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MetLife Auto & Home®
Homeowner Operations Field Claim Office
Attention: Claims
P.O. Box 6040
Scranton, PA 18505
(800)854-6011
March 4, 2015
North Andover Building Inspection
1600 Osgood St, Suite 2035
North Andover, MA 01845
Our Customer: Joseph D. and Valerie Cinseruli
Claim Number: JDE94322 OG
Date of Loss: February 18, 2015
Dear North Andover Building Inspection:
Pursuant to M.G.L. 139 § 313, please be advised that a property loss at the address referenced below has
been estimated to have damage to the dwelling or other structures that will exceed one thousand dollars.
Please let us know within ten (10) days if there is a pending or existing lien against the property as
provided by M.G.L. 139 § 313, or if there is an intent to initiate proceedings to perfect such a lien.
Loss Location: 10 Pine Ridge Rd, North Andover, MA
Sincerely,
Home Ops CAT Team Sarah Lackey
Metropolitan Property and Casualty Insurance Company
Claim Adjuster
(800) 854-6011 Ext. 7440
Fax: (855) 411-6689
Email: MetLifeCatTeam@metlife.com
MetLife Auto & Home is a brand of Metropolitan Property and Casualty Insurance Company and its affiliates, Warwick, RI.
MPL MA-REGDEPT Printed in U.S.A 0698
Location
No. Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee
Other Permit Fee
TOTAL
Check# os -:y
13 tr-' 7 8
guilding Inspector
TOWN OF NORTH ANDOVER
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVAT OR DEMOLISH A ONE OR TWO FAMILY DWELLING
BUILDING PERMIT NUMBER: r ` DATE ISSUED: ! 6V L) A
SIGNATURE: /P A
Building Commissioaer pectdYof Buildings Date
Zm
SECTION 1- SITE INFORMATION-"
1.1 Property Address:
/o eii)e Ri h&e RQA-b
1.2 Assessors Map and Parcel Number:
a / as
D (P5 AMR
Map 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 R red Provided
R red
Provided
1.7 Water Supply M.GL.C.40. 54) 1.5. Flood Zone Information:
Public ❑ Private 0 Zone Outside Flood Zone ❑
1.8 Sewerage Disposal System:
Municipal 0 On Site Disposal System ❑
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record
)P,v,`D i'rnb Li r,Dra/ern h 2rt1,
Name (Print) Address for Service:
- e,3- is
Signature Telephone
2.2 Owner of Record:
Name Print Address for Service:
Signature Telephone
SECTION 3 - CONSTRUCTION SERVICES
.1 Licensed Construction Supervisor:
/?a. &e - Wn A LLeN J P
'Licensed Construction Supervisor:
(o A Nb O ve- /2 5-f - AMv/2+ p !Z M
d ,� ��
Address
Signature Telephone
Not Applicable ❑
License Number
- a
Expiration Date
3.2 Registered Home Improvement Contractor
A LLe n
Not Applicable ❑
Company Name
16-, Aldl oVe.f2 �r NOS- i -P AIVD-yfie �H-
Registration Number
ay- aQ�o
Address
/� • �7�-�ga -y5�
L
Expiration Date
Signature Telephone
e
SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 § 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 .......0 No ....... ❑
SECTION 5 Description of Proposed Work check an a licable
New Construction ❑
Existing Building ❑
Repair(s) ❑ Alterations(s)`
Addition ❑
Accessory Bldg. ❑
Demolition ❑
Other ❑ Specify
Brief Description of Proposed Work:
—
VeF-s 306a 6 K�L,'�A fs.: 13L, 4-D Tom= rc^2
SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost (Dollar) to be
Completed b ermit a licant
OFFICIAL^.USE;ONLY
t�
1. Building _ v
V`
(a) Building Permit Fee
Multiplier
2 Electrical
(b) Estimated Total Cost of
Construction
3 Plumbing
Building Permit fee (81 X (b)
4 Mechanical (HVAC)
5 Fire Protection
6 Total 1+2+3+4+5
Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner/Authorized Agent of subject property
Hereby authorize to act on
My behalf in all matters relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
1, le --a 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 pp f, l /
Print Name
Signature of Owner/Agent �— Date
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TIMBERS 1ST 2 ND 3 RD
SPAN
DIMENSIONS OF SILLS
DEv ENSIONS OF POSTS
DIMENSIONS 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
PrA
BUILDING DEPARTMENT
DEBRIS DISPOSAL FORM
In accordance with.the provisions of MGL.c 40 S 54, a condition of Building Permit Number
Is that the debris resulting form this work shall be disposed of in- a property licensed solid waste disposal facility as
defined by MGL c 11, S 150A
The debris will be disposed of in: /-,,7
P L
-5110e-1-61- RD,- A1,1174— 0 3�
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
. ccese �
The Commonvvealth of iLlassac,�usetts
Department of lndustrral—�'Ccidents
Gf;`ice cf Investiaatians
Eoston, Klass. 0� 111
�tiorkers' Comp-.,lsarlon Irlsurci,ce ,Aff'Cavit
Name Please
Mznme: vel" kZ- e ry
Lr,'C"ticn (a j>< Nb oye— a S
/
C12m 2 hcmecwrer p-errcrminc all work myself.
am a sole crCrrletcr 2nd (eve ne cne `NCrIUmQ In 2ny CaCaC:P/
I I am an emcicver mvidina wcrkers' CGmpensaticn fcr my Em`!G!/els wcr:<inc Cn i iS jcb.
