HomeMy WebLinkAboutMiscellaneous - 96 DALE STREET 4/30/2018., /� 9800 Fredericksburg Road
wh&San Antonio, TX 78288
USAW
04664.20RYD.JSS1095358677.01.01.2407
TOWN OF NORTH ANDOVER
120 MAIN ST
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:
Gilbert C Nicholas
Reference #:
003264177-15
Date of loss:
June 28, 2015
Location of loss:
North Andover, Massachusetts
Address:
96 DALE ST 01845
August 10, 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 659460
SAN ANTONIO, TEXAS 78265
Fax: 1-800-531-8669
Phone: 1-800-531-8722 ext. 74267
Sincerely,
Valeria Rosales
USAA Property Claims
USAA Casualty Insurance Company
PO Box 33490
San Antonio, TX 78265
Phone: 1-800-531-8722 ext. 74267
Fax: 1-800-531-8669
JDB/VR
003264177 - DM -04664 - 15 - 7335 - 37
54577-0715
Page 1 of 1
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TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that c/o /,A �.............J...". �.............................
has permission to perform .......................W.......... �4. L. .........
plumbing in the buildings of �...epl% 4�C.;........
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No h Andover Mass.
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Fee12 Qv..... Lic. No. ...... .
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G I SPECTOR
Check # 76Ftl
Date...................................................
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION .
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,This certifies that ............ C-774/
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has permission for gasins�allati ... ..... .. ....... .
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inthe buildings of ...................................................................................................................
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Fee ./.. Lic. No.1.1> .....
GAS INSPECTOR
Check #
9133
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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
POWNER
TYPE OR
PRINT
CLEARLY
CITY (7 �A- A -A( MA. DATE � - 1 � i � PERMIT #
JOBSITE ADDRESS ALL S i f fi OWNER'S NAME -!'EW 00
ADDRESS TEL FAX
OCCUPANCY TYPE: COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL]
.NEW'P El REPLACEMENT: ❑ PLANS SUBMITTED: YES ElNO F1
FIXTURES Z FLOOR BSMT 1 2 3 4 5 S 7 8 9 10 11 12 13 14
BATHTUB 2
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYS
DEDICATED GAS/OlUSAND SYS
DEDICATED GREASE SYS
DEDICATD GRAY WATER SYS
DEDICATED WATER RECYCLE SYS
DRINKING FOUNTAIN
DISHWASHER
FOOD DISPOSER
FLOOR / AREA DRAIN
INTERCEPTOR (INTERIOR)
KITCHEN SINK 1
LAVATORY I
ROOF DRAIN
SHOWER STALL i
SERVICE / MOP SINK
TOILET I Z
URINAL i
WASHING MACHINE CONNECTION j
WATER HEATER ALL TYPES '
WATER PIPING
OTHER
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which, meets the requirements of MGL Ch. 142. Yes ZNo ❑
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY g OTHER TYPE OF INDEMNITY ❑ BOND ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 942 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
CHECK ONE BOX ONLY: OWNER ❑ AGENT []
Signature of Owner or Owner's Agent
I hereby certify that all of the details and information 1 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 NAME S 1 EPOE0 C- GALII.3SKY SIGNATURE
LIC4f I031t S MP [r JP ❑ CORPORATION [) # -31941 PARTNERSHIP ❑ # LLC ❑ #
COMPANY NAME &Al-10SKY PLUi•'lojAjb *' IWAT-q.1 ADDRESS: P.D. GGX 1-701
CITY tlravERl+1i�L STATE m -A- ZIP 0I131 EMAIL w%,vw. mt plymbegWl, Com
FEL g7t- 37q- 1743 CELL FAX 97$- 5a1 - 4131
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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 bew' compliance with all Pertinent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. hl�l� oe
PLUM BER/GASFITTER NAME: STEPHEN C. GAL.TNSKY LICENSE# 103yis SIGN
COMPANYNAME: CGAL4!3Kq Pf.UAINIOG + 14C41-11 & ADDRESS: P.Q.I�QX 1701
CITY: 14AVEA.HiLL, STATE: m•A- ZIP: 01831 FAX: 479- 6al-1631
TEL: 9-79 - 3714— VM3 CELL: 5,0rd - S'tA- 59014 EMAIL: W VV"W • +x+'11'' f c9'Mbe O� rn
MASTER V JOURNEYMAN ❑ LP INSTALLER ❑ CORPORATION [�# i �� PARTNERSHIP ❑ # LLC ❑ # , �
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
GOWNER
TYPE OR
PRINT
CLEARLY
CITY:,/�� MA. DATE: 3 -1 Zd� PERMIT #
JOBSITE ADDRESS: I t �iJ 1 = �� OWNER'S NAME: lif-F
ADDRESS: TEL: FAX:
OCCUPANCY TYPE: COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL,
NEW: RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED:- YES ❑ NO ❑
APPLIANCESZ
FLOOR--, Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE I
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCK
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM / SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER i
INSURANCE COVERAGE
I have a current liabili insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES NO ❑
If you have checked YES, please indicate the type of coverage by checking the appropriate box below.
