Loading...
HomeMy WebLinkAboutMiscellaneous - 109 HIGH STREET 4/30/2018 109 HIGH STREET 2101067.0-0075-0000.0 !_ t P-/ 1 ti I �I i Phone: 978-632-2660 Fax: 978-632-2662 JAMES A. TRUDEAU Adjustment Service Inc. P.O.Box 7 Gardner,MA 01440 claims(a�trudeauadi.com Notice of Casualty Loss of Building Under Massachusetts General Laws, Chapter 139, Section 3B December 1,2014 Building Inspector 1.20 Main Street North Andover,MA 01845 Board of Health 20 Main Street North Andover,MA 01845 Fire Department Dept.of Records 124 Main Street North Andover,MA 01845 Insured: Kevin&Wendy Diaz Loss Location: 109 High Street,North Andover,MA 01845 Insurance Company: Preferred Mutual Insurance Co. Policy No.: PHOO100638731 Date of Loss: November 21,2014 File Number: 14-12443 Claim Number: 14124521 Type of Loss: Property Damage 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 writer and include a reference to the captioned insured, location,policy number,date of loss,and file or claim number. On this date, I cause copies of this notice to be sent to the person(s)named above at the address indicated by first class mail. Sincerely, Robert P. Blais Claims Adjuster Date..:.f.- Z.?=:n4�.�. NORTH °`�"`° :•�"� TOWN OF NORTH ANDOVER 6. p PERMIT FOR WIRING SAcMusf� This certifies that .............A.jk..4....!'.. ...................... i x // has permission to perform ......��.6P,Z.'. o..!ll//-Iz� (Cv............. wiring in the building of...........1�...............!gr...4........................................ at.........,1©1 U.....5T ,North Andover,Mas . r ism ° Fee....0.."""... Lic.No.............. �..................... ............. ........:......... .. i ELE RICALINSPECTOR j� f j Check # i-3 8 '103 Commonwealth of Massachusetts official Use Only Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] peave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Mass achusetts Electrical Code MEC 527 CMR 12.0 (PLEASE PRINT WINK OR TYPE ALL INFORMATION) Date: ( -Zo City or Town of. NORTH ANDOVER To the Ins ector of ir^es: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) /.0 Owner or Tenant r,� � w t � `� Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes 2 No ❑ (Check Appropriate Boz) Purpose of Building l .���t h6y Utility Authorization No. Existing Service /Cie Amps f / 7,%'Volts Overhead 211"'Undgrd❑ No.of Meters / New Service Amps / Volts Overhead❑ Und rd g ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: r I Completion of the ollowin table may be waived b the Inspector of Wires. No.of Recessed Luminaires No.of Ceil.-Sus addle No•of Total .r p (Paddle) Transformers KVA No.of Luminaire Outlets 3 No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In ❑ o,o mergency Lighting d. d. BatteryUnits No.of Receptacle Outlets g' No.of Oil Burners FIRE ALARMS No. of Zones R No.of Switches �� No. of Gas Burners No.of Detection and initiating Devices No.of RangesNo. of Air Cond. Tonsl- No.of Alerting Devices No.of Waste Disposers HeatP Number Tons KW No.of Self-Contained Totals: __.....__...... ...._._..__. .._..._.._.._.... Detection/Alerting Devices No.of Dishwashers / Space/Area HeatingKW Municipal Local❑ Connection Other No.of Dryers Heating Appliances KW Security Systems:* No.of WaterNo.of No.of No,of Devices or Equivalent Heaters KW Sips Ballasts. Data Wiring: No.of Devices or Equivalent r No.Hydromassage Bath Tel tubs No.of Motors Total HP ecommunications firing: No.of Devices or E uivalent i OTHER: j Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Worlye P� (When required by municipal policy.) Work to Start: 'Y Z p4K 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 cove ge is in force,and has exhibited proof of same to the permit issuing office.. CHECK ONE: INSURANCE ,BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties 0 perjury,that the infor n on a lication is true and complet& FIRM NAME: I J YG se>�rr� LIC.NO.: Licensee: Signa LIC.NO.: /��lo (If applicable, enter"exe pt"in t e license number li Bus.TeL No.: T�1—�77.3 5z Address: _ /` Xcr S �A,a rvs off, . Ol 2 Alt.Tel.No.: *Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.No. 