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HomeMy WebLinkAboutMiscellaneous - 987 FOREST STREET 4/30/2018ARBE LLA INSURANCE GROUP January 9, 2018 NORTH ANDOVER BUILDING COMMISSIONER 1600 OSGOOD STREET, BUILDING 20, SUITE 2035 NORTH ANDOVER, MA 01845 Claim Number: 033890464 Policy Number: 78164400002 Company Name: Arbella Mutual Insurance Company Date of Loss: 01/03/2018 Insured: RICHARD SOUTHWICK Property Location: 987 FOREST ST, NORTH ANDOVER, MA Dear Sir/Madam, 1100 Crown Colony Drive P.O. Box 699103 Quincy, MA 02269-9103 617.328.2800 arbella.com A claim has been made involving loss, damage, or destruction of the above captioned property, which may either exceed $1,000 or cause Massachusetts General Laws, Chapter 143, Section 6, to be applicable. If any notice under Massachusetts General Law, Chapter 139, Section 3B is appropriate, please direct it to the attention of the writer. Please include a reference to the captioned insured, location, date of loss and claim number. Thank you for your assistance. Sincerely, Cynthia Holden -Amor Claim Service Specialist Property Claim Office 800-272-3552 ext.7549 Fax 617-773-4760 CC: NORTH ANDOVER HEALTH DEPARTMENT 1600 OSGOOD STREET, BLDG 20, SUITE 2035 NORTH ANDOVER, MA 01845 CC: NORTH ANDOVER FIRE DEPARTMENT 795 CHICKERING ROAD NORTH ANDOVER, MA 01845 �aORT�{ Of ,••" �• 1'bC O 9 ,SSACMUSE� Date ... �.. �. �..�.v. 7.. TOWN OF NORTH ANDOVER PERMIT FOR WIRING Thiscertifies that ............ .................. �................12 ..................................... has permission to perform ... ©' L �� .. �. �Q � f ................................................................... lz- wiring in the building of................Do u7/,/ ('V/ C .................................................................... at ........ . e �o-1 Ss� North Andover, Mass. .................................. Fee 9? .. Lic. No. -P.V' ! 74........ /�.cG! !s'ai ELECTRICAL INSPECTOR 1 i Check # -� l 33 \J, pp qq���q ! FJR fficial Use Only Commonweah o/ 1/lamac%aaetb k1 rartaw' � of Jiro sarviM Fee Checked ____________ BOARD OF FIRE PREVENTION REGULATIONS eave blank R PERMIT TO PERFOR.M�ELECTRICA o WORK APPLICATION PO CMR All work to be performed in accordance with the Massachusetts Electrical � l Date: ! (PLEASE PRINT IN INK OR TYP LL INFOR TION V e To the Inspector of Wires: City or Town of: B this application the undersigne gives notice of his or her intention to perform the electrical work described below. By 'Z7 r Location (Street & Number) e Telephone No. _T j Owner or Tenant r �! �-- Owner's Address No (Check Appropriate Box) - is this permit in canlunction with a building permit? Yes ® � � � i� Utility Authorization No. Purpose of Bit#ldtng� �,,��,, -- Undgrd ❑ No. of Meters y r,xisting Service Amps Volts Overhead ❑ v ;,;rvlce Amps ____ �__.�..�Volts Overhead E] Undgrd ❑ No. of Meters Numu feeders and Ampacity 0 Locado.. -...,4 N+�ture of Proposed Elect��al Work: Comb ` the ollowin !able tna be waived b the Insoetc4 r o Wires. al 010 KVA No. of Recessed Luminaires No. of Cell. -SA" ,e) Fans Transformers KVA No, of Hot Tubs Generators No. of Luminaire Outlets o. o mergency g ng No. of Luminaires Swimming Pool rud rnd. E3 Batte Units No, o it Burners FIRE ALARMS No. of Zones No. of Receptacle Outlets o, o elect on and No, of Switches No, of Gas Burners Initiatln Devices ota No, of Alerting Devices No, of Air Cond. Tons t No. of Ranges o, o e - onto ne eat Pump.....P..!!!�Qx.......o���................................. Detection/Alertin pDevices No. of Waste Disposers Total s: unie a l No, of Dishwashers Space/Area Heating KW Connection Other LocaQ ecur . ystems:* Heating Appliances KW No. of Devices or >~ uivalent No. of Dryers o. o Data Wiring: No, o ater KW o, of Ballasts Na. of Devices or E uivalent _ Heaters Signs elecommunications it n No. Hydromassage Bathtubs Na. of Motors Total HP No. of Devices or E uivalent OTHER: Attach additional derail if desired, or as required by the inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: 0 le f4�_ Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COV RAGE: Unless waived e including ,complee owner, no ted operation" coit for the ve age or its substaance of lntial equivalenork may t The ss the licensee provides proof of liability in un suranc undersigned certifies that such covers a is in force, and has exhibited pro of of sam�t�' the permit issuing ���� Jr CHECK ONE: INSURANCE OND Q OTHER ❑ (Specify:) I