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HomeMy WebLinkAboutMiscellaneous - 89 BEVERLY STREET 4/30/2018z� ® MAPFRE The Commerce Insurance Company1m Citation Insurance Company'"1 Commerce" Gore Road, Webster, Massachusetts 01570 INSURANCE- 508.949.1500 www.commerceinsurance.com March 03, 2015 BUILDING COMMISSIONER or Board of Health or INSPECTOR OF BUILDINGS Board of Selectmen TOWN/CITY HALL Town/City Hall NORTH ANDOVER MA 01845 RE: Our Insured: MARGARET VERVILLE / MARK VERVILLE Property Address: 89 BEVERLY STREET Policyk B CDPPN Date of Loss: 02/23/2015 Filek JXVY41-HPMXR3 Claim has been made involving loss, damage, or destruction of the above captioned property which may exceed $1,000, 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. Please reference the above captioned insured, location, policy number, date of loss, and file number on any correspondence. JANE SMITH Telephone: (508)949-1500 Ext: 15163 CLAIM SPECIALIST, PROPERTY Toll Free: 1-800-221-1605, Ext: 15163 On this date, I cause copies of this notice to be sent to the persons indicated above, at the address above, by first class mail. March 03, 2015 CIC 254 (Rev. 4/95) MAIL M48 Date../:......:. ° "'° '• " TOWN OF NORTH ANDOVER .o .!.r -...,_ • of P PW PERMIT FOR WIRING This certifies that ............I ...... `.^ ........................... has permission to perform ..................... f......................................... wiring in the building of ..... ~... J:....'. f........!n...:.:......................................... at .... ...... X............. �.......`. ' '..- /........ North Andover, Mass. Fee. .............. Lic. ............. irv`" l .y ... ......... ELECTRICAL INSPE R Check # �5UL; r �v Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. BOARD OF FIRE PREVENTION REGULATIONSOccupancy and Fee Checked [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: 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. Location (Street & Number) 491 , S � Owner or Tenant A -f— . �� Telephone No. %Yl'�0 Owner's Address r—v 'O S Is this permit in conjunction with a buil g permit? Yes ❑ N0 (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead ❑ 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: /N No. of Recessed Luminaires o. of Ceil: Susp. (Paddl No. of Luminaire Outlets f No. oTotal No. of Hot Tubs No. of Luminaires Swimming Pool AN No. of Receptacle Outlets Generators KVA No. of Oil Burners No. of Switches d. No. of Gas Burners No. of Ranges FIRE ALARMS No. of Air Cond. No. of Waste Disposers No. of Detection and Heat Pump •^ Number __ _ ._. No. of Dishwashers Space/Area Heating No. of Dryers Heating Appliances Heaters KW 11q°' O1 N Skzms B No. Hydromassage Bathtubs No. of Motors T OTHER: of the followin table maybe waived by the Ins ector of Wir e) Fans f No. oTotal Transformers KVA Generators KVA ❑ In- ❑ o. o mergency ig d. BattervUnits FIRE ALARMS No. of Zones No. of Detection and Initiating Devices Total Tons No. of Alerting Devices Dns No. of Self -Contained Detection/Alertin Devices ' Locat ❑ Municipal ❑ Other Connection KW Security Systems:* No, Devices o. of allasts of or Equivalent Data Wiring: . No. of Devices or E uivalent ital Telecommunications firing: No, of Devices or E uivalent R Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: %J` (When required by municipal policy.) Work to Start: �2 Oir Inspections to be requested in accordance with MEC Rule 10, and upon coletion. INSURANCE COVERAGE: Unless waived by the ownermp , 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 of perjury, that the information on this application is true and complete FIRM NAME: Licensee: r� ^LIC. NO.: e icense nSignature (Ifapplicable, enter "exempt" thumberline. LIC. NO.: Address: // 4400.4, [ S l (o (P Bus. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Deparhment of Public Safety "S" License: Alt L c. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability is ce coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) LJ 0 ner ❑ owner's agent. Owner/Ag en i'u Signature Telephone No. / / I o �3 t PERMIT FEE. I. The Commonwealth of Massachusetts k� r! Department of Industrial Accidents c 1 Dffice of Investigations 600 Washington Street =lEt� i Boston, MA 02111 t t www.nzass.gov/dia Workers' Compensation Insitrance Affidavit: Builders/Contractors/Electricians/Piambers rllllilramlt TRf'n�.�wn4:.... Name Address: City/State/Zig: Phone #:. Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and 1 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 me .in 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 MGL myself. [No•workers' comp, c..152, § 1(4),'and we have no insurance required.] t employees, [No workers' *A­....t:...�a_. _�__.. _ comp. insurance required.] TYPe.of Project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demoliti.on` g. ❑ Building addition 10.❑ Electrical repairs or additions 11.[] Plumbing repairs or additions 12. ❑ Roof repairs 13J] -Other - t Ho.� R ' must luso nu out the section below showing their workers' compensation policy information. meowners who submit this affidavit indicating they ate doing all work and then hire outside contractors must submit a new affidavit indicating such. ;Contractor; that check this box must attached an additional sheat showing the name of the sub,contractms and their workers' comp. policy information. I ant an employer that.is prq"ng workers' compensation insurance for my employees: information below is the policy and job site Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: 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 pains and penalties of perjury that the information provided aboveis true and correct Signature: Date Phone #: FFiW7cial use only. Do not write in this area, to be completed by city or town officiaL City or Town: Permit/License # Issuing Authorify (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, assodiation, 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 is 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 performaztee 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 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 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, notthe Department of Industrial Accidents. Should you have any questions regarding the law or if you an required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should entertheir self insurance license number on the appropriate dine. 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 ref=nce number. in addition, an applicant that must submit multiple permittlicense 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 ffidavit 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 Industria( Accidents Office of Investigations 600 Washington Stieet Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1 -x.77 -MAS SAFE Fax # 617-727-77451 Revised 5-26-05 vvww.mass.govIdle b o m c � a Q m A N 0 � O 0 n y OQ 42/ O m 0 C -� D m a occ n 0�_ C TSI m o CD c Z CD M