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 lm y this requirement I am the(check one)❑ owner Downer's agent. Owner/Agent Signature Telephone No. PERMIT FEE:$ •r _ The Commonwealth of massachusetts Department of Industrial Accidents d ' Office of Investigations Ft •k vaitt ° 600 Washin,ton Street Boston, MA 02111 t www mass gov/dia Workers, Compensation Insetran ce Affidavit­. Builders/Contractors/Eiectricians/pinmbers A !leant Information . . Please Print Leaih! NaIIm(Business/Orpniza6on/Individurd); / Address: City/State/Zip: Phone #: . 97ff-777 3 C_ Are you an employer?Check the appropriate box: I.❑ I atm a employer with 4Type of project(requirett): ❑ !am a general contractor and I ployees(full and/or-part-time).* have have hired the sub-contractors 6• ❑New construction 2. I am.asole proprietor.or partner. listed on the attached sheet 7• ❑ Remodeling ship and have no employees These sub-contractors have 11. [�Demolition' j working for me in any capacity• workers' comp.insurance. [No workers comp.insurance 5. g• ❑Building addition ' p ❑ We are a corporation and its . required..] officers have exercised their 10•D Electrical repairs or additions 3.E3 I ani a homeowner doing all work right of exemption per MGL I I-[] Plumbing repairs or additions myself.[No-workers'camp. C. 152, §14) and we have insurance required:]t .employees. [No workers' no 12.[]Roof repairs Any applicant that r comp. insurance required.] 13•[]Other ' checks boi#l must also fill out the section below showing their workers'compensation policy information, 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,comnictom and their worke.s'comp.policy infinmiation. I am an employer th w.is providing:workers'compensation insurance for my.employees: Below is the policy and job site information. I Insurance Company Name: Policy#or Self-ins.Lic.4: 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 required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 an 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 DIA for insurance coverage verification. 1 I do hereby cert'y nder poi a allies of perjury that the information provided above is true and correct Si afore: Lf Date: Phone 4: 'Z 7-7- 17 Official usr 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 j 6.Other Contact Person: Phone#: , rz. 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 ofthe'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 shall not 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 pmrfornrance 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,not1he 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 tine. 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 permittlicense 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 indicatingcurrent policy information(if necessary)and under,"Job Site Address"the applicant should write"all locations in (city or town)."A copy ofthe 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 Industrial Accidents ' Office of Investi ggations " 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-8.77-MASSAFE Fax#617-727-774 Revised 5-26-45 www.mass.gov/dia Date. ,/. . . . O' NORTH 1 TOWN OF N07TH ANDOVER a PERMIT FOR PLUMBING ,SSACHUS�This certifies that .u. . . . .10. . . .P.� . . . . . . . . . . . . . . . . . . . . . . . . . has permission to perform . . . .t` .5. . . . . . . . . . . . . . . . . . . . . . . . . . plumbing in the //buildings of . . . . . . . . . . . . . . . . . . . . . . . . . . . at. . v.�. . . K.�.�y.� . . : . . . . . . . . . . . . . . .. North Andover, Mass. Fee. Lic. No 2 C s' 3!, �. . !` !'-. . . . . . . . . . . PLUMBING INSPECTOR Check # & 7795 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS Building Location Owners Name � ( ? Date #7_ -30-�~ 0 Permit S Y Amount 3 0 Type of Occupancy New Renovation ❑ Replacement 'n Plans Submitted Yes ❑ N0 FIXTURES H C/) a 0 w A u, a w r a a ca a A 0 � ss<:sl� >AME�r BE MOOR MFLOCIZ 3M FLOCR 4IHI+7OM SM ELOM 61H FL" 9M FLOM (Print or type) f 2 �j ` Check one: Certificate Installing Company Name �f U T ty rn 1 r\.