Ccmcanv name:
C!-,r-rp
Insurance Cc. Polic/ T
I
Comconv name
Address
Insurance Cc. Fcllc/ =
Failure to secure ccverace as recuirec uncer Sac -.:en 25A cr MC -L 152 con lege to the ;mc--smcn cr cnmirat .penalties cr aine uc to S .5CC.CC
anc/cr one years' imcnrc
scnment as .ve:! as c:vii cenalties it .he rrn c; a -TCF V`ICRK CFCE= and .'.ne c;51CG CCl a day acains, me.
uncerstana that a cocy of ;`is s -,a -,e ren: may ce Fcr,varcec cc the Cr`ca cr Invesccaticns c the CIA ."'Cr ccverace /enr;C=;cn.
I co heresy cera; y uncar he can and cenalti c%r/;,erjury tha^i :he in
Clcn2ture
Print name s �2� IIAJ A �
accve is .. L arc ccn-c-
ate
ocic:al use oni y cc nct wrre in this area cc ce ccmcietec .py c::y cr tc:m cr;c:a(
C;ty or Tc,vn F= m;tlUce^s nc
L CU;lGIrQ C20t
L'cE!7sInc ECard
.E!EC:�71aris JrICE
i�e2lth GEp2rmEnr
[C`eck ;r immediate resccrse ,s recuired
Ccrrc: cersc,-r
a
✓fe {orrvir�orarrreal� a�✓l/��zciu�6eCr6
BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR
Number: CS 040927
Birthdate: 05/04/1957
Expires: 05/04/2001 Tr, no: 8479
Restricted To: 00
ROBERT W ALLEN
86 ANDOVER ST
N ANDOVER, MA 01845 Administrator
t)
ON�1 ��G'1 QR aTid
' ME lg Requ ' ° RoamHOAilX 01. yf
gaa� a of � h�' aY toy` � � lace h�` r t ts
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` R�gi�tYation 1
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EXPITai10t1
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aoMfnnsrRaroR N ANDOVER 0184
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Date./72. .......
WIOX
TOWN OF NORTH ANDOVER
0
PERMIT FOR GAS INSTALLATION
This certifies that ....
has permission for gas installation
..............
in the buildings of ..........................
at ................. I North Andover, Mass,
Fee..2. ..... Lic. No..4�
G�S INSPECTOR
Check #
3894
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING 2
(Print or Type)
X) 1 6y v L5 , Mass. Date/ y`' �'�" C 11 g Permit #
Building Location J0 d ��� ^P"'40 Owner's dame 111A1067
Type of lupancy D U'G'L LGdti ,
New ( Renovation ❑ Replacement ❑ PlIns Submitted:,.-Yesp No ❑
Installing Company Name ji r, C P;A,#Iy l; r_ ,L ,�• f r
Address ��? L''L l��(e. I'/� A--,40
i N
Business Telephone ot
Name of Licensed Plumber or Gas Fitter J O SA7PO
Check one:
Corporation
Partnership
.❑ Firm/Co.
Certificate
VL P
INSURANCE COVERAGE:
1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes LA'No LJ
If you have checked ys. please indicate the type coverage by checking the appropriate box.
A liability insurance policy A 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 ❑
_s n,.....,.... /l..ner'e Anont
I .rync.w— -1 _. — _.:_ -
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 Gas Code and Chapter 142 of the General Laws.
T of License: Z
BY Plumber &gngti re of Ucensed Plum er or Gas Fitter
Title. Gasfitter LiIF—
Master
Master cense Number
City/Town U Journeyman
APPROVED (OFFICE USE ONLI�
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BASEMENT
IST FLOOR
2ND FLOOR
'
3RD FLOOR
_
I,
4TH FLOOR
STH FLOOR
6TH FLOOR
7TH FLOOR
STH FLOOR
Installing Company Name ji r, C P;A,#Iy l; r_ ,L ,�• f r
Address ��? L''L l��(e. I'/� A--,40
i N
Business Telephone ot
Name of Licensed Plumber or Gas Fitter J O SA7PO
Check one:
Corporation
Partnership
.❑ Firm/Co.
Certificate
VL P
INSURANCE COVERAGE:
1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes LA'No LJ
If you have checked ys. please indicate the type coverage by checking the appropriate box.
A liability insurance policy A 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 ❑
_s n,.....,.... /l..ner'e Anont
I .rync.w— -1 _. — _.:_ -
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 Gas Code and Chapter 142 of the General Laws.
