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HomeMy WebLinkAboutMiscellaneous - 98 MIFFLIN DRIVE 4/30/2018m' o ! ® MAPFRE The Commerce Insurance Companysm Citation Insurance Companyw 11 Gore Road, Webster, Massachusetts 01570 Commerce f N S U R A N C E- 508.949.15001 www.commerceinsurance.com September 08, 2014 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: THOMAS J REUSCH / ELLEN M REUSCH Property Address: 98 MIFFLIN DR Policy#: YY0987 Date of Loss: 09/06/2014 File#: JMKM43-CYTCR6 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. ESTHER O'NEILL Telephone: (508)949-1500 Ext: 15388 Sr Claim Representative, Property Toll Free: 1-800-221-1605, Ext: 15388 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. September 08, 2014 CIC 254 (Rev. 4/95) MAIL M80 0 Date ......... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ............. D .... has permission to perform ......... wiring in the building of .................. ..............5.....'7....................................... at ......... 5.; .... ':Te .. ............... . ]"hkndovei, Mass. ...... Lic.No..55?,9_4 ................. ... .. .. ..... ELE RICAL INSPECTOR v Check # commona,& 0 va66ac" Official Use Only Apartment o/..tire Servicers Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS ev. iw] 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 IN INK OR TYPE ALL INFORMATION) Date: 0 — 0 & C-iger- 'own of: _ A, 4;1jQ Q V8, R 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)9 R 40,_,� Zf -D i Owner or Tenant Owner's Address Telephone No. Is this permit in conjunction with a building permit? ` Yes ff No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts verhead ❑ Undgrd ❑ New Service Amps / Volts Overhead ❑ Undgrd ❑ Number of Feeders and Ampacity No. of Meters No. of Meters Location and Nature of Proposed Electrical Work: , I'm Completion o theollowi table m be waived the Ins ctor o Wires No. of Recessed Luminaires f 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-Elo. d. d. o Emergency g Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of SwitchesNo. of Gas Burners o. o etection an Initiatin Devices No. of Ranges No. of Air Cond. Total Tons No. of Alertin Devices g No. of Waste Disposers eat nip Totals:I umber ons o. of Self -Contained Detection/Alerting Devices I No. of Dishwashers Space/Area Heating KW Locai ❑ Municipal ❑ Other, Connection No. of Dryers Heating Appliances KW Security Systems: No. of Devices or Equivalent No. of Water ICM Heaters No. of No. o Si s Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP TelecommunicationsWiring: No. of Devices or Equivalent OTHER: ti "—\ 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: 3 - 7 — I ) Inspections to be requested in accordance with NEC 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 covera a is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSUR BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties ofperjury, that the information on this application is true and complete. FIRM NAME: j.. v � 6, 1/` LIC. NO.:J,:3, Licensee: Signature� LIC. NO.: _ (Ifapplicable, enter "exempt" in the license number line.) Bus. Tel. No.• �7#r 6-31&6 Address: Z / )9,12, .6 & RiSPM•7DR , z!V)iq Of 8 4 U 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 ent. Owner/Agent Signature Telephone No. PERMIT FEE. $ s (�, el � 3 -17- // 2t Date l h// '..... . I'll D I's.. TOWN OF NORTH ANDOVER - 9 PERMIT FOR PLUMBING 41 In This certifies that.............. . has permission to perform .....�S: !:.`...I !" .:.-.'........... . � plumbing in the buildings of ..�.`. `. ! .`.. `.................... at. .......... . . . North Andover, Mass. Fee Lic. No. 1.3.3./..2 . ....... � c �t.<r� .� ......... /PLUMBING INSPECTOR Check .7 / C G r MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING City/Town:fd 1 Vl &Y8MA. Date: 3— Permit# Building Location: / 0 rn � ELA� Owners Name: Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential [� New: U Alteration: ❑ Renovation: ❑ Replacement: ❑ Plans Submitted Yes ❑ No ❑ FIXTURES DEDICATED W Z SYSTEMS of D F- Z y Y Z O W Z tn y to a Z �'.' Y Q 'n � a W Z W Z = cQ y Ln LU W 0 Z Q� Z (n y W x N f' H y Q O Z O 0 C N W Z �_ Q U E: LL N EW 3Q W F� O W U E- x C 0 F U Z a W a >> Y Z t/f F� EW- W 0� 0 �W i W7 Q Q 75 o o O= 0 a m m o o W x x g g oc y N� Q a 3 a a F 3 3 0 u a a z a SUB BSMT. BASEMENT IrFLOOR / 2ND FLOOR 3RD FLOOR 4T" FLOOR ST" FLOOR 6T" FLOOR 7" FLOOR 8T" FLOOR Check One Only Certificate # Installing Company Name: q� �r� UV1� Ln Address: • I( El Corporation City/Townk