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HomeMy WebLinkAboutMiscellaneous - 91 MILLPOND 4/30/2018O O O CT b 0 b 0 0 0 0 Lib_qyMutual. a INSURANCE May 12, 2015 Town of North Andover Attn: Building Inspector 120 Main Street North Andover, MA 01845 Re: Property Address: 91 Mill Pond, North Andover, Ma 01845 Policy Number: H6521831437670 Underwriting Company: LM Insurance Corporation Claim Number: 031667769-0001 Date of Loss: 2/15/2015 Attn: Town/City Official Liberty Mutual Insurance New England Region Central Property Unit 75 Sylvan Street Danvers, MA 01923 Tel: (800)566-0323 Pursuant to M.G.L. c. 139, 5 3B, please be aware that a homeowners insurance claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or causes the condition of a building or other structure to render Mass. General Laws, Ch. 143, § 6 applicable. You are required to notify Liberty Mutual by certified mail in accordance with Mass. General Laws Ch: 175, §99, if you intend to initiate proceedings designed to perfect alien pursuant to Mass. General Laws, Ch. 139, 5 3A & B, or Mass. General Laws, Ch. 143, 5 9, or Mass. General Laws, Ch. 111, 5 127B. This letter should not be construed as a waiver or estoppel of any of the terms, conditions or defenses afforded by the policy or applicable law. Please direct your notice to the attention of the undersigned and include a reference to the above captioned property address, policy number, claim number, and date of loss. Sincerely, Liberty Mutual Support Liberty Mutual Insurance New England Region Central Property Unit 1-800-566-0323 Date .....M. �e:.... /./ ... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that /,;-�....................... � ... ... ........... ...... ...".. has permission to perform .......`U'... ................... wiring in the building of ........... ! `..a�¢-.Ll.. -............................................ at ............ 1. IAW ..........:..................... N Andover, Mass. Fee ..... .0. Lic. No .............. .........................� ELECTRICAL INS R Check #s 7-5 10.483 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: hi 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 I 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 be 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. e. 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 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 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 puipose 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. 1.3knle 8 — Permit/Date Closed: A *** Note: Reapply for new permul,'Q_ 0 Permit Extension Act — Permit/Date Closed: .y Commonwealth of Massachusetts official Use Only Department ®f Fere Services Permit No. q Occupancy and Fee Checked k BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORD All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT •ININK 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) 91 A 1 U_ Po M D P—D Owner or Tenant y4�;I Q l� C (� G Telephone No. Owner's Address 'Z) ')� U_ po H © P -J) Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building C6 jam, D Q `j Utility Authorization No. Existing Service Amps Volts New Service Amps / Volts Number of Feeders and.Ampacity Overhead ❑ Undgrd ❑ Overhead ❑ Undgrd ❑ No. of Meters No. of Meters N 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 Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ 'In- ❑ nd. rad. o. o mergency ig ng Battery Units No. of Receptacle Outlets No. of Oil BlUrners FI RE ALARMS No. of Zones No. of Switches • No. of Gas Burners NO..Inof Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices . No. of Waste Disposers Heat Pump Number Tons KW No. of Self -Contained p Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ElMunicipal ❑ Other Connection No. of Dryers Heating Appliances KWSecurity Systems:* No. of Devices or Equivalent No. of Water KW No. of No. of Data Wiring: Heaters Signs Ballasts . No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: 4b Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: i k t, u 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 [I OTHER 171 (Specify:) I certify, under the pains an penalties of perjury, that the information on this application is true and complete. FIRM NAME: 11v . 0-A.1- C_�PH (-J4 t -tET F_ - t LIC. NO.: _-3 3 +/6 6 �- Licensee: %, I � g� Signature / o �/� -�-- LIC. NO.: (If applicable, enter "exempt" in the license nu bei line.) ,I Bus. Tel. No.: 972 -3(©0 -S-6 11 Address: S�ke3 P�. � � i l-tp it, k G l W � T 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 agent. Owner/Agent 0_._..�__ Te,, ..,,.. N PERMIT FEE: S t The Commonwetalth of Massachusetts ! Department ofI. ndustriral Accidents f Office of Investigations 11i3 600 Washington Street : ` Boston, MA 02111 www.hwss gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contracto><s&lectricians/Plnmbers Applicant Information Please Print Le�bly Name (Business/organization/Individual): Address': City/State/Zip: Phone #: . Are you an employer? Check.the appropriate box: ' 1. ❑ 1 am' a employer with 4, ❑ 1 am a general contractor and 1 roject (required): employees (full and/or part-time).* 2. ❑ T am.a.sole proprietor. or partner- have hired the sub -contractors listed on the attached sheet construction odeling ship and. have no employees These su&contractors have olition F working for mein any capacity, [No workers' comp. insurance workers' comp. insurance. 5. ❑ We are a corporation and its• ding addition required.] 3. ❑ I am a homeowner doing officers have exercised their right trical repairs or additions all work of exemption per MGL bing repairs or additions myself, [No•workers' camp. c. 1.52, § 1(4),' and we have no 12.0 Roof repairs insurance required.] t employees. [No workers' 13•❑.Other camp. insurance required.] ' - rr••.... •..a. ­ —mb uux,f i must siso nit outthe section below showing theirworkers' bompensation policy information, t 1-lomeowne rs who submit this affidavit indicating they am doing all work and then hire outside contractors must submit anew affidavit indicating such. $Contractors that check this'box must Lanched an additional shyershowiag ohename ofthe subcontractor and the:!- 4ferkes' comp. polis; Information. I a;n asa effrlVYOr that islrtovldlr-ag:wDrlxrs1 cornpensadoic as surancefoP information. 'nYeftP10YeeS; Below is the policy- andjob site Insurance Company Policy # or Self -ins. Lie, #: Job Site Address: 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 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 tl:e information provided ahOve is true and correct. Signature: Phone #: Offficial use only. Do not w. rte %n mkis a: ea, to bz c,,;,,#feted by ck o; toivrr official. City or Town: Permit/License # Issuing Authority (circle one): I. Board of Health 2. 13uilding Department 3. City/Town -Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone .9 The Commonwealth ofMassachusetts Department oflndustrialAccidents Office ofInvestigaflong 600 Washington Street Boston, MA 02111 www.ma_ssgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors)Electricians/Plumbers IDUCanf Tnfnvmo+:.,,, Name(Business/Organization/Individual): C&KtE�� Address: City/State,/Zip:_ LLa A. 6 Are you an employer? Check the appropriate box: L ❑ I am a employer with 4. ❑ I am a general contractor and I loyees (full and/or part-time).* have hired the sub -contractors 2. I am a sole proprietor or partner- listed on the attached sheget. t 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 all work .officers have exercised their right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.]r employees. [No workers' comp, insurance required j Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10 EIectricaI repairs or additions 11.❑ Plumbingrepairs or additions 12.❑ Roofrepairs I3.❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. i L eownrswho submitthis affidavit indiFating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. actors 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 the policy and job site information. Insurance Company Name: Policy # or SeIf-ins. Lic. #: Expiration Date: rob Site Address: , Cify/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 uhder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $I,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 Iuvestigations of the DIA. for insurance coverage verification. t do hereby c elolluiderthe airs dpenattles OfPerjury that the information provided above is true and correct. 3i nature: / Date: � •— / `hone#: 27� 34 �J l Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # .Yssuing Authority (circle one): I. Board of Health 2. Building Department 3. City/Torun Clerk 4. Electric 6. Other al inspector S. plumbing Inspector Contact Person: Phone #: