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Home My WebLink AboutMiscellaneous - 1 HARVEST DRIVE 4/30/2018Safety Insurance AUTO • HOME • BUSINESS P.O. Box 55098 Boston MA 02205 617-951-0600 January 11, 2018 Building Commissioner or Inspector of Buildings Fire Department or Arson Squad Board of Health or Board of Selectman City Hall NORTH ANDOVER, MA 01845 Insured: KATIE PRIESTLY Property Address: 1 HARVEST DRIVE, UNIT 311, NORTH ANDOVER MA Policy Number: HMA0145727 Claim Number: BOS00080470 Date of Loss: 1/1/2018 Notice of Loss Under M.G.L. c. 139, § 3B This communication shall serve as written notice pursuant to M.G.L. c. 139, § 313 that [Safety Insurance Company] ("Safety") has received a claim involving loss, damage or destruction to a building or other structure at the above -referenced address which may either: (1) meet or exceed $1,000; or (2) cause the condition or the building or other structure to render M.G.L. c. 143, § 6 applicable. In accordance with M.G.L. c. 139, § 3B, if the city or town intends to initiate proceedings designed to perfect a lien under Section 3B, M.G.L. c. 143, § 9 or M.G.L. c. 111, § 127B, please notify Safety of the same by certified mail. Kindly forward such notice to my attention, at the address indicated above, and include with such notice a reference to the above-described insured, property address, policy number and claim number. If you have any questions regarding this notice, please feel free to contact me directly at 617-951-0600, extension 5015. Sincerely, Allan Leavitt Claim Examiner Glaim`Examiner Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS, Ch. 139, Sec. 3B To: Building Department Building 20, Suite 2035 1600 Osgood Street North Andover, MA 01845 RE: Insured: Property Address: Company: Policy/Claim Number: Date/Cause of Loss: Our File Number: Steven Perlini & Scott Spindler 2 Harvest Drive, Unit 102 Vermont Mutual Insurance Company DF13054159, DFA19938 10/24/2016, Water/Washing Machine Leak 33782 -RP Claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 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 the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim or file number. Rob Parilla, Ext. 119 On this date, I caused copies of this Notice to be sent to the persons named above at the addresses indicated above by First Class Mail. Sigi ur and Date ANDERSON ADJUSTMENT CO., INC. 50 Nashua Road, Suite 303 PO Box 1098 Londonderry, NH 03053 Cc: North Andover Health Department North Andover Fire Department Building 20, Suite 2035 795 Chickering Road 1600 Osgood Street North Andover, MA 01845 North Andover, MA 01845 i�I Safety Insurance SS P.O. Box 55098 Boston MA 02205 617-951-0600 November 18, 2016 Building Commissioner or Inspector of Buildings Fire Department or Arson Squad Board of Health or Board of Selectman City Hall NORTH ANDOVER, MA 01845 Insured: ELIZABETH DESMARAIS Property Address: 3 HARVEST DR UNIT 104, NORTH ANDOVER MA Policy Number: HMA0384849 Claim Number: BOS00072601 Date of Loss: 11/1/2016 Notice of Loss Under M.G.L. c. 139,§ 3B This communication shall serve as written notice pursuant to M.G.L. c. 139, § 3B that [Safety Insurance Company] ("Safety") has received a claim involving loss, damage or destruction to a building or other structure at the above -referenced address which may either: (1) meet or exceed $1,000; or (2) cause the condition or the building or other structure to render M.G.L. c. 143, § 6 applicable. In accordance with M.G.L. c. 139, § 313, if the city or town intends to initiate proceedings designed to perfect a lien under Section 36, M.G.L. c. 143, § 9 or M.G.L. c. 111, § 127B, please notify Safety of the same by certified mail. Kindly forward such notice to my attention, at the address indicated above, and include with such notice a reference to the above-described insured, property address, policy number and claim number. If you have any questions regarding this notice, please feel free to contact me directly at 617-951-0600, extension 5015. Sincerely, Allan Leavitt Claim Examiner Date ..... A� ........ TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that -1 A LJ has permission to perform ......... ��!. ........... wiring in the building of at ......................... r 0 ....... /J ... 4 1 .... K ... 4 ........ "tC- North Andover, Mass. Fee ' L/,f- 13�� 7 ........... Lic. No . ................. .................................................................................... ELECTRICAL INSPECTOR Check # 5-66-1q I 1 2 7 5 a In WWAOM R CommonweaIg v/ Vajdack"Jeffi BOARD OF FIRE PREVENTION RE GULA,TI NS Official Use Only Permit No. 12-11 4�-' Occupancy and Fee Checked [Rev. 1/07] (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: October 12, 2015 City or Town of: North Andover, MA_ 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) 2 Harvest Dr # 106 Owner or Tenant Shirley Cabral Telephone No. (978) 957-8761 Owner's Address 2 Harvest Dr # 106 Is this permit in conjunction with a building permit? Yes El No 19,1 (Check Appropriate Box) Purpose of Building f �_�X a Utility Authorization No. Existing Service Amps / Volts Overhead Q Undgrd No. of Meters New Service Amps / Volts Overhead M Undgrd No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Installation of a low -voltage, wireless burglar alarm system. Completion of the ollowin table may be waived by the In ector of Wires, No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans o. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above 0 In- nd. nd. o. of Emergency Lighting BatteryUnits No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS o. of Zones No. of Switches No. of Gas Burners o. of Detection and _Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices g O. of Waste Disposers eat Pumpumber Totals:Detection/Alerting ons W o. of Self -Contained Devices No. of Dishwashers Space/Area Heating KW Local Municipal Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of WaterKW Heaters o. 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 Wires. Estimated Value of Electrical Work: $850.00 (When required by municipal policy.) Work to Start: October 12, 2015 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 F❑ BOND El OTHER ❑e" (Specify:) I certify, under the pains and penalties of perjury, that the information og this appliction is true atWcomplete. MRM NAM : Defen S urit C a - % , - LIC. NO.: C 1355 Licensee: Signature - LIC. NO.: D 434 (If applicable, enter "exempt" in the license number line.) Bus. Tel. No.: 800-689-9554 Address: 3750 Priority Way S Drive, Suite 200, Indianapolis, IN 46240 Alt. Tel. No.: 866-502-3559 *Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. SSCO-001258 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) M owner f-` owner's agent. Owner/Agent Telephone ERMIT FEE: $ Signature No. <, The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 } www. mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leeibly Name (Business/Organization/Individual): Defenders, Inc. dba Protect Your Home Address: 3750 Priority Wav S Drive, Suite 200 city/state/zip: Indianapolis, IN 46240 Phone#: 317-810-4720 Are you an employer? Check the appropriate box: Type of project (required): 1. N I am a employer with 3 4. 0 I am a general contractor and I 6. ❑ New construction employees (full and/or part-time). have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. [] Remodeling ship and have no em to ees p p y These sub -contractors have g ❑Demolition working for me in any capacity. employees and have workers' 9 E] Building addition [No workers' comp. insurance comp. insurance.t bg required.] 5• E] We are a corporation and its 10.Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have exercised their I L Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.[] Roof repairs insurance required.] t c. 152, § 1(4), and we have no 13. ❑ Other employees. [No workers' comp. insurance required] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. I Homeowners who submit this affidavit indicating they are 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 state whether or not those entities have employees. If the subcontractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is thepolicy andjob site information. insurance Company Name: MJ Insurance Policy # or Self -ins. Lic. #: TCJ U B 1116 LO3015 Expiration Date: 07/01/2016 Job Site Address: �' t � �� 1/ �, ( uo City/State/Zip. -nd 6v2�. I N(A 6045- Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct