HomeMy WebLinkAboutMiscellaneous - 101 EDGELAWN AVENUE 4/30/2018u _N
Insurance Adjustment Service, Inc.
435 King St.
Littleton, NIA 01460
(978) 952-6966
Fax (978) 952-2459
UNDER MASSACHUSETTS GENERAL LAWS CHAPTER 139 SECTION 3B
TO: Board of Health/Building Inspector
Town of N Andover
N Andover, MA 01845
RE: Insured: Nancy Wardwell
Property Address: 101 Edge Lawn Ave. #11
North Andover, MA 01845
Date of Loss: 2/22/2005
Policy Number: HP0482773
Type of Loss: Ice dam
File or Claim Number: 21444
Date: March 7, 2005
R�C
MAR 1 1 2005
7oWN CJt- N �rH
HEALTH DCATH AMoov&�
Claim has been made involving loss, damage or destruction of the above captioned property, which may either
exceed $1,000.00 or cause Mass. Gen. Laws, Chapter 143, Section 6, to be applicable.
If any notice under Mass. Gen. Laws, Ch. 139, Sec. 38 is appropriate, please direct it to the attention of the
writer and include a reference to the captioned insured, locations, policy number, date of loss and claim or file
number.
Thank you/for your cooperation.
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120 MAIN STREET TEL: 682-6483
NORTH ANDOVER, MASS. 01845 Ext. 32 or 33
COMPLAINT FORM
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TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that ..., ..:� .-...."..................... .
has permission for gas installation ...................
in the buildings ob.
at/p%.... ,� �°-� .... , North,Andover, Mass.
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qji GAS INSPE C R
Check # �• 3 / `
6329
MASSACHUSETTS UNIFORM APPUCATON FOR PERVIlT TO DO GAS FITTING
(Type or print) Date e
NORTH ANDOVER, MASSACHUSETTS
Building Locations - �� I ��I C rj�//�% S TPermit # ; 4//
V N �T ' Amount $
Owner's Name PAA-tz
New D Renovation Replacement Plans Submitted 1 `
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Name of Licensed Plumber'or Gas Fitter
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Check one: Certif at sta 'ng Company
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INSURANCE COVERAGE Check one:
I have a current liability Insurance, policy or it's substantial equivalent. Yes 2---- NoO
If you have checked Les, please indicate the type coverage by checking the appropriate box.
Liability insurance policy 00-� Other type of indemnity D Bond 13
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:
Signature of Owner or Owner's Aaent
Owner
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 rmed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts S Code d�442 of the General Laws.
By:
Title
City/Town,,
ROVED (OFFICE USE ONLY)
Plumber
Gas Fitter
Master
Journeyman
sed Plumber O as Fitter
License um er
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11 Partner.
Firm/Co.
INSURANCE COVERAGE Check one:
I have a current liability Insurance, policy or it's substantial equivalent. Yes 2---- NoO
If you have checked Les, please indicate the type coverage by checking the appropriate box.
Liability insurance policy 00-� Other type of indemnity D Bond 13
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:
Signature of Owner or Owner's Aaent
Owner
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 rmed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts S Code d�442 of the General Laws.
By:
Title
City/Town,,
ROVED (OFFICE USE ONLY)
Plumber
Gas Fitter
Master
Journeyman
sed Plumber O as Fitter
License um er
Date C� .... .......
Of .NORTH 1ti
TOWN OF NO TH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that ... -.1. .................................... .
has permission for gas installation ........................
in the buildings -of.. �'` ... ......-.............. .
at . /!......-":".'�-'�C -�' ... .
,North Andover, Mass.
Fec.9 ...... Lic. No:....`....
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Check #' a I�COR
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MASSACHUSETTS UNIFORM --a°PLICATION FOR PERMIT TO DO GAS FITTING
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CityJTown:� , Nha av X"' MA. Date: 2d O� Permit#
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Building Location:V-3\ N=6,k`�ai`f1 5� Owners NameAtle q�Q GrQe�
Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential Y
New: ❑ Alteration: ❑ Renovation: 5Q Replacement: ® Plans Submitted: Yes ❑ No [�
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FIYTI IRFC
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes X No ❑
If you have checked Yes, please indicate the type of coverage by checking the appropriate box below.
A liability insurance policy X 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 information I have submitted (or entered) regarding this application are true and
.. . .. .. I - — –__ :1 ; ..-4 4— 6 ;o nnii—tinn will hp in
accurate to the best or my tcnowieoge ano tnat aii pwn:uu:y vvv: N a::u 1-4 1-4--
......._ , -• ••••• •___-- -- ----- -, .
compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
Type of License:
By ® Plumber
❑ Gas Fitter Signature of Lice sed Plumber/Gas Fitter
Title [R Master
[]Journeyman
City/Town E] LP Installer License Number:
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_ Check One Only Certificate #
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Address% 1A1ev%3An% ❑ Partnership
Business Tel: �� ��� ���, Fax: ❑ Firm/Company
Name of Licensed Plumber/Gas Fitter: rq.� Q -T kt�
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes X No ❑
If you have checked Yes, please indicate the type of coverage by checking the appropriate box below.
A liability insurance policy X 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 information I have submitted (or entered) regarding this application are true and
.. . .. .. I - — –__ :1 ; ..-4 4— 6 ;o nnii—tinn will hp in
accurate to the best or my tcnowieoge ano tnat aii pwn:uu:y vvv: N a::u 1-4 1-4--
......._ , -• ••••• •___-- -- ----- -, .
compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
Type of License:
By ® Plumber
❑ Gas Fitter Signature of Lice sed Plumber/Gas Fitter
Title [R Master
[]Journeyman
City/Town E] LP Installer License Number:
APPROVED (OFFICE USE ONLY i