HomeMy WebLinkAboutMiscellaneous - 105 MARTIN AVENUE 4/30/2018LaMarche Associates
5 North Road, P.O. Box 250
Chelmsford, MA 01824
800-349-1525
Fax: 978-256-8590
January 9, 2018
Building Commissioner/Inspector of Buildings
North Andover, MA 01845-4318
Board of Health/Board of Selectmen
North Andover, MA 01845-4318
NOTICE OF CASUALTY LOSS TO BUILDING
UNDER MASSACHUSETTS GENERAL LAWS, CHAPTER 139, SECTION 3B
Claim has been made involving loss, damage or destruction of the property captioned
below, 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, cause
of loss and LA file number.
Insured: Arthur & Gloria Lidstone
Loss Location: 105 Martin Avenue
North Andover, MA 01845-4318
Policy Number:
HP296132
Date of Loss:
01/09/2018
Cause of Loss:
Freeze Up
LA File Number: MA -2-34078
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.
John Anderson
Adjuster
LaMarche Associates, Inc. - 600-349-1525
Page 1 of 1
LaMarche Associates
5 North Road, P.O. Box 250
Chelmsford, MA 01824
800-349-1525
Fax: 978-256-8590
February 18, 2015
Building Commissioner/Inspector of Buildings
North Andover, MA 01845
Board of Health/Board of Selectmen
North Andover, MA 01845
NOTICE OF CASUALTY LOSS TO BUILDING
UNDER MASSACHUSETTS GENERAL LAWS, CHAPTER 139, SECTION 3B
Claim has been made involving loss, damage or destruction of the property captioned below, 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, cause of loss and LA file number.
Insured: Arthur Lidstone
Loss Location: 105 Martin Avenue
North Andover, MA 01845
Policy Number: HP296132
Date of Loss: 02/13/2015
Cause of Loss: Water
LA File Number: MA -2-26102
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.
Joseph Walkup
Adjuster
LaMarche Associates, Inc. - 800-349-1525
Page 1 of 1
Date
.....1
......... ..............
...............
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that H&�.6.e, ....... PI -4-
.... ..... ...... .... ............. .
his permission for gas installation ...... Com.....:.6 ........J...._- ......................
iii the
building
f ................... ......I .... '**
....js .. .....r.. .......................................
at........... ...... .....kR.. ................, North Andover,
Mass.
FeA.��.. Lic. No. O
..................................................
GAS INSPECTOR
Check #
s
PRINT
CLEARLYTYPE OR
MASSACHUSETTS UNIFORM APPLICATION FOR A'OERMIT TO PERFORM GAS FITTING WORK
OWNER ADDRESSi.' FAX
OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL
NEW:F] RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NI
04
APPLIANCES -1 FLOORS
COOK STOVE
DIRECT VENT HEATER
ON• j • -
INFRARED HEATER
MAKEUP AIR UNIT
POOL HEATE-ROOM/
SPACE ER
ROOF TOP UNIT
IMIZ
LINVENTED ROOM HEATER
INSURANCE COVERAGE
•I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YE NO ❑
I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OFC VERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 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.
SIGNATURE OF OWNER OR AGENT
CHECK ONE ONLY: OWNER ❑ AGENT ❑
I hereby certify that all of the details and information I have submitted or entered regarding this application are true
and that all plumbing work and installations performed under the permit issued for this application will be in coA
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
of the
T
PLUMBER-GASFITTER NAME LICENSE # 3 IGNATURE `'
MP MGF ❑ JP ❑ JGF ❑ LPGI ❑ CORPORATION ❑ # PARTNERSHIP ❑ # LLC ❑ #
COMPANY NAME 1��� /��U��/i[� � 1/ y ADDRESS '
CITY STATE IVI ZIP �dJ �6 TEL6!5)—Z,
n _
FAX CELL EMAIL
y� The Commonwealth of Massachusetts
Department of IndustriqlAccidints
Office of Investigations
600 Washington Street
Boston, MA. 02111
UV . www.mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print LeLFibly
Name (Business/Organization/Individual): Xl�Ae "zwn'6
Address:_—I
City/State/Zip:,2 /'11'V, Iq Phone #• �b �% ��J G s
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with
4. ❑ I am a general contractor and I
employees (full and/or part-time).*
have Hired the sub -contractors
I am a sole proprietor or partner-
listed on the attached sheet. I
ship and'have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. ❑ We are a corporation and its
required.]
officers have exercised their
3. ❑ I am a homeowner doing all work
right of exemption per MGL
myself. [No workers' comp.
c. 152, § 1(4), and we have no
insurance required.] t
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. F1 Remodeling
8. ❑ Demolition
9. ❑ Building addition
10. Electrical repairs or additions
1 Plumbing repairs or additions
12.❑ Roof repairs
13.❑ Other
*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 are doing all work and then hire outside contractors must submit a new affidavit indicating such.
TContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
lam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information. f %
Insurance Company Name:
Policy # or Self -ins. Lic. #:
j �✓
Expiration Date:
Job Site Address: '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 DIAAor insurance coverage verification.
Ido hereby cer th ' s e alt! ofperjury that the information provided above is tru and correct.
� 3
V
Phone #• Go _ G/ ✓s S
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 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 shallnot 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 bum 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 l dustrial .Accidents
Office of Investigations
600 Washington Street
Bostor4 MA 02111
Tel, # 617-727_4900 ez t 406 or 1-877,7MASSAFB
Revised 5-26-05 Fax # 617-727-7749
www.wass.guldia
>=COMMONWEALTH OF MASSACHUSETTS
NEE.
PLUMBERS AND GASFITTERS
LICENSED AS A MASTER PLUMBER
i, ISSUES THE ABOVE LICENSE TO: C
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