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HomeMy WebLinkAboutMiscellaneous - 87 Pleasant Street00 J ro cD 0 cn ft rt n m m rt Safety Insurance Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS, Ch. 139, Sec. 3B To: Building Commissioner or Board of Health or Inspector of Buildings Board of Selectman City Hall City Hall NORTH ANDOVER, MA 01854 NORTH ANDOVER, MA 01854 RE:.: . Insured: RUSSELL STOTT Property Address: 87 89 PLEASANT ST, NORTH ANDOVER, MA Policy Number: HMA 0359847 Claim Number: BOS00045153 Date of Loss: 9/6/2014 Company: Safety Insurance Company Claim has been made involving loss, damage or destruction of the above -captioned property, which may either exceed $15000.00. or cause Mass. Gen. Laws, Chapter 143, Section 6 to be applicable. If any notice under Mass. Gen. Laws, Chapter 139, Section 3B is appropriate, please direct.it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim number. Lisa Monette Claim Examiner 9/9/2014 Safety Insurance Company Homeowners Claims Unit P. 0. Box 55098 Boston, MA 02205-5098 Phone: (857) 233-8618 Fax: (617) 535-5833 . Email: lisamonette@safetyinsurance.com mmm_ Date-. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ... .................. has permission fo perform ... ....................... plumbing in the buildings of.. ........................ aP. ............. , North Andover, Mass. Lic. No4l PLUMBING INSPECTOR) Check 4 2 2 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY _ __- MA DATE[12$$_ PERMIT # f JOBSITE ADDRESS 7 s OWNER'S NAME POWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL 01 RESIDENTIAL 0 PRINT CLEARLY NEW: F-11 RENOVATION: REPLACEMENT: 0 PLANS SUBMITTED: YES ® NO© FIXTURES 7 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOILISAND SYSTEM _f .._- ( _..f ! f _.. _f DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM f I , f I DEDICATED WATER RECYCLE SYSTEM F -i _.-_—I ._.__J _-_-_._1 f DISHWASHER DRINKING FOUNTAIN f -_-...._. L _._.._! ---.__I ___.._( _ _f --.._..._f ..... .... f F OD DISPOSER __._� FLOOR/AREA DRAIN INTERCEPTOR INTERIOR _ f ( --_.._-.f __.__._i ....._.___! 1 -_- __. KITCHEN SINK LAVATORY ROOF DRAIN S ,jWER STALL SERVICE / MOP SINKf TOILET _ I -- ._- _-- f ..__ _.. _ ._._. ___... ._ f _._..... ..... URINAL f .__.---! f __.._.._._1 �--_..._.. .....__.__ WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER.............. __.-___J __I - f _------ .._._..-..... - — ----- _ INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES 0 NO D IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ®i OTHER TYPE OF INDEMNITY D BOND 0 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 _i AGENT �0 SIGNATURE OF OWNER OR AGENT I 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 be in complian a with all Pertine rovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME _KJA/i LICENSE # i V SIGNATURE MP MI JP-tj CORPORATION 0#=PARTNERSHIP �]_.I # !1 LLC � �{ COMPANY NAME h r �r ADDRESS /�__t e �Yi!_11'I CITY ��Q �7�� ,� _..� STATE � ZIP -(T /9 33 i TEL AA FAXCELL EMAIL H °z 0 F U W a w 0 E z N❑ } o C40D w o Z W au LU O Q w co a W W � co p a z a w a as � a a �a Q co 2 w Ln H z° 0 H U a C7 i a 0 a r c The Commonwealth of Massachusetts Department ofIndustrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 u4p www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): _ I^G �j /Oh 4 lelem Address: �( A, .,artti Poirt City/State/Zip: Geo fo(,kd /11 d O/,5 3 S Phone #: 77E 76 7 SSS i 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. ❑ New construction _,employees (full and/or part-time).* have hired the sub -contractors listed the sheet. 7• ❑ Remodeling 2.0 I am a sole proprietor or partner- ship and'have no employees on attached These sub -contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. g E] Building addition [No workers' comp. insurance 5. El We are a corporation and its 10. El Electrical repairs or additions required.] 3. ❑ I am a homeowner doing all work officers have exercised their 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 aie doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors 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. Insurance Company Name: Policy # or Self -ins. Lic. #: 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 requireclunder 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. X do Hereby certtO unze pains and�lties ofperjury that the information provided above is true and correct. Phone #: Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License 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 employeiis 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 Commonwealth of Massachusetts Department of industrial .A.ccldents Office of Investigafiiolts. 