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Home My WebLink AboutMiscellaneous - 105 WINTERGREEN DRIVE 4/30/2018 (2)i PO Box 55098 Boston, MA 02205-5098 617-951-0600 Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS, Ch. 139, Sec. 3B To: Building Commissioner or Board of Health or Inspector of Buildings Board of Selectman City Hall City Hall NORTH ANDOVER, MA 01845 NORTH ANDOVER, MA 01845 RE: Insured: SHAWN P CLEARY and MICHELLE D CLEARY Property Address: 105 WINTERGREEN DR, NORTH ANDOVER, MA Policy Number: HMA 0389663 Claim Number: BOS00051931 Date of Loss: 2/22/2015 Company: Safety Property and Casualty Insurance Company 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, 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 number. Dane Iovino Claim Examiner 2/26/2015 Safety Insurance Company Homeowners Claims Unit P. 0. Box 55098 Boston, MA 02205-5098 Phone: (617) 951-0600 EXT 3533. Fax: (617) 535-5851 Email: DaneIovino@Safetylnsurance.com Commonwealth of Massachusetts Official Use Only 02M Department of Fire Services Permit No. 573 ONDU 1WOccupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 9/05] 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 ORMATION) Date: // �-p0 City or Town of:'To the Inspector o Wires: By this application the undersigned gives notice `` of his or her intention to perform the electrical work described below. W Location (Street & Number) _ //} S . n �, i a Owner or Tenant Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No Purpose of Building Util Existing Service Amps / Volts Overhead ❑ Date.... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ......i �!\ S � �C��1 has permission to perform ........ GG/t/ y t /i ............. wrong in the building of ....14 . . .:...... /..'. /L, ................................. % t9.5 ..Z1Jf!9 ... ,..... <...... , North Andover, Mass. 7.011>1 Fee..."'` Lic. No 3c �-®..............................:......................... ELECTRICAL IN 1 / Check #- 7393 Telephone No. Cj ZE 4wy-2 c� (Check Appropriate Boa) ?thtorization No. Undgrd ❑ No. of Meters I_Tndard ❑ No. of Meters ble may be waived by the Inspector of Wires. o. of Total ransformers KVA enerators KVA lo. ol Emergency Lighting attery Units IREALARMS No. of Zones o. of Detection and Initiating Devices o. of Alerting Devices o. of Self -Contained etection/Alerting Devices ocal Municipal El Other ?ecurity S stems:* . uivalent ata Wiring: No. of Devices or Equivalent elecommunications Wiring: No. of Devices or Equivalent - • —}--- = wed, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: 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 BOND ❑ OTHER ❑ (Specify:) I certify, underains aid na tf perjury, that the information on this application is true and complete. FIRM NAME:, ,r; n S (9-IMp -eC-IAI- xl LIC. NO.:-% (Y"1 Ti C Licensee: --�X)k t, 4& 0, Yhyl ,'' Signature ► LIC. NO.: � (If applicable, enter "exem t" in the license number line.) Bus. Tel. No. — Address: J�r 7 m 1 p� l�l/1 �� Alt. Tel. No.: l-� *Security System Contractor License required for this work; if appl' e, eli er is nse number here: 55[ NH3- 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) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: PATRICK J. DONOVAN ASSOCIATES, INC. claim and Foss .?M iadments P. O. BOX 110 WAKEFIELD, MA 01880 TEL. (781) 245.5540 — FAX (781) 245.7016 February 26, 2002 Building Commissioner City or Town Hall North Andover, MA 01845 Insured Property Address Insurer Policy Number Type of Loss Date of Loss Our File # : Melody C. Palmer : 1G5 Wintergreen Drive, North Andover : Preferred Mutual Insurance Company : PHOO100535387 Water Damage 2/22/02 WAP33383 Claim has been made involving loss, damage or destruction of the above -captioned. property, which may either exceed $1,000 or cause Mass. Gen. Laws, Chapter 143, Section 6, to be applicable. If any notice under Mass. Gen. 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 file number. 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. L2i Vern Laws, Adjuster VL/mn JSSOCIATION OF INDEPENDENT INSURANCE MUSTERS T�ro WMANCE of Massachusetts WDEPENDENT