl) 0 F CO) 'O CD a Z CD O C r O O d. a� .o .p o C) p CL c CD O ao co CD COO) 10 CD O d O -2z ' OM U) cl) CD O CD y� CD CA Cl O CD 0 c CD V 2 O z Cn O c?�O m Z Q H • VJ O C, V) ?m m C! Vl _ = m P. 9.0 NCD �1 ._.►fi d -►m H T m d d = m y O =m m = C, O z`-'� O H Cf CD Er 5'a a ac=o _ o CL C C s:g CO, CD m H mom: m H dye: cr`A c CD C CD N m m . r N = m � a: CD "► A CD m o � 3 o m ._FN ED d � m W CO d� C a -o n � _ 3 °' 7 0 �- G� d � 1 � F CO) 'O CD a Z CD O C r O O d. a� .o .p o C) p CL c CD O ao co CD COO) 10 CD O d O -2z ' OM U) cl) CD O CD y� CD CA Cl O CD 0 c CD V 2 O z Cn O c?�O m Z Q H • VJ O C, V) ?m m C! Vl _ = m P. 9.0 NCD �1 ._.►fi d -►m H T m d d = m y O =m m = C, O z`-'� O H Cf CD Er 5'a a ac=o _ o CL C C s:g CO, CD m H mom: m H dye: cr`A c CD C CD N m m . r N = m � a: CD "► A CD m o � 3 o m ._FN ED d � m W CO d� C a -o n � _ z 0 4 1 A y 0 9 0 c °' 7 0 �- G� •7D , o x r n o rb � o a 0 aJ r � (D r , o nC rD tzO o x z 0 4 1 A y 0 9 0 c TOWN OF NORTH ANDOVER Building Department 1600 Osgood Street Building 2- Suite 2-36 Building Dept North Andover MA 01845 Tel: (978) 688-9545 Fax (978) 688-9542 COMPLAINT FOR INVESTIGATION DATE: I � j4g16 r' TEL #: '179-701-61P? NAME OF CDWL;AWTANT: Nr-r-4 R " DRES !',3 COMPLAINT TYPE: Electrical: Plumbing: Gas: Building: S�,e� 16 �aek'e� �'�' �%9 f 4 v4 k I C, be r� I& rt Property Owner: Address: Other: 4- Vt4 S on ftr 60 -,O -c 6- I .S Signed: i Complaint Form - Revised 6.2007