` 5 eQ J S Co SOR01 na �-� ,� � 7 ❑ Partner. business elephobe p _ 3 X 7 7 Y ❑ Firm/Co. Name of Licensed Plumber: L W Insurance Coverage: indicate^—the hof insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity uuu ❑ Bond Insurance Waiver: I, the undersigned,have been made aware that the licensee of this applicatio three insurance n does not have any one of the above Signature OwnerE] Agent ❑ I hereby certify that all of the details and informa'o: ha a submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing wor and ns ations a ormed under Permit Issued for this application will be in compliance with all pertinent provisions of the assa s Sta bing Cod pter 142 of the General Laws. a By: aEuyr,o lcense um er TitleType of Plumbing License City/Town cense um er Master ❑ Journeyman I, APPROVED(OFFICE USE ONLY L:� The Commonwealth of Massachusetts O:iicc Use Only �— Perric No: Department of Public Safety occupancy S Fee Checked BOARD OF FIRE PREVEN11ON REGULATIONS S27 CMR 1200 3/90 heave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code. 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date , �ZT City or Town of /rd C44,0� To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number) /191 W1C/� •�T Owner or Tenant" Owner's Address Is this permit in conjunction with a building permit: Yes ❑ No (Check.Appropriate Box) Purpose of Building / /'G y Utility Authorization NO. -703 76pf _ Existing Service Amps / Volts Overhead ❑ Undgrd❑ No. of Meters New Service I Qt) Amps IZIJ / Z-VO Volts Overhead Undgrd❑ No. of Meters Number of Feeders and Ampacity 3 Location and Nature of Proposed Electrical WorkfN<� C�o No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA AboveIn- No. of Lighting Fixtures Swimming Pool grnd. ❑ grnd. ❑ Generators KVA f No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting Batter Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Ranges Total No. of Detection and g No. of Air Cond. tons Initiating Devices No. of Disposals No. of pumps Total Total Tons KW No. of Sounding Devices No. of Dishwashers Space/Area Heating KW No. of Self Contained Detection/Sounding Devices No. of Dryers Heating Devices KW Local❑ Municipal ❑Other Connection No. of Water Heaters KW No, of No. of Low Voltage Signs Ballasts Wiring No. Hydro Massage Tubs No. of Motors Total HP OTHER: INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent. YES6� NO E] I have submitted valid proof of same to this office. YES N NO If you have checked'YES, please indicate the type of coverage by checking the appropriate box. INSURANCE 0 BOND ❑ OTHER ❑ (Please Specify) Expiration Date Estimated Value of Electrical Work $ Work to Start Inspection Date Requested: Rough Final z!.(J- Signed under the enalties of perjury: FIRM tWE t/ lGl'e-r12L-Y0 . LIC. NO.�,'��3 Licensee S ` � 7v � Signature LIC. N0. 14 S9 3 3 Address 6 Z /LL 5� �� C, �YeA� G� 4jaus. No. Alt. Tel. No. 014NERIS INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its sub- stantial equivalent as required by Massachusetts General Laws, and that my signature on this permit application waives this requirement. Owner Agent (Please check one) ' Telephone No. PERMIT FEE S � Signature of Owner or Agent Date... -yn 013 0 TOWN OF NORTH ANDOVER 0 swim - 00 PERMIT FOR WIRING �,SSACMUSEt This certifies that ............... . ....... .... has permission to perform .......... ...... .. .......... ................................. wiring in the building of... ....... ... . . ................................. ....... ....................North Andover,Mass. Fee...... ... Lic.No. ............. ............................................................... ELECTRICAL INSPECTOR 0 24 97 35-00 PAID WHITE: Applicant 6/ / CAM Building Dept. PINK:Treasurer Location' No. Date y Z a i NORTH TOWN OF NORTH ANDOVER O F w 9 • y Certificate of Occupancy $ Building/Frame/Frame Permit Fee $ s�cMust 9 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ rd Check # Q� /�� Building Inspector,,-' i TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REP RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: DATE ISSUED: �.