600 Washington. Street Boston, MA. 02111 Tel, # 617-727-4900 ext 406 or 1-877. MASS.ABE Revised 5-26-05 Fax # 617-727-7749 www.m,ass.govfdia r� %I J- 1 i 1 N T !JJ • :` . , Ill N . �U WZ.- E -Q O M N z Q U)W -'Q^z 1 _w U. 11 m LU co Ln aQ W u � .. Q w NN .' i Z � W� t,p �' T • Cp .�N z aw s, :: n. :: � U a p IU LD Datp)�//�... . TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ................... ................. has permission for gas installation ��4��.................. . in the buildings of.. ............................ at .5.... -! , ,+, .... , ... , North Andover, Mass. GAS INSPECf R Check 8610 6 1 0 �• " � v � I po MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY�ey ems. MA DATE" & - 3 PERMIT # JOBSITE ADDRESS? P-�g 5,/t—OWNER'S NAME GOWNER ADDRESS r ---I TEL IFAX TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL r-1 EDUCATIONAL RESIDENTIALER CLEARLY NEW: [Q RENOVATION: F REPLACEMENT: [ PLANS SUBMITTED: YES 0_I NOF APPLIANCES 1 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER FXJ BOOSTER CONVERSION BURNER - COOK STOVE --J1 _ .. _. _ _.. _ .� ,- DIRECT VENT HEATER_.. T DRYER _ I. _ _ 1 FIREPLACE FRYOLATOR _ _ z_.J _-_ _ _ FURNACE GENERATOR GRILLE INFRARED HEATER(.—_,�fLABORATORY COCKS IL—.- r-=! MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOFTOP UNIT TEST UNIT)HEATER _._ __.I (�� L _. UNVE TED ROOM HEATER WATER HEATER I 1 _ 1_ —J --- L. _ _ - _.J —dT H—ERF l -- - - -- I INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL. Ch. 142 YES IDZNO Ej IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Pr 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 0-1 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 be in compliance wit II Pertinen - ovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME��y�T _ LICENSE #= _�_� SIGNATURE MP El MGF El JP J JGF ��( LPGI CORPORATION Q# _ PARTNERSHIP # LLC D# COMPANY NAME:ADDRESS [ G _ S]�d r► ,:_ CITY STATE �ZIP Mfr 3 "? TEL FAXCELLREMAIL aI'C�ISI�A< I po t'= o o z a� W a aj w LL -V The Commonwealth of Massachusetts Department ofIndustrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Uf www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address:/ � el" e� /��jtwL 12 � City/State/Zip: TIS,,, 94 QYS 3 3 Phone #: 7,>6 76 Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 4. ❑ I am a general contractor and 1 6. ❑ New construction employees (full and/or part-time).* have hired the sub -contractors �• ❑Remodeling 2. aI am a sole proprietor or partner- listed on the attached sheet. # ship and'have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. g, ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.E1 Electrical repairs or additions required.] officers have exercised their 3111 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.[i 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 aie doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors 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 1s providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. Policy # or Self -ins. Lic. #: Expiration Date: Job Site 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 requiredunder 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. Ido hereby certto un4yoiepains adpenalties ofperjury that the information provided above is true and correct. Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # WIN= 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 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 Commonwealth of Massachosetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston., MA. 02111 Tei, # 617-727-4900 ext 406 or 1-877:MASSAFE Revised 5-26-05 Fax## 617-727-7749 __WWW-mass,govldia This certifies that .... G r.z: has permission for gas ' � E,�\... . .................. in the buildings ++ .. C. at .. ! tit �SZ S f. ..... . ... . . . North Andover, Mass. Fee 3P:W... Lic. No. !7 L.. ....... . GASINSPECTOR Check # 8437 ka V IV MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY MA DATE _ILjj PERMIT # JOBSITE ADDRESS5-OWNER'S NAME - GOWNER ADDRESS TELF___._ __ FAX TYPE OR PRINT OCCUPANCYTYPE COMMERCIAL EDUCATIONAL [JI RESIDENTIAL CLEARLY NEW: L�IJ_ RENOVATION: D REPLACEMENT: PLANS SUBMITTED: VESn. NO APPLIANCES 7 FLOORS- BSM 1 1 2 1 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER -I CONVERSION BURNERJ= 1 -_-- COOK COOK STOVE_.._.. .... _al DIRECT ENT HEATER ,--J .