m M CD m = 409 .6969fA691696� z O m ll -.R6 0 D M Z o O n 0 N CD m O O n z Z m r_ n m m r § ac ac 0 O 3 A r C n C>>>> r= m A Z p > D z m Y I] > > fnn 0 0 m m m a N - 0 �I T = rr N O m N N N m m 0 n N N N W z UI H A C 0 J 0 Z 0 W H 9 0 m NO N N N A 0 0 0 C A** 0 O 3 A r C C C>>>> r= m A Z p > D z m 0 0 m cO_ r r r 0 O_ z m z m z A a N N G O > r Z _O 2 0 Z r 0 m N n i > Z Z 'n r O 4 m A 3 A 3 0 z Z N z 0 > m A > O i 0 f m 3 m> A m y Z A < 0 i A 1311 N > m - z r m -4 j Z z 0 z �rllI Z m i to C N r i 0 o J 31c p >m a l I m 0 \ p< Z p < < A m C ,� v, N � r•� 3N..H m z U' z to 0. 0 na 0 A 0 m 0 i A m > > A 0 m N N N N 3 N I O 9 N N z 'o N c c c m 0 m Z m m 0 9A9 O c O m O O A I O r = i z 0 3 Z ,1 N 0 M m r m 0 0 a o0 i n 0 cii czioN o OA a m O O O z n z C z tl A N N C 0 Z Z Z Z 2 N= pr 61 A �I N N 1 > 2 r p 2 > 0 r N N m m Z lin lin O < Z H 61 C O O O A Z 0 O O i C z z 0 I A N r > m f > -1 Z 0 N 61 > A A N N m D r z " i z ° d D m z Q N I VV w 0 0 A �I ID I H 9 0 m Nt II O Im O V W Im O Z m 00 (� W U1 WW UI Z y0 _a o= Z�z 0 0 IL J H IL ?o IL?o Oa N o Z=N OmU WIL 0(L INW Z U�iy azo W1W 36N yV(L NW W IL �Z7 Z<N 0NU FW WZ W NF(5 F0Ir ��I I I I I I I f Imo- 11�TII�-I I I 1 I I = Z_11171 hi d 8Qz W Z Q -�T LL w Q Z w G O � = d et 2 Z _ X W �, = W LL Q Oe Q > Z mI I -IT (O Q GC LL LL f i I-- fV N Y 0 11 W z Q OL Z Q OAC Z Or W Z J Q W u Y w v� d X LL K 2�wmp 2 Z Z 3 LL OC 00 i /� LLO _ 0- oe F yi =�- Z N N H w o Q ''>i F Z w Z Q O� �,'„°C�iom°`LLo V o: f S Z Q oi300z °�_ ;v Z<a�Z maa° ='s~ W _ W J W aO�p ZZ i LL LL 0 Q1 Oa U Q0 w S n u a - Q Vf jo Q^ QOQQ.u-pFO�� m H 3 J u Z N H H dI LLI NI SI QZ¢J�0 QI OC �::) Q W Z I I I Z 1 1 1 1 0 U ° 0 Or t O W W ., t oc O > Z m� aZ D O a O wp dQi 2 W N _Z f J OJ V O 2 O ae J J H Y m0 Z Q ; w 2 Q Q `ice¢ v1 < Z FLL ZO wZ LL -0W N O N f7 O LL h O F NQl70OC'1 O Z Z N Z Z Z LL V S Z > N 4 ti Q Z LLaZ wW o j ,.. p0 aoN JOo002Z000 O -I< ~ N u Z X N u W M W m s a m d QOpd Q O w m/ �»_ O Q v u u V W Z Z 00 W 2 Ip iz-� m i Q = o W 0 1dJQ 10 OZd OOu n OU and Q=ZI= V03Q"O(�LLQ3N7ti& Jd0 J°` ..N> m� y 10 coZ CD O CL r CD n� v C"C C7 CD O ff-w-.—m s0 C0! 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This plot plan was not made from an instrument survey and is for the use of the bank only- .Under no circumstances are offsets to be used for establishing property lines or constructing fences, etc. de ✓��/y S7 11 �IIA Of-\ ��y� QLD% FLAN OF L -41W -'• � y ]BHN „� . p IN_:. :> . r • No,2Tf� f3/�/OGY.r e UR i 1�?E�AIED a y �T�B J6�FVZ - _-I certify that the building on this property located on the ground substantially as shown, and that conformed to the zoning laws, of this f &,-/I'when constructed. This lot is not on the flood plain. �• .t '- •-` _ 4 ��•_ • rte` .� i tr w a -Q de ✓��/y S7 11 �IIA Of-\ ��y� QLD% FLAN OF L -41W -'• � y ]BHN „� . p IN_:. :> . r • No,2Tf� f3/�/OGY.r e UR i 1�?E�AIED a y �T�B J6�FVZ - _-I certify that the building on this property located on the ground substantially as shown, and that conformed to the zoning laws, of this f &,-/I'when constructed. This lot is not on the flood plain. �• .t '- •-` _ 4 ��•_ • rte` .� i tr de ✓��/y S7 11 �IIA Of-\ ��y� QLD% FLAN OF L -41W -'• � y ]BHN „� . p IN_:. :> . r • No,2Tf� f3/�/OGY.r e UR i 1�?E�AIED a y �T�B J6�FVZ - _-I certify that the building on this property located on the ground substantially as shown, and that conformed to the zoning laws, of this f &,-/I'when constructed. This lot is not on the flood plain. �• .t '- •-` _ 4 ��•_ • rte` .