T of License: Z
BY Plumber &gngti re of Ucensed Plum er or Gas Fitter
Title. Gasfitter LiIF—
Master
Master cense Number
City/Town U Journeyman
APPROVED (OFFICE USE ONLI�
Location
cl, Date 'e -Y
No.
TOWN OF NORTH ANDOVER
i +-..a L Certificate of Occupancy $
Building/Frame Permit Fee s 66
CHU
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
1,5435
Building Insp r
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TOWN OF NORTH ANDOVER
I f
BUILDING DEPARTMENT
APPLICATION TO CONSTRUCT REPAIR, RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING
1.2 Assessors Map and Parcel Number:
+� _
BUILDING PERMIT NUMBER:
DATE ISSUED:
AL
SIGNATURE:
Map Number
Buiidi7g onlmissioner for of Buildings Date
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sr:UIL11014 i-J11L, MroxlVll� ]LUn
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1.1 Property Address:
r i
1.2 Assessors Map and Parcel Number:
16 A 14 4
AL
Map Number
Parcel Number
1.3 Zoning Information:
1.4 Property Dimensions:
Zoning District Proposed Use
h- Lot Area
Frontage ft
1.6 BUILDING SETBACKS ft
Front Yard
Side Yard
Rear Yard
Required Provide
Required Provided
aired Provided
t
1.7 Water Supply M.G.L.C.40. 54)
1.5. Flood Zone Information:
1.8 Sewerage Disposal System:
Public 0 Private ❑ Zone
Outside Flood Zone 0
Municipal ❑ On Site Disposal System 0
SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1Owner of Record
�
1
a77_J
LL7P,
r
Name-,( Print)
`g Address for Service
Signature
Telephone
2.2 Owner of Record:
Name Print
Address for Service:
Signature
Telephone
"
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
Not Applicable ❑
/� �)
0/4y) 1/ 0,AS i/ 1 CD9Y
{� / /
F- R G'. +- 5—P& �
Licensed Construction Supervisor:
o ® a S
License Number
Adfir�es
J
9r
Expiration Date
Signature
Telephone
3.2 Registered Home Improvement Contractor
Not Applicable ❑
U l 1 co
AI E kF,!;,
Company Name
q O � LL �,�6 AI S, .T
+rte.
r , A 6 � O Q, �
��/�/�.
Registra on Number
s
Cu�
.a 43
Expiration Date
Si nature
Telephone
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SECTION 4 - WORKERS COMPENSATION (NLG.L C 152 § 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 .......0 No ....... 0
SECTION 5 Description of Proposed Work(check all applicable)
New Construction ❑
Existing Building ❑
Repair(s)
❑
Alterations(s) 0
Addition ❑
Accessory Bldg. ❑
Demolition ❑
Other
❑ Specify
Brief Description of Proposed Work:
�7'P.��' �- /; F�'ao
e �, �, ;amu; J%\
SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Estimated Cost (Dollar) to be
Completed by permit applicant
,Item
S d
U�S11L I}
1. Building
d O
(a) Building Permit Fee
Multiplier
2 Electrical
(b) Estimated Total.Cost of
Construction
3 Plumbing
ITuilding Permit fee tal x tel
v
4 Mechanical HVAC,
5 Fire Protection��
6 Total 1+2+3+4+5
fj
Check Number
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUII.DING PERMIT"
I, as Owner/Authorized Agent of subject property
Hereby authorize to act on
My behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
T, LAV 1.) CA -5 nk L as Owner uthorized Agen of subject
properly
Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief ' y
V C
Print _
Si ature of Owner/Agent
NO. OF STORIES
-CIZZ4 /a 2
Date
SIZE
BASEMENT OR SLAB
SIZE OF 'F1,OOR TIMBERS 1ST
2 Nu 3
SPAN
DIMENSIONS OFSILLS
DIMENSIONS OF POSTS
DIMENSIONS OF GIRDERS
HEIGHT OF FOUNDATION
THICKNESS
SIZE OF FOOTING
X
MATERIAL OF CH vINEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
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TOWN OF NORTH ANDOVER
Office of the .Build ng Department
•� '
Community Development and Services
27 Charles Street
North Andover, Massachusetts 01845
D, Robert INlieetta,
. aikfing Commissioner
DEBRIS DISPOSAL FORM
Telephone (978) 688-9545
FAX (9-18) 688-9542
In accordance with the provisions of MGL c 40 s 54, and as a condition of
building permit # the debris resulting from the work shall be
disposed of in a properly licensed solid waste disposal facility as defined by MGL c
11, s 150a.
The debris will be disposed of at / in:
CJ,
,57 tj�j, ,; — S
(Site location)
Signature of permit applicant Date
y ,
Michael McGuire, Local Building Inspector James Decola, Electrical Inspector James Diozzi, Gas/plumbing Inspector
and Gf;l3uildrn�/�
Regulauoris:aud,Sta+f�7ards `
F . HOlIr1E "MPROVEMENT CONTF'.gCTn,^, '
kegwtMtion 1()4569
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7/.14/02.
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