LIABILITY INSURANCE POLICY [jj' OTHER TYPE INDEMNITY ❑ BOND ❑
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 bew' compliance with all Pertinent
provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. hl�l� oe
PLUM BER/GASFITTER NAME: STEPHEN C. GAL.TNSKY LICENSE# 103yis SIGN
COMPANYNAME: CGAL4!3Kq Pf.UAINIOG + 14C41-11 & ADDRESS: P.Q.I�QX 1701
CITY: 14AVEA.HiLL, STATE: m•A- ZIP: 01831 FAX: 479- 6al-1631
TEL: 9-79 - 3714— VM3 CELL: 5,0rd - S'tA- 59014 EMAIL: W VV"W • +x+'11'' f c9'Mbe O� rn
MASTER V JOURNEYMAN ❑ LP INSTALLER ❑ CORPORATION [�# i �� PARTNERSHIP ❑ # LLC ❑ # , �
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TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that
has permission to perform
.................................................. \(i cp"�
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wiring in the building of....
. ................ ............. * .. .......................................................
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Check #
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fficial Use Only
%- Commonwealth of Massachusetts O7 (/Z U/]i
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Department of Fire Services Permit No.
p Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. l/07] (leaveblank
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 W INK OR TYPE ALL INFORMATION) Date:
City or Town oh NORTH ANDOVER To the Inspector of Noires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number) ce 6 befa s�-
Owner or Tenant C oOUZ-� Telephone No:5 671
Owner's Address / S C
Is this permit in conjunction with a building permit? Yes, No ❑ (Check A nate Box)
Purpose of Building %]C � I�vTM` �t d� Utility Authorization No. 147- `1 FC> - z 7
Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. o
New Service Z� Amps / Volts Overhead ❑ Undgrd No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:��
Completion ofthe followinz 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 Luminaires1 g
Swimmin Pool Above El In- Elo.
g rnd. rnd.
o mergency Lighting
Battery Units
No. of Receptacle Outlets <fd
No. of Oil Burners
FIRE ALARMS
No, of Zones
No. of Stitches Ifo
No. of Gas Burners /
t
No. of Detection and 125
Initiatin Devices Ci
No. of Ranges
No. of Air Cond. Z Tons Tot
No. of Alerting Devices 75-
No. of Waste Disposers
p
Heat Pump
Totals:
Number
Tons
KW
No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
Local E]MunicipalConnection El Other
No. of Dryers !
Heating Appliances KW
Security Systems:*
No. of Devices or Equivalent
No. of Water / KW
Heaters /
No. of 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 of *rhes.
Estimated Value of Electrical Work: //cam (When required by municipal policy.)
Work to Start: ue 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 coverage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:)
X certify, under the ains and pe It. � perjury, r iat inglnformation on this application is true and complete.
FIRM NAME:. , Cc �- �� LIC. NO.:
Licensee: ( LCM 1- m Signature LTC. NO.:
(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 agent.
Owner/Agent PERMIT FEE. $
Signature Telephone No.
❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In 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
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 4
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. c. 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 he
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
purpose 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.
❑ Rule 8 — Permit/Date Closed: *** Note: Reapply for new permit ❑
❑ Permit Extension Act — Permit/Date Closed:
Trench Inspection
Pass EN
Failed
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
SERVICE INSPECTION:
Pass
Failed
Re- Inspection Required ($.) ❑
Inspectors Commen :
Inspectors Signature:
Date:
PARTIAL ROUGH INSPECTION:
Pass F?1
Failed 0
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
ROUGH INSPECTION:
Pass
Failed ❑'
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
FINAL INSPECTION:
Pass 0s<
Failed
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
6M
DEB WEINHOLD ...TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com
R
The Commonwealth of Massachusetts
Department of IndustrialAccWnts
Office of Investigations
kvi 600 Washington Street
Boston, MA 02111
www.mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):�A �/y(T
Address:
City/State/Zip :,,�� ,L_ �i �3 Phone #: !�J
Are you an employer? Check the appropriate box:
Type of project (required):
L ❑ I am a employer with
4. ❑ I am a general contractor and I
6. ew construction
employees (full and/or part-time).*
2� I am a sole proprietor or partner-
have Hired the sub -contractors
listed on the attached sheet.
❑Remodeling
ship and'have no employees
These sub -contractors have
8. ❑ Demolition
working for me in any capacity.
workers' comp. insurance.
5. ElWe are a corporation and its
9. E] Building addition
[No workers' comp. insurance
required.]
officers have exercised their
10.❑ Electrical repairs or additions
3. ❑ I am a homeowner doing all work
right of exemption per MGL
11.❑ Plumbing repairs or additions
myself. [No workers' comp.
c. 152, § 1(4), and we have no
12. ❑ Roof repairs
insurance required.] t
employees. [No workers'
13. ❑ Other
comp. insurance required.]
*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 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. A
Insurance Company Name:. 004e__
Policy # or Self -ins. Lic. #: Expiration Date:
Job Site Address:�� �?q /� 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
fitne 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 cert
penalties ofperjury that the
Ste- Tt S S Z25Z�_
Official use only. Do not write in this area, to be completed by city or town official.
City or Town:
Permit/License #
above is true and correct
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 #:
.e
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 ofhire,"
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 -contractors) 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 Cox onwealthofMassacNsetts
145
Revised 5-26-05
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA. 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
www.raass.gov/data
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