� X lilt"AdIf ic SIGNATURE: Building Commissioner/Inspector of Buildings Date z SECTION 1-SITE INFORMATION 0 1.1 Property Address: 1.2 Assessors Map and Parcel Number: hab QTY v u l p Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: zQs1 &V\Tt0. I Zoning Nkric­t Proposed Use Lot Area 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.G.L.C.40. 54) 1.5. Flood Zone Infomoation: 1.8 Sewerage Disposal System: Public j Private 0 Zone Outside Flood Zone ❑ Municipal On Site Disposal System 0 SECTIO 2-PROPERTY OWNERSIIIP/AUTHORIZED AGENT Historic Distric ' m 2.1 Owner of Record log S-1 Name(Print) Address for Service: Signature Telephone 2.2 Owner of Record: Name Print Address for Service: M� Signature Telephone SECTION 3-CONSTRUCTION SERVICES 90 3.1 Licensed Construction Supervisor: Not Applicable ❑ 24n yr &`.L/-, 3 Licensed Construction Supervisor: �' A."kv r Q License Number Addr s / I+ 2..0 y q 7S �o-4 S-0 Expiration Date Telephone r 3.2 Registered Home Improvement Contractor Not Applicable Company Name M Registration Number r Address r z Expiration Date G1 Signature Tel hone � V� 1 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..... No.......❑ SECTION 5 Descri tion of Proposed Work check au applicable) New Construction ❑ Existing BuildingRepair(s) Alterations(s) ❑ _F ddition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: (1 a' Q�O�,T SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to beOFFICIATE USE ONLY- . -, Completed by permit applicant 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee(a)x (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 7 DO . Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUEL DING PERMIT 1> ,as Owner/Authorized Agent of subject property Kbehalf, riz o act on matters relative work o e b this building permit applicatio . �i 0 Siafar f Owner Date SEC ON 7b OWNER/AUTHORIZED AGENT DECLARATION 1, 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 Print Name Si ature of Owner/Agent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS iST2ND 3RD SPAN DIN ENSIONS OF SILLS DIIvMNSIONS 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 NORTH Town of No. LAK o dover, Mass., COCMICKEWICK �. S RATED PPF`�,�5 V BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System 'A 04 BUILDING INSPECTOR THISCERTIFIES THAT............... ......P................ .... ............................... .. ......�.. ........... .................................... Foundation has permission to erect........................................ buil s on ..� ......... ... ....... ............................. Rough to be occupied as ..... ..... ...... ....................... Chimney ................................................................................................................. provided that t person accep g this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisio of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION JW Rough ..................................................................... ... ...... ................ Service .. . ........ BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises - Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT . Until Inspected and'Approved by the .Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building-Permit Number is that the debris resulting from this work shall be ' fK disposed of in a properly licensed solid waste disposal facility as defined by MGL c11, S150A. The debris will be disposed of in: Ca* (Location of Fac' ity) Sign tur 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 The Commonwveallfi�of Massachusetts usetts Department of Industrial Accidents r face of investigations Boston, Mass. 0211-1 Workers'Compensai5on Insurance Afdavff Name — Please Print Name: ( `� Location: Cl V`4r/ 3 Phone # 72 U 1 am a homeowner performinE all work myself. 1 am a sole proprietor and have no one worldng in any capacity . QI am an employer providing workers'compensation for my employees working on,thin job. Comnanv name: Aiddress Insurance Co. Politer#. CorngM name. Address . Irtsurance:Go. pbticvr:#. Fo to secure image as required gndet Section 25A of tt+1SL 752 cartlesitWhe ihpasiiton d a aR:per ltie of artrtte ups =�� andlor am years'impris t �rePJ[�s 7 pe nalti�3n�beScres=a wdemtand that a copy stabernent racy be forwarded to O! Of Of gati, cit the DIA w ° / gage�iesifPca�oir. fdoheteby /underf and Prow"d above isr bw and coffect Signatu ✓ L Print name . UY— phwe-*-2-22 �©��(J c rrda! use only do not write in this areata be completed by cdy or town dficiar Giiat.a«.Town JL-]Check#urrr mdafe response is r+egei ed - Limsn8 Contact person phone I] f-lealfh Dept Q Other Date......! ..�1.. �.`�...................... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION HU This certifies that K� 1X1�1 C .f/rSc`h� has permission for gas installation ../'YI P.. P ............� in the buildings of.... ....J at........... ` .j .. .... ......... / ...... � %�.... , North Andover, Mass. Fee.Q� �.... Lic. No"I.J.�. . ... . ..................................................... . GASINSPECTOR Check# i J i U MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY L; ,___. ; �. Avid o tt<<L MA DATE / /2014 ERMIT# JOBSITE ADDRESS 10 -:� A: ti OWNER'S NAME GOWNER ADDRESS I Same TEtF— —IFAX�� TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIALO PRINT CLEARLY NEW: RENOVATION: REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ APPLIANCES 1 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER ,__ BOOSTER = CONVERSION BURNER � �� LR. � �J� } COOK STOVE ._. - � f DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE ___- GENERATOR I GRILLE _ � I INFRARED HEATER I __ LABORATORY COCKS MAKEUP AIR UNIT OVENm _ POOL HEATER �. ROOM/SPACE HEATER ROOF TOP UNIT ; TEST j UNIT HEATER UNVENTED ROOM HEATER i WATER HEATER OTHER Re lace Gas Meter(s)._.._...- -E�l X —E I and Associated Piping �..._._ L- L--Jr-- 1=1H :j INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Q NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE 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. CHECK ONE ONLY: OWNER ❑ AGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this 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 c mpliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME Joseph Marino LICENSE# 8736 SIGNATURE MP 0 MGF F-1JP[jJGF❑ LPGI❑ CORPORATION Q# 3285C PARTNERSHIP❑#_ LLC❑#0 COMPANY NAME: RH White Construction Co ADDRESS 141 Central St CITY I Auburn STATE MA ZIP 01501�TEL (508 832-3295 FAX 508-926-4347 CELL 508 832-4614 EMAIL JMarino@RHWhite.com 41N, ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES l Phone: 978-632-2660 Fax. 978-632-2662 JAMES A. TRUDEAU Adjustment Service Inc. P.O.Box 7 Gardner,MA 01440 claims antrudeauadUom Notice of Casualty Loss of Building Under Massachusetts General Laws, Chapter 139, Section 3B December 1,2014 wilding Inspector 120 Main Street North Andover,MA 01845 Board of Health 120 Main Street North Andover,MA 01845 Fire Department Dept.of Records 124 Main Street North Andover,MA 01845 Insured: Kevin&Wendy Diaz Loss Location: 109 High Street,North Andover,MA 01845 Insurance Company: Preferred Mutual Insurance Co. Policy No.: PHOO100638731 Date of Loss: November 21,2014 File Number: 14-12443 Claim Number: 14124521 Type of Loss: Property Damage 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 1.43, Section 6"to be applicable. If any notice under"Mass. Gen. Laws, Chapter 139, Section 3B" is appropriate, please direct it to the writer and include a reference to the captioned insured,location,policy number,date of loss,and file or claim number. On this date,I cause copies of this notice to be sent to the person(s)named above at the address indicated by first class mail. Sincerely, Robert P.Blais Claims Adjuster I l