l` State: ❑ Partnership Business Tel: / tq ), a0 J Fax: Firm/Company Name of Licensed Plumber: INSURANCE COVERAGE: I have a current liability 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. A liability insurance policy 1�' Other type of indemnity [:1 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 Agent Owner ❑ Agent E]Signature of Owner or Owner's I hereby certify that all of the details and mformat!on 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. By I Type of License: I /17) /)„ -14.4 17 O ," Title City/Town E ❑ Plumber Sfgnature of 1-16ensed Plumber ❑ Master I �G ❑Journeyman License Number: 0 I N The Commonwealth of Massach usetts ., �F Department oflndustrialAccidents have hired the sub -contractors Office of Investigations ' 600 Washington Street These sub -contractors have Boston, MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information . Please Prinf Legibly Name (Business/Organization/Individual):��iMC{ Address: �Lq lit City/State/Zip: J'-,Vc-A J � . ft . 6 i YT�- Phone ##: 9 `T- u 7g- 2 )2� Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I mployees (full and/or part-time).* have hired the sub -contractors 2. I 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. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. El am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.0 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 anew affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub -contractors acid 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 Self -ins. Lie. #: 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 fonn 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 maybe forwarded to the Office of Investigations of the DIA for insurance*coverage verification. X do hereby eeipLfy under the pat is and penalties of perjury that the information pro vided above is true and coirect Phone #: 9 79 42 Official use only. Do not write in this area, to be completed by city or town officlaL City or Town: Permit/License # 3._ 1 ( 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 #: 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, 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 bokes that apply to your situation and, if necessary, supply sub-contractor(s) 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 cant' workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for confinnation of insurance coverage. AIso 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 ifyou 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 pennit/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 pen -nit 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 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 Industrial Accidents Office of Investigations 604 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia ®� ooseP MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING/// (Print or Type) 94S5�i. Date Cf 19 b BuildingQCq Permit # Location, % �i m 1 t'1'L IN -D Owner's ARM18 A/1CDliyaR --- Name �VCWIe, v�(luru New [q Renovation ❑ Replacement ❑ FIXTURES Plans Submitted: Yes ❑ No ❑ Building Permit No. Check one: Certificate Installing Company Name �� S�C,It., ❑ Corp. Address 3l0 �u�ew� ❑ Partnership C) t yZ1 p/ irm/Co. Business Telephone &(103 SIJ? 70 Name of Licensed Plumber %1 I STey c -,l INSURANCE COVERAGE: Checkons/ I have a current liability insurance policy or its substantial equivalent. Yes p No ❑ If you have checked yes, please indicate the type coverage by checking the appropriate box. A liability insurance policy ❑ Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee sloes not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner ❑ Agent ❑ Signature of Owner or Owner's Agent I hereby certify that all of the details and information I have submitted (or entered) in the above 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 provisions of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. Fee Check # Date APPROVED (Office Use Only) C��- '11-� - Signature of Licensed Plumber License Number /13-60 Type or Plumbing License: Master p� Journeyman ❑ Z 0Z Y i AFI N ZiV) �j0 0Q 2 i FQ ZI �p Z 2 a Z) �'^jwa miv~ilv2i �'} Q'Wiv YjQala IU' Q ajQ � X U W: 0 7 a Q w a Q w Zip Q -j a o of 0 LL ` w 2 Q 2 1 3 3 O Z 2 Q H> F O I O i Y l a F Q Y F Z a O Z Z Q w F I O U Y U w 2 3 YIJimIv2il� o 3 2 F�OiLL 0 0 0 Q 3�� 0 J m SUB-BSMT. BASEMENT 1 ST FLOOR I I I I I I I I I I I I I I I I 2ND FLOOR 3RD FLOOR I I I I I I I I I I I I I I I I 4TH FLOOR IIIIII ! 