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HomeMy WebLinkAboutMiscellaneous - 10 COVENTRY LANE 4/30/2018Cunningham Lindsey U.S., Inc. P.O. Box 703689 Cunx in a.Iit Dallas, TX 75370-3689 Cunning 1�i�S�� Telephone (888) 738-8714 Facsimile (214) 488-6766 j� CLCAT@CL-NA.COM Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS Ch. 139, Sec 3B Building Commissioner or Inspector of Buildings 1600 Osgood Street Building 20, Suite 2035 North Andover, MA 01845 Claim Number: 1006486 Policy Number: 1006486 28 Company Name: BAY STATE INSURANCE COMPANY Date of Loss: 02/15/2015 Insured: JOHN & CAROL OBERT Property Location: 10 COVENTRY LN, N ANDOVER, MA 01845 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. Kindly include a reference to the captioned insured, location, date of loss and claim number. Section 3B. No insurer shall pay any claims (1) covering the loss, damage, or destructions to a building or other structure, amounting to the one thousand dollars or more, or (2) covering any loss, damage or destruction of any amount, which causes the condition of a building or other structure to render section six of chapter one hundred and forty-three applicable, without having at least ten days previously given written notice to the building commissioner or inspector of buildings appointed pursuant to the state building code, to the fire department or arson squad of the city or town and to the board of health or board of selectmen of the city or town in which the same is located. If at any time prior to the payment the said city or town notifies the insurer by certified mail of its intent to initiate proceedings designed to perfect a lien pursuant to section three A, or to section nine of chapter one hundred and forty-three, or section one hundred and twenty-seven B of chapter one hundred and eleven, the said payment shall not be made while the said proceedings are pending; provided, however, that said proceedings are initiated within thirty days of receipt of such notification. Any lien perfected pursuant to section three A, or to section nine of chapter one hundred and forty-three or section one hundred and twenty-seven B of chapter one hundred and eleven, shall extend to and may be enforced by the city or town against any casualty insurance policy or policies covering any loss, damage, or destruction pursuant to which the proceedings to perfect the lien were initiated. No insurer shall be liable to any insured owner, mortgagee, assignee, city or town, or other interested party for amounts disbursed to a city or town under the provisions of this section, or for amounts not disbursed to a city or town under the provisions of this section. 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. Cunningham Lindsey Catastrophe Department cicat@cl-na.com 800-867-3885 Date............................ TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ................................ has permission to perform . /11-) wiring in the building of.... .... ........ ........................................................... at ...... ...... ....... ........ ............... n 9 North Andover, Mass. .. ..... .. .... ..... ..... Lic. No ELEcrRICAL INspEcro Check # Z/7 9093 t�ofnmonwe o�=//(aeeaclfe BOARD OF FIRE PREVENTION REGULATIONS Permit No,G 4 Occupancy and Fee Checked Rov, 1/07) Cleave blanMd� �^ All work to be porformod in a000rdance`with the Massachusetts Bleotrioat Code (MBC), S27 CMR 12.011 t .- (P.LEASE PRINT IN IMK OR TYPE ALL INFORMAYt?I) t , .I}htt3a Imo: 1. q a 9 J' ! \ i n r ►-. Av. ���r To the Inspector oftres } Hy this application thd'undersigned gives notice of his or hot intention ro perform the electrical work described below, ' Location (Street & Number)-� �!' � , t _1�i �ny� in G to r, jt�l ,{•, • t.., :) ,, Owne. `or-`i"ertant N h TelepinKo1No. ,� ©Osl Owner's Address 10 C A L J 0 t,. -1-v. 'L i.. A/ m-4 1 A JA, I A A' * Is this permit in conjunction with a bulidlrig permit? Yes [!g--- No Q (Check Appropriate Box) ' '•' I . Purpose of Building d �..� t l ; �Utility, Authorization No. 49*11 Mg Service' '' ' { Ainpi ! . ! ,;Volts.,t ' iOverheadfll i Undgrd-r No -of 10eters, J J, r Yolts()V"rhead 0 Number of FeedeV4'aisd Ampacity ! Location and Nature°nf Proposed )Electrical.Works Oq Undgrd 15 of Meters , ►Twof->tedbaasin�es;. { { � 1 .=14 v ..,p V.W.►(fl N�. eT����AnS' .RUM for Q1 wfn s. a i! ',.' .11 ! 