__.._. ._._f ._•_.J .� _ DRYER— FIREPLACE FRYOLATOR FURNACE _.- `J ._ - l GENERATOR GRILLE INFRARED HEATER:.= __: LABORATORY COCKS J _ ,-, . 1 :-__---.J T--iJ _._ (� _ — . MAKEUP AIR UNIT OVEN POOL HEATER ROOM 1 SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER ..._.. UNVENTED ROOM HEATER .._.., << ..I _ .I [ --,1( 1 :T _,f -�-_ (__._I WATER HEATER.._..—._ OTHER __I I JJ - ._ J .. INSURANCE COVERAGE have a current liability insurance policy or Its substantial equivalent which meets the requirements of MGL. Ch. 142 YES ONO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY EJ 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 applicationaw lues this requirement. CHECK ONE ONLY: OWNER 0 AGENT r SIGNATURE OF OWNER OR AGENT I 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 be in oompllance with Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME _✓..= LICENSE #F3%5-_ SIGNATURE MP 0 MGF LI JP [, J' F LPGI0 CORPORATION jj# - - PARTNERSHIP D. #= LLC [j#��_ COMPANY NAME: .- rr.St� -[ ADDRESS CITY-wha.__.___._...---_ ........ STATE[ij�ZIP _-_JTEL FAX��_���—, J1 CELL.u��-►IEMAIL ....Aiawoul i V IV �7J'Ni2-C. c��� P✓a'ra-2� V�yl-tom 0- did HEALTH OFMAUSE PLUMBERS A AND ,GASpITTERPLUMgER i JOURNEYMAN l LICENSED AS ISSUES THE ABOVE LICENSE?� ARCHER , ..' FARM RD,. ti 19 PIN GREE MA P.�833 z r GERGETQWN 172+9 05/01/1+ . e it 3 CGNTR i�rypORTANT Bo at the. notify your B . St., is lost or destroyed X000 Washington If this license610®. i Division of Boston, t2118 sur , our board Suite 710+ B°ston, notify Y shown is changed,ailingmailing of next e or address to insure propel license number. i If your nam address licatlon. Always refer to y of the General Laws of correct name or provisions Renewal App ect to the p , and must not be loaned is subj nwlege, our This license It is a personal p Keep this license on y asamended•to any other person. or assfgne ed as required by law - person or p THE COMMONWEALTH OF MASSACHUSETTS .BOARD -OF HEALTH TY/TOWN ��' �--'" ARTMENT DRESS TELEPHONE Occupant �f/E�__ e� i ;cupants _ ..�oms No. dwelling or rooming units _ No. Stories Name and address of owner Remarks Ranvin YARD Out Bldgs.: Fences: Garbage and Rubbish: Containers: Drainage Infestation Rats or other: STRUCTURE EXT. El B ❑ F ❑ M Steps, Stairs, Porches: Dual Egress: and Obst'n.: Doors, Windows: Roof Gutters, Drains: Walls: Foundation: Chimney: BASEMENT Gen. Sanitation: Dampness: Stairs: _ Lighting: _ STRUCTURE INT. Hall, Stairway: Obst'n.: Hall, Floor, Wall, Ceiling: Hall Lighting: Hall Windows: HEATING Central ❑ Y ❑ N TYPE: Chimneys: Equip. Repair Stacks, Flues, Vents: PLUMBING: ❑ MS ❑ ST ❑ P Supply Line: Waste Line: _ H.W. Tank(s) Safety and Vent(s) ELECTRICAL ❑ 110 ❑ 220 AMP: Panels, Meters, Cir.: Fusing, Grnd.: Gen. Cond. Distrib. Box: Gen. Basement Wiring: Kitchen DWELLING UNIT Ventil. Lgtng. Outlets Walls Ceils. Wind. Doors Floors Locks _ Bathroom Pantry Den Living Room M _ Bedroom 1 Bedroom (2) Bedroom (3) Bedroom (4) Hot Water Facil. Sup. Ten., Gas, Oil, Elect.: Stacks Flues Vents Safeties: _ Kitchen Facilities Sink Stove Bathing, Toilet Facil. Vent., Plumb., Sanit'n.: Wash Basin, Shower or Tub: _ Infestation Rats, Mice, Roaches or Other: Egress Dual and Obst'n: General Building Posted: Locks on doors: ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR. (See Over) "THIS INSPECTION REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND PENALTIES OF PERJ Y." /� INSPECTOR 0 6 • TIT E _ r DATE TIME /_._� f —__-M. THE NEXT SCHEDULED REINSPECTION A. M. P. M. 410.750: Conditions Deemed to Endanger or Impair Health or Safet The following conditions, when found to exist in residential premises, shall be deemed conditions which may endanger or impair the health, or safety and well-being of a person or persons occupying the premises. This listing is composed of these items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the occupants or the public. Because Chapter II, 105 CMR 410.000 through 410.499 state minimum requirements of fitness for human habitation, any violation has the potential to fall within, this category in any given situation but may not do so in every case and therefore cannot be included in this listing. Failure to include shall in no way be construed as,a determination that other violations may not be found to fall within this category. Nor shall failure to include affect the duty of the local health official to order repair or correction of the violation(s) pursuant to 410 CMR 410.830 through 410.833 nor shall it affect the legal obligation of the person to whom the order is issued to comply with such order. (A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold, to meet the ordinary needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer. (B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as prohibited by 105 CMR 410.200(B) and 410.202. (C) Shut-off and/or failure to restore electricity or gas. (D) Failure to supply the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253(A), 410.253(B) and the lighting in common area required by 105 CMR 410.254. (E) Failure to provide a safe supply of water. (F) Failure to provide a toilet and maintain a sewage system in operable condition as required by 105 CMR 410.150(A)(1) and 410.300. (G), Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused.by an object, including garbage or trash, which prevents egress in case of an emergency 105 CMR 410.450 and 410.451. (H) Failure to comply with the security requirements of 105 CMR 410.480(D). (I) Failure to comply with any provisions of 105 CMR 410.600 through 410.602 which results in any accumulation of garbage, rubbish, filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests or otherwise contribute to accidents or to the creation or spread of disease. (J) The presence of lead-based paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public Health Regualtions for Lead Poisoning Prevention and Control 105 CMR 460.000. (K) Roof, foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or other dangers or impairment to health or dafety. (L) Failure to install electrical, plumbing, heating and gas -burning facilities in accordance with accepted plumbing, heating, gas -fitting and electrical wiring standards or failure to maintain such facilities as are required by 105 CMR 410.351 and 410.352 so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety. (M) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or knowledge of the owner of said condition or conditions: (1) lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven or any defect that renders either operable. (2) failure to provide a washbasin and a shower or bathtub as required in 105 CMR 410.150(A)(2) and 410.150(A)(3) and any defect which renders them inoperable. (3) any defect in the electrical, plumbing, or heating system which makes such system or any part thereof in violation of generally accepted plumbing heating, gas -fitting, or electrical wiring standards that do not create an immediate hazard. (4) failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as required by 105 CMR 410.503(A) and 410.503(B). (5) failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550. (N) Amy other violation of Chapter II not enumerated in 105 CMR 410.750(A) through (M) shall be deemed to be a condition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner to remedy said condition within the time so ordered by the board 0 z U Z Z W Ir CE a .e U) m m 0 2 0 0 U_ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Let., , • c� / //�,c E,s� C�I%T]Y/TOWN • _ E ARTC���--- • ADDRES TELEPHONE Address�ra.M Occupant Floor _ _ Apartment No. No. Occupants No. of Habitable Rooms _"_ No. Sleeping Rooms No. dwelling or rooming units -_ o. Stories �� Name and address of owner ���%`C✓____ _ Remarks Rem YARD Out Bld s.: Fences: Garbage and Rubbish.- ubbish:Containers: Containers: Drainage Infestation Rats or other: STRUCTURE EXT. ❑ B ❑ F E7 M Steps, Stairs, Porches:, Dual Egress: and Obst'n.: TV Doors, Windows: Roof Gutters, Drains: Walls: Foundation: Chimney: BASEMENT _ Gen. Sanitation: Dampness: Stairs: _ Lighting: STRUCTURE INT. Hall, Stairway: 0bst'n.: Hall, Floor, Wall, Ceiling: Hall Lighting: Hall Windows: HEATING Central ❑ Y ❑ N TYPE: Chimneys: Equip. Repair Stacks, Flues, Vents: PLUMBING: ❑ MS ❑ ST ❑ P Supply Line: Waste Line: _ H.W. Tank(s) Safety and Vents) ELECTRICAL ❑ 110 ❑ 220 AMP: Panels, Meters, Cir.: Fusing, Grnd.: - Gen. Cond. Distrib. Box: Gen. Basement Wiring: Kitchen DWELLING UNIT Ventil. Lgtng. Outlets Walls Ceils. Wind. Doors Floors Locks _ Bathroom Pantry Den Living Room _ Bedroom (1) Bedroom (2) Bedroom (3) Bedroom (4) Hot Water Facil. Sup. Ten., Gas, Oil, Elect.: _ Stacks Flues Vents Safeties: Kitchen Facilities Sink Stove Bathing, Toilet Facil. Vent., Plumb., Sanit'n.: Wash Basin, Shower or Tub: Infestation Rats, Mice, Roaches or Other: Egress Dual and Obst'n: General Building Posted: Locks on doors: ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR. (See Over) "THIS INSPECTION REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND PENALTIES OF PERJURY." INSPECTOR L am. rl TITLE -- A. DATE ___ TIME _C� M. THE NEXT CHEDULED REINSPECTIONr7 iqlh---- Via) 410.750: Conditions Deemed to Endanger or Impair Health or Safety The following conditions, when found to exist in residential premises, shall be deemed conditions which may endanger or impair the health, or safety and well-being of a person or persons occupying the premises. This listing is composed of these items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the occupants or the public. Because Chapter II, 105 CMR 410.000 through 410.499 state minimum requirements of fitness for human habitation, any violation has the potential to fall within this category in any given situation but may not do so in every case and therefore cannot be included in this listing. Failure to include shall in no way be construed as.a determination that other violations may not be found to fall within this category. Nor shall failure to include affect the duty of the local health official to order repair or correction of the violation(s) pursuant to 410 CMR 410:830 through 410.833 nor shall it affect the legal obligation of the person to whom the order is issued to comply with such order. (A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold, to meet the ordinary needs of -the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer. (B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as prohibited by 105 CMR 410.200(B) and 410.202. (C) Shut-off and/or failure to restore electricity or gas. (D) Failure to supply the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253(A), 410.253(8) and the lighting in common area required by 105 CMR 410.254. (E) Failure to provide a safe supply of water. (F) Failure to provide a toilet and maintain a sewage system in operable condition as required by 105 CMR 410.150(A)(1) and 410.300. (G). Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by an object, including garbage or trash, which prevents egress in case of an emergency 105 CMR 410.450 and 410.451. (H) Failure to comply with the security requirements of 105 CMR 410.480(D). (I) Failure to comply with any provisions of 105 CMR 410.600 through 410.602 which results in any accumulation of garbage, rubbish, filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests or otherwise contribute to accidents or to the creation or spread of disease. (J) The presence of lead-based paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public Health Regualtions for Lead Poisoning Prevention and Control 105 CMR 460.000. (K) Roof, foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or other dangers or impairment to health or dafety. - (L) Failure to install electrical, plumbing, heating and gas -burning facilities in accordance with accepted plumbing, heating, gas -fitting and electrical wiring standards or failure to maintain such facilities as are required by 105 CMR 410.351 and 410.352 so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety. (M) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or knowledge of the owner of said condition or conditions: (1) lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven or any defect that renders either operable. (2) failure to provide a washbasin and a shower or bathtub as required in 105 CMR'410.150(A)(2) and 410.150(A)(3) and any defect which renders them inoperable. (3) any defect in the electrical, plumbing, or heating system which makes such system or any part thereof in violation of generally accepted plumbing heating, gas -fitting, or electrical wiring standards that do not create an immediate hazard. (moi) failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as required by 105 CMR 410.503(A) and 410.503(B). (5) failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550. (N) Amy other violation of Chapter II not enumerated in 105 CMR 410.750(A) through (M) shall be deemed to be a condition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner to remedy said condition within the time so ordered byYhe board of health. V, JUIo 16 ryO\ •a p� Co C p�AA TED �PP'y.�y ��SSA�uu5E4 tiad.e . by Address _ Nature of complaint BOARD OF HEALTH 120 MAIN STREET NORTH ANDOVER, MASS. 01845 COMPLAI14T TORN TEL. 682-6400 DATE 7/�9d Tel. V Locationg% C Occupant ant '.' ,Owner or Agent24,&, Address 16,o Cv4412, ; 9 7f 5 —Sid s�9 DO NOT WRITE BELOW THIS LIr1E II . , �/Dl.+e. /yto — 8'G SC•2/ to D ..Referred to Date of Investigation ,.':Result of investigation Recommendations Action taken