1 1 1 1 1 1 1 1 1► 1 1 1 1 1 !III 5TH FLOOR 6TH FLOOR I I I I I I I I I I I I I III I I I I_ I III 7TH FLOOR 8TH FLOOR Check one: Certificate Installing Company Name �� S�C,It., ❑ Corp. Address 3l0 �u�ew� ❑ Partnership C) t yZ1 p/ irm/Co. Business Telephone &(103 SIJ? 70 Name of Licensed Plumber %1 I STey c -,l INSURANCE COVERAGE: Checkons/ I have a current liability insurance policy or its substantial equivalent. Yes p No ❑ If you have checked yes, please indicate the type coverage by checking the appropriate box. A liability insurance policy ❑ Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee sloes not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner ❑ Agent ❑ Signature of Owner or Owner's Agent I hereby certify that all of the details and information I have submitted (or entered) in the above 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 provisions of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. Fee Check # Date APPROVED (Office Use Only) C��- '11-� - Signature of Licensed Plumber License Number /13-60 Type or Plumbing License: Master p� Journeyman ❑ Cl) z O H U w IL CO z w C7 O Ir a w w LL N w U F - w Y cn Cl) z O H U w a z J Q z M R O z m D J a O 0 O H I— w a T O LL z O H Q U J CL IL Q C'3 z_ D J_ m LL O w a H od w z 0 _z J_ 5 m U- 0 O z O H Ua O Ir w m D J a. 0 w z U F- cc w a w Q D cc O U w IL z c9 z m J a r Date41. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that . P/ (*/* *:C....��c has permission to perform ... Q. �.......................... plumbing in the buildings of ..1� licd''c t �r at. q ........... ,North Andover, Mass. Fee. Lic. No.. ........ PLUMBIN�TOR 05/19/98 09:00 15.40 PAID WHITE: Applicant CANARY: Building Dept. PINK: Treasurer L1 Office UseQ� 0`ja 44 mnwn� mtI d B$caL ptftS Permit No. Erprtntnt of Vublic en&q Occupancy A Fee Checked BOARD OF FIRE PREVENTION REGULATIONS 527 CUR 12:00 - 0eave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massacnusetts Electrical Ccdeti527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date _ 9l5— To(( or Town of NORTH ANDOVER To the Inspector of Wires: The udersigned applies for a permit to perfe n -the electrical work described below. Location (Street & Number) 9� / /ill �� ��� Cwner or Tenant P� AJ �� �y e1/1 Cwner's Address '? ��1i� vn Is —:s ^er•'^ t in ^n unc•ion with a butldina cerm,t: Yes No _✓ (Check Appropriate Box) cse of Buiici^g ��'"��/rw ' Utility Authorization No. existing Sar✓ice ZD Amps ��� i zYD -"'c- I's Cvernead r` Undgrnd r� No. of Meters New Service Amps 'fcits Cverneaa _ Uncgrma r No. of Meters Nurrcer of=eecers anc Amcacity A?1/Z uw� av�JiiJ,P Write 4/7Gn/ S�/i% /9 � _ cat: ,, and Nat, -,e _, rcpcsec=.ec:•, Nor. S,Y S ky"f No. ;f Lign;mc Cuuets Jc. n_. '.cs _ 'ctai No. of -anstormers KVA No. or-.gntng c:xtures Accve— n - Sw'mmmg grnc. -,^c. _ Generators KVA No. cf Emergency L:gnting =ecec.ac:s --ut!e!s ..c..., Cil=_.r.ers j Battery Units 'c.:f Sw;t-„ Cutlets No. of Gas ourners I FIRE AL.�kRMS No. of _ones No. at _erection anc Ne. o4 =.antes No. _. A:r _ rc. `-s I Irnnat:ng Devicas No. of Sounding Devices No. of elf Contained No.ct rte' ciai :a No. of Dacosals �umcs ons {:J Ne. of Disr•wasr.ers ScacerArea -1eat:rg < "J I Detect:cniSouneing Devices — Mun,c:oal Locai ,Other Connec::en _ No. of Dryers `!eating Devices 4rV No. gf No. of Low Voitace i No. --fNf '.ater Heaters :i:✓ Sicr.s aa:tas:s Wiring NO 1-iya'o `tassace cos •I No. gt Mctcrs 3 ctai ;"H E' . NSUFANCE "=?AGc. ?•.:rsuant :o the ecuirerre^:s c• '.tassacr:usars general Laws have a current L:ac:iity Insurance Policy nc:::cirg Ccrrc.etec Cce.a::cns Coverage or is sues:antral ecuivaient. YES NC hv_ nave sucm,ree vatic proof at same to the Cffics. "_S- = NO 2"'t you nave checkee YES, crease inc:ca:e :he type at coverage oV cneck,ng the accrocnate Dox. ,t<� tis INSURANCE �BCNO — OTHER ::tP'ease Stec:^:) C !� ts4: (Exo)rat)on Date) snmatec Value of E:ec:ncar Work 5 7� >^— /Q - 5 S Work :o Star. 5 - p A/C- rise__.._.. __._-.ecues:ec. Pouch S,gnee :neer :he PenaineR nt erury/ =:R.M NAMES�i9 t� �ffr,�/L(•}rd�� i tit✓l-t j/ �C. NO. �7���v✓� :c. NO. �yyeZ� L.censee t.t /SI'. i It /'1 S�� f S..crature �y�`" /� T Bus. 'ei. No. 3 rFA / Aggress /�v y G✓1,6 cv i' 01� vC rf�i PW 1� 1( >n t ✓1 , Alt. lei. No. , 7 ; u CWNER'S iNSURANCE WAIVER: I am aware :^at —.e '_cersee cces not nave the insurance coverage or its substantial equivalent as re- guirea by Massachusetts General Laws. arta .hat my signature on permit aoplicat)on waives this recuirement. Owner f Agent ,,P°ease check one) _ :e,eonone No. -- PERMIT --=_E 5 (/ ,,Signature at owner or Agent)