'd `'(3'{:i h , ., K A. No. of Luminaire Outlets No. ofHot Tubs ; Generators „'.,N KYA , NO, of Lamiaaires ,Swimming Pool Above d. _.. grnd ergacy1311 Units No. of Receptacle Outlets S : ` ` No. of Oil Burners FiRB ALARMS No: of Zones PW Nq�ofsialifarnere-'�, • .. - - _ _.... _ .. Devices No. of Ranges No. -of Air Cond. ° Tons No. of Atertla g > Ne, of WJaste Disposers,v. am ar ts1o, ,p • _ , , . . Local ❑ q ❑ Other n 1 1 No. of MWoshers Space/Area Heating KW Ne. of Dryers Heating Appliances : ata 1'Vffirgr . No. f Do' lector Spulglent Heaters KAP - . signs Ballasts No. Hydromassage Bathtubs . ' ' ' No. of Motoes To"tui fife a ecomman ns ns . No. of D c v lent THBR; s. t:res , �' .- ;t .. B�titnated Value ork.' {' of Bi�Gt€ical llid"7 a5 r t a l r Aluma�aaf�rjfo�n{afitetaH jl aR+rr cast o�r�>ar�sgah+eAbyNre lerapssfor of Wlrrs. Work to 11 StaTG inspecone fio be rogaeeted in aasordattoe whhialBC:Rute ataaon compteNoa. t{. INSURANCE COVERAGM Unless waived by the of m, no paWt fbr the performance of electrical worknuiy issue unless the 1ltaMOO provides proof of lialtfil4ty 4nettraitee including „eoMpteted opetatloa" coverWat its eubstiintiai equi'valont,' The undersigned dettities that such coverage is in throe, and has exhibited proof of same to tho permit issuing office, CIUCK-ONE: INSURANCE M— BOND -(Q OTHER Q (Specitj+:) - d s' A txxder Me Pak" amf pexaTUJ of 04ary, (hal the kvwwtaUYoft 0#1M& applleallon fs &M andcom�ptete..ItIR�IVE-I�FkIdISt rOL ►1 c ".NO.: 3 Fs 7 L . Lkeasee: r. Sgpt�ttprQ_ �^LA�� /l, t`• • \ i Jam:% UC. NO.t: 93 $L =h�rtwc enter "wcsmpf hr (looms WM t") Bus. Te(. Nio.L .B; !J 02. ! 5�&- s o .L� ,.,.kLs�C.'�Jr, .�.. ®� , _®�. C AIt. Tel. Noa *Per M.O.G, a. 147, s, 57.6 1, seoarity work requires Depatftneut of Public Sahty "S" We= P0. No. OWMIR'S INSURANCE WAIVRRt Tun swam-aat tho ikone doff not !rave the fiabili 'lasivam notmalTy ' 0wn . fli my; t#iigttatal+o W110% I hetbyee-tf�r wCoq MW,!* t• lar he �+ 0 fl W ►B 'Stglitttare Telephone No. FBRJN'! s . 0 0 The -Commonwealth of Massachusetts Y ' Departnient-of Industrial Accidents ' Office of lnvwdgadons y 600 Washington Street &ston, MA 02111 ' � J www. mass gQyIM Workers' Compensation Insurance Aff davit' Burtd�rs 'n'tractorsMiectricians/Plumbers Applicant Inf rmation s P styr!"cLegibIl ' Name (Business(Organization4ndividual): roy\ C� Address: cam- O St- _ t•e you an employer? Check (lie fll)l)f opriate Uox: 1. ❑ I am a empl6yer with 4' ❑ I am a general contractor -and I employees (full andTr part-time). * have hired the sub -contractors 2. M-i'am a sole proprietor or partner- listed on the attached sheet. ship and havenaGW44eyees- - These sub -contractors have working for me in any capacity.. employees and have workers''' [No workers' comp, insurance comp. insurance.t m�.� t , ,. : 5, ❑ We area corporation and its 3. ❑ I am a homeowner doing all worst - officers have exercised their m myself., [No workers' comp. ' right of exemption per MOL instuance-reqj-t c. 152, §.1(41, and we have no , employees. [No worker',. - _ -- - comp, instirance required.] Typc of project (4•equhvd): . 6. ❑ New construction ?' ❑ Itemodelutg t 8..0Deaiftion „ 9. ❑ Building audition 10.0 Electrical repairs or additions 11.❑ Plumbing,repairs or additions 12.0 Roof mpahs .. 13:gOther -- 'Any applicant that checks box #1 must also fill out the section below showing their workers' oompensatlon policy information" 1 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-contraotors and state whether or not those entities have eMloyeea. If the sub -contractors have employees, they must I am an employer flratprovtidiag tcnmpeasaBou irurrre xry err�ploy R4&WiY1*ep011cyanZj6 Wormadon. +` Insurance Company Name.,, Policy # or Self -ills. Lica#: _ Expiration Date: Job Site Address CitytStatelZip Attach a ca _ .. py oi'tGe workers' compensation policy declaration page (allowing 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 FM up to $1,500.00 and/or one-year imprisonment, as welt 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 lovestigations of the DIA for insurance coverage verifroatieh, ' f dor Jbereby,, a+rdar>rlre pairs sed � propels true lard carred: , ,; 1 Phone#: QJW we only. Do not ttvrlte In this army to be carrpleted bycT{y o`r ttortxr,o,/l'Iclal City or Town: PermitMcense.il Issuing Authority (cCrcie ole): I. Board of Health 2. Building Department 3. CityiTown Clerk 4. Electrical Inspector S. Pla'mbing Inspector 6. Other Cct P ' ' t'. • - - - - � - outil - g Phone P. h Crawford@ U.S. Property & Casualty Robert Pageau, AIC, Director New England Service Center February 22, 2011 Town of North Andover John & Carol Obert Public Health Dept VIAR — 12011 1600 Osgood St 1 Building 20, Suite 2-36 TOWN OF NORTH ANDOVER North Andover, MA 01845 HEALTH DEPARTMENT Notice of Property Loss Under M.G.L. 139, Section 3B RE: Insured: John & Carol Obert Loss Location: 10 Coventry Ln, North Andover, MA 01845 Insurer: Merrimack Mutual Insurance Company Insurer Reference: HP1006486 Policy Number: HP 1006486 Type of Loss: Water Loss Date: 02/05/2011 Our File Number: 1791610 Dear Sir/Madame: Crawford & Company has been retained as independent insurance adjusters by Merrimack Mutual Insurance Company to investigate a first party property loss presented by their insured. Our initial investigation has determined loss or damage to the above referenced property may either exceed $1,000.00 or cause MGL, Chapter 143, Section 6 to apply. Under Chapter 139, Section 3B of the Act of 1977, you are hereby notified that a claim payment of more than $1,000 is expected. If any notice under MGL, Ch. 139 Sec. 3B is appropriate, please contact the undersigned immediately. We thank you in advance for your assistance in this matter. Respectfully, CR.4 WFORD & COMPANY Adam Lucas Property Adjuster CC: Building Department Preferred Mutual Insurance Company EXCELLENCE IN EVERYTHING WE TOUCH 204 Second Ave ■ Waltham, MA 02451 ■ Tel: 866-641-8175 ■ Fax: 800-651-3743 0 www.crawfordandcompany.com Date - '�/ - 7 ...... 0* 40RTPI 0 TOWN OF NORTH AN60VER PERMIT F R ASINSTALLATION This certifies that .......... has permission for gas installation F(- Ah .44 r in the buildings of ................................ at 46;� ... t-� ..... North Andover, Mass. Fee ... 3 Lic. No. q..fl GAS INSPECTOR Check# �k 7/ 6261 r\� 0 FIXTHRFS MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING Y CitylTown rN Andover Date: 12/06/2007 PermitX Building Locatic' 10 Coventry lane Owners Name: John &Carol Olbert Type of Occupancy: Commercials Educational Industrials Institutional Residential/ New:! -,,,'I Alteration: Renovation Replacement: Plans Submitted: Yes - No? FIXTHRFS INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YeSY,No .._,_ If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy 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 Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only Owner Agent Signature of Owner or Owner's Agent _ By checking this box ❑; I hereby certify that all of the details and inf6rmationve mitte or entered) regarding this application are true and accurate to the best of my Knowledge and that all plumbing work a installatio s p rformed un r the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State lu bing Co a nd Ch o e General Laws. Type of License: Plumber . _- Title j Gas Fitter Master i oSf LicensedPlumber/Gas Fitter Journeyman ciry/Town,,M y License Number. 9875 APPROVED (OFFICE USE ONLY) LP Installerm W W Y to z Q m 00 O ~ 2 WU' W z 1— QQ z p Cn w N W W O I— W W m z M U) W w W g m 0 a a IW— W w_j a x > z W ~ W Q W W W Z U U Q � N W y x W O_ Q x W 0 w X LU U a w tY W > W Z J F_ H O Q w w O m z w —j U O z W 0~ � H z W z W W W x U D W C7 C7 x x w O a W W H>> Q Q Q O SUB BSMT. BASEMENT 1 FLOOR -i 'FLOOR 3 FLOOR 4 FLOOR 5 FLOOR 6 FLOOR 7 FLOOR 8 FLOOR ,., Installing Company Name ,Climate Design Heating A C L L C Check One Only Certificate # H � Corporation 2884C Address:[ 5 South Summer St City/Town: Radford Stat e:MA � , Partnership Business Tel 1978-372-9999 Fax �� Name of Licensed Plumber/Gas Fitter: Glenn Bosteels IFirm/C ompany,__„ INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YeSY,No .._,_ If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy 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 Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only Owner Agent Signature of Owner or Owner's Agent _ By checking this box ❑; I hereby certify that all of the details and inf6rmationve mitte or entered) regarding this application are true and accurate to the best of my Knowledge and that all plumbing work a installatio s p rformed un r the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State lu bing Co a nd Ch o e General Laws. Type of License: Plumber . _- Title j Gas Fitter Master i oSf LicensedPlumber/Gas Fitter Journeyman ciry/Town,,M y License Number. 9875 APPROVED (OFFICE USE ONLY) LP Installerm