certify, under' the pains and penalties of perjury, that the informal non this application is true and complete. LIC. NO.: % FIRM NAME: LIC. NO.: Licensee: ee✓Pe* Signator G D%+��� Bus. Tel. No.: (Ifapplicabte, enter "exempt"int a license nu b line.) Alt, Tel. No. - Address: uires --------^ *Per M.C.L. c. l 7, sl��V `+`1iraeaware that the Licen ee does not have the liability lity insurance coverage normally OWNER'S INSURANCE required by law, By my signature below, I hereby waive this requirement. I am the (check PERMIT FEE: caner s a gent. Owner/Agent Teleplione No. Signature I n .! Location 98`/ F�- esi 5�� s"— No. 3 Q /7 Date n 3, NORTH TOWN OF NORTH ANDOVER Of ,�O +"•O '• i • OL s Certificate of Occupancy $ '�s "'"° •'���' s.KMU Building/Frame Permit Fee $ C J Foundation Permit Fee $ Other Permit Fee $ U TOTAL $ f- Check # 10,4 3 1 7ZJ _ Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT RE PAI RENOVATE,OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: DATE ISSUED: t 4 ZOP 7 SIGNATURE: Building Commissioner/I for of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Map umber Parcel Number: Parcel Number 1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Required 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 ❑ On Site Disposal System ❑ SECTION 2 -PROPERTY OWNERSHIP/AUTHORIZED AGENT historicDistrict: Yes NO 2.1 Owner of Record 1"/1r/ k,f �% Fore_. Name (Print) Address for Service : / / /! A -J, Signature f v Telephone 2P Owner of Record: dame Print Address for Service: Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: 5--Avw ©r ( i h "Ow A Licensed Construction Supervisor: Address —_ >0/- 3 / Si ature Telephone Not Applicable ❑ License Number Expiration Date 3.2 Registered Home Improvement Contractor A i L k"A"—)v Not Applicable ❑ ` Company Name16 , . o Atew dw 6 Registration Number -?*1 Address 21/- 3 - 3 3 3 ,)-- / / Si re Telephone Expiration Date 0 p� M X 3 z O G� SECTION 4 - WORKERS COMPENSATION (M.G.L C 152 6 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 au applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) ❑ 1 Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: SECTION 6 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollar) to be Completed by permit applicant OFFICIAL USE ONLY 1. Building 7 S 0'D (a) Building Permit Fee Multiplier 2 Electrical Ute' G'U (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) x (b) D 4 Mechanical (HVAC)�- 5 Fire Protection 6 Total 1+2+3+4+5 , 4:1V Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR "PLIES FOR BUILDING PERMIT /f I, ! ' � a c , n Lc tI 7 tit y j - C (_11 as Owner/Authorized Agent of subject property Hereby authorize 'r '61 cIr to act on My half, in all matters rel at(i/VYp\J to au rued by this building permit application. Signatigtof Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I, b r C "fe'l 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 VCA-lt,A- JY Print Nam �_o $� - //dl bY Si a e of Owner/A ent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIIVIBERS Isr2 ND 3 RD SPAN DIIVIENSIONS OF SILLS DIMENSIONS OF POSTS DIN ENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02911 Workers' Compensation Insurance Affidavit Name Please Print Name: S �''�q�t� n 1-A I� ,- ✓� Location: / �� w e-5 / S f Ch 'U- A,--d0yt1l, Phone # 7 P/- I am a homeowner performing all work myself. 1 am a sole proprietor and have no one working in any capacity I am an employer providing workers' compensation for my employees working on this job. Company name: p . `c � Ri'4 G Address f,0 � o Y 3 5- 4 A,1 Jr City: Phone # Insurance. Co. oNe. f3��co�✓ Poliev # Company name: Address City: Phone # Insurance Co. Policy # Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of,a fine up to $1,500.00 and/or one years' imprisonment_as w&U_as.cml.penaltiesinbefmnde..STOPWDWORDERand.a.fine.of.($10o DD) -allay against.me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I db hereby certify unfler the pains d penalties of perjury that the information provided above is true and correct. Signature *V Date c Print name oir rt Phone # Official use only do not write in this area to be completed by city or town official' City or Town PermiUUcensi []Check if immediate response is required 11 Building Dept ❑ Licensing Board Contact person: Phone #. ❑ Selectman's Office ❑ Health Department ❑ Other North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit Number is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11,S150A. The debris will be disposed of in: watsk^4,v (Location of Facility) Signature of Permit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector J .r 91te -C Board of Building Regula ions and Standards One Ashburton Place - Room 1301 " Boston. Massachusetts 02108 Home Improvement Contractor Registration Reqistration: 116688 Type: Individual Expiration: 7/6/2006 STEVEN PAUL DICHIARA STEVEN DICHIARA 68 WHITTIER ST NEWTON, NH 03858 SPS-CiA1 Co 50M -04/04-G101216 Fl.�omirnaizu�Pa�/ a�✓�iaaaae�ivaelt Board of Building Regulations and Standards _ — HOME IMPROVEMENT CONTRACTOR Registration: 116688 Expiration: 7/6/2006 Type: Individual STEVEN PAUL DICHIARA STEVEN DICHIARA 68 WHITTIER STS NEWTON, NH 03858 Administrator Update Address and return card. Mark reason for chang E] Address [:] Renewal [:] Employment E] Lost Card License or registration valid for individul use only before the expiration date. if found return to: Board of Building Regulations and Standards One Ashburton Place Rm 1301 Boston, Ms. 02108 *-,- Not valid without signature ' 071 i�anvirtarzu�ea�� o� aaac/ivaelta BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR Number: CS 055622 Birthdate: 06/11/1964 ' i Expires: 06/11/2006 Tr, no: 472.0 Restricted: 1G STEVEN P DICHIARA 68 WHITTIER ST NEWTON, NH 03858 Commissioner m m m x m m COD CD az Co06 0 d a� .0 0 o v CL Q d O CO CO COD .0 CD 0 Cos 'O d d O CA C2 0 COD C7 CDO CD CD 3, CO) CD CA CN O CD 0 CD Co Z� 0 �g =_ dp m y o �gn� 3 m Z �m ca T aT �n�n a m m -4ra 0m 0 y o so m 2 -14 ft c r o Z .o o � a .4o•;Qw C � y mTOIL do o m CL 1 CD3 Oo N � M y z 00 CIO ib o NIP, t0 n n O '`y CA ca r Ro OR: it z CO vJ m y =0 cr C )=3 0 0 10. a. '� �'- o�c 0 �.cp O )=3 0 0 °t tNORTM 1,t, 0 F SA US Date. t TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that 11 �. has permission to perform '........................ . plumbing in the buildings of ...5,-. .................... f .............. . North Andover, Mass. Fee. . .. PLUMBING INSPECTOR Check # MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Print or Type) I _ /in,� � cij n dw i/ a—mass. Date �07 Permit # 3 X3 Building LocationOwner's Name ��� 1 / J!� //''// // 9%S'— 6 e?- j7 Ca (n Type of Occupancy Residential New ❑ Renovation O Replacement Plans Submitted: Yes 0 No O FIXTURES Installing Company Name Heritage Htg . &Pl'g . Co. Inc. Address 35 Pleasant Street Stoneham, Ma 02180 Business Telephone -. 781 —43 8-77 7 6 Name of Licensed Plumber Gordon Switzer Check one: EX Corporation O Partnership F] Firm/Co. Certificate 71A 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 coverage by checking the appropriate box. A liability insurance policy 3 Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does 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 O I hereby certify that all of the details and information I have submitted (or entered) in 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 Co e and Chapter 142 of the General Laws. By L. /1y17 I/ 1 4- 17-4Z A Signature L. ens d um e Title Type of License: Master CZ Journeyman ❑ City/Town $ 3 2 2 APPROVED (0 FICE USE ONLY) License Number r/z" Watts 9D bfp on water line to water boiler -- VZ3 r zx .O W i3 i W Y N J v I c o v � Fa ) _ Q � i4 ro i4 N Z 0 a c e _ z G _U N a x O lJ q t:l N U W G7 cn < G d z d Z t. 3 IJ 49 R�S1 (��1( B 1-I U z Q m K W 1 0 ¢ U Z S .� �(q x x rM x i W = a 2 Lu 3 Q d W a o~ i a W Y r C) > r o = a u' r o ° __ a N 49 i4 Q a o Q J J a¢ o' m 3 c t7- a 4 4-) cnk n a m SUa—BSMT. BASEMENT, 1ST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR 5TH FLOOR 6TH FLOOR 7TH FLOOR 8TH FLOOR i Installing Company Name Heritage Htg . &Pl'g . Co. Inc. Address 35 Pleasant Street Stoneham, Ma 02180 Business Telephone -. 781 —43 8-77 7 6 Name of Licensed Plumber Gordon Switzer Check one: EX Corporation O Partnership F] Firm/Co. Certificate 71A 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 coverage by checking the appropriate box. A liability insurance policy 3 Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does 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 O I hereby certify that all of the details and information I have submitted (or entered) in 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 Co e and Chapter 142 of the General Laws. By L. /1y17 I/ 1 4- 17-4Z A Signature L. ens d um e Title Type of License: Master CZ Journeyman ❑ City/Town $ 3 2 2 APPROVED (0 FICE USE ONLY) License Number r/z" Watts 9D bfp on water line to water boiler -- VZ3