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Home My WebLink AboutMiscellaneous - 11 FOSS ROAD 4/30/2018 _ a � 11 FOSS ROAD f - --- - - -- - - -- - 210/047.0-0088-0000.0 United Services Automobile Association CLAIM INFORMATION W. %V0. 04664. 47K2Q. JSS1546467615. 01 . 01 . 1834 TOWN OF NORTH ANDOVER 120 MAIN STREET NORTH ANDOVER MA 01845-2420 MASSACHUSETTS GENERAL LAWS, CHAPTER 139, SECTION 313 January 5, 2018 Dear Building Commissioner, r I'm writing regarding the claim referenced below. . USAA;policyholder. Carl L Danielson <Cla�m number: 003514836 044 Date of loss January 2,2018 ;Loss location North Andover, Massachusetts Address 11 Foss Rd,01845 A claim has been made involving loss,damage or destruction of the property referenced above,which may either exceed $1000.00 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 my attention and include the reference#. You may submit correspondence or questions to me using one of the following options: Address: USAA Claims Department P.O. Box 33490 San Antonio,TX 78265 Fax: 800-531-8669 Phone: 800-531-8722, ext 61266 Sincerely, Cindy L. Otte Property-SAT-E Unit 9 United Services Automobile Association I I 003514836-DM-04664-44-7357-59 54577-1217 Page 1 of 1 9800 Fredericksburg Road San Antonio, Texas 78288 USW 04664 . 196GQ.JSS830617133 . 01 . 01 . 51 TOWN OF NORTH ANDOVER, MA April 3, 2014 TOWN OFFICES 120 MAIN STREET NORTH ANDOVER MA 01845-2420 Reference: MASSACHUSETTS GENERAL LAWS, CHAPTER 139, SECTION 3B Dear Building Commissioner, I am writing regarding the claim referenced below. Policyholder: Carl L Danielson Reference #: 003514836-37 Date of loss: August 12, 2013 Location of loss: 11 Foss Rd, North Andover, Massachusetts A claim has been made involving loss, damage or destruction of the property referenced above, which may either exceed $1000.00 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 my attention and include the reference #. You may submit correspondence or questions to me. My contact information is: Address: P.O. BOX 33490 SAN ANTONIO, TEXAS 78265 Fax: 1-800-531-8669 Phone: 1-800-531-8722 Ext: 42618 Sincerely, Marjorie Dawn Baker Prop Unit 6 United Services Automobile Association PO Box 33490 San Antonio, TX 78265 Phone: 1-800-531-8722 Ext: 42618 Fax Phone: 1-800-531-8669 LTT/MDB 003514836 - DM-04664 - 37- 4528 - 09 54577-0813 Page 1 of 1 7 4 b l Date. .�l.1.�/�`........ Of NORTH ,h TOWN OF NORTH ANDOVER • PERMIT FOR GAS INSTALLATION w 9 . ,SSwcNu5E` 'This certifies that . . .�'7 4.Cl� {I•A.7. - : . . . . . . . . . . . . . . . . . has permission for gas installation . . . . ./-/ ,/3. .. . . . . . . . . . . . . . . . . in the buildings of . . . . ,tom./.r�.`rc. .�- . . . . . . . . . . . . . . . . . . . . at . . 4.S.� . . . j? . . . . . . . . . . ��A�I'N�'PE Nh AndoverMass. Fee. .—. . Lic. No./JZ.L 1. . . . . , — . . . . .CTORr — Check# �t/ MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) C Z ,Mass. Date / 20-IL Permit# Building Location f F0 9-S Owner's Name_LA /L So/V Owner Tel# Type of Occupancy es)D New ❑ Renovation ❑ Replacement u3-- Plan Submitted: Yes ❑ No ❑ FIXTURES coLuUo O CO) W 0) w Z Q xw' W O W E" rA a: xy F. cr.] �. aa P.5 ¢ = 0 =Of w 3 A CQ7 1 U Oa' > A H O w SUB-BSMT BASEMENT 1ST FLOOR 2ND FLOOR 3RD FLOOR r 4'H FLOOR 5TH FLOOR ^ ETH FLOOR TH 7 FLOOR 8TH FLOOR j� Installing Company Name CSI LL1a- ( D Check one: Certificate Address L/�J f�� atorporation CIRPLIA ❑Partnership Business Telephone# �7 ,Z_ V []Fir /C . Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. Yes,. — No ❑ If you have checked y2s,please indicate the type coverage by checking the appropriate box. A liability insurance policy 0---O—thertype 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 ❑ Signature of Owner or Owner's Agent I hereby certify that all of the details and information I have submitted(or entered)in above plication are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issue is application will be in compliance with all ertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gen ws. By- Type of License: umbe Sig u ease Plumber or Gas Fitter Title •Gas fitter License Number J Cityfrown oumeyman APPROVED(OFFICE USE ONLY) I Date. . . _ h Y 7 , , NORTM TOWN OF NORTH ANDOVER 3�O5tt`fD .a9ti�L O PERMIT FOR GAS INSTALLATION _. P • ^ # ssAC`HUs�t RECEIVED � YIV1E 7'--'r This certifies that .". . `l �:?�{. 1._. . .j�.. � . . . . . . . . has permission for 9-aA1 ta-1Wi in the builddin-zs MO4-104//?/- j,jJ.--. . . . . . . . . . . . . . . . . . . . . at . . . . . . North Andover, Mass. Fee. Lic. Nc .-73:�. ... . . . . . . . . . . . . . . . . . . . . . . . . . . /+ yU GAS INSPECTOR WHITE:Applicant ANARY: Building Dept. PINK:Treasurer GOLD: File MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITING — (Print or Type) �^ l0 1►p C/11,-e�' Mass. Date d�� `� `� 19� # Building w„ Location 1"05.54, Permit# Oo6l .5 Name V�IUe (s New ❑ Renovation ❑ Replacement Plans Submitted: Yes ❑ No ❑ Ycr irN M cc W W O ¢ F W Z J cr F- a >- m z 0 F- W oar mol-0 Lu W Wocr oamwa CC D o v w_ = cn z ~ o °C > w w a Q F o C.7 F Z J F- Z W W Cr crU W lL W U J W _ W J F- F > F- a W > Cr W � Z a M a m O O W O W F- or x 0 0 M LL D a 0 g U Cr > o a F- o SUB-BSMT. BASEMENT 1ST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR 5TH FLOOR 6TH FLOOR 7TH FLOOR 8TH FLOOR +1 CCheecck one: Certificate Installing Company Name ,,d//oYGr' P�ZX�a �. - .�.i In'C;orp. �G2 sl Address �5-7 j Z;— ❑ Partnership 4WVrc4c� /"�y ❑Firm/Co. Business Telephone � es_ C�3 Name of Licensed Plumber INSURANCE COVERAGE: Che9K One I have a current liability insurance policy or its substantial equivalent. Yes V No ❑ If you have checked yes, please indicate the type coverage by checking the appropriate box. A liability insurance policy 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: Signature of Owner or Owner's Agent Owner El Agent El 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 Plumbing Code and Chapter 142of a Gener I Laws. L By Typ"f License: ++, Title Plumber Signature of Licensed Plumber 4 El 9asfitter License Number 4 -73 City/Town gMaster APPROVED(OFFICE USE ONLY) ❑Journeyman IORTH BUILDING PERMIT o�tt��° bg10 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION y '° Permit NO: Date Received�� - `"°hwrc°•�' �SSACHl1S Date Issued: IMPORTANT:Applicant must complete all items on this page LflCATIOhI v Vv JPERTX flWaIER,, I"` �� ' Rtr �' } I IAP NO 3 j ARC1=L m ZRO�IiNU^�1 IS-1 R C`T F i1'sto4&-,DistrJct _ yes no x �rt Y4r t-7 N4%L 4 V Ir']Clfle sIIQ'RVdlage Ryes, T10 ?.j ' TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Addition Two or more family Industrial Alteration No. of units: Commercial Repair, replacement Assessory Bldg Others: Demolition Other ML- Q ,11l;ell _ Ftoodpla�n Wetlands y Wa#ersled C3astrrct Y '$' ^ DESCRIPTION OF WORK TO BE PREFORMED: e /-0 C, D1/ Identification Please Type or Print Clearly) OWNER: Name: CA f—L 12,9W Z Phone: g Address: 1 f t XWR a— Kry COTITCTOFlame '66 r : i �' e= w k A - x _ si i = _'� `t Address . SupervisorsMA --6-n strctb &cense p` date try ,. Horne`Irri roverrtent License . ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $� 5�" 6r FEE: $ 4P.22-- Check PyCheck No.: 1-43 Receipt No.: 0 NOTE: Persons contracting with unregistered contractors do not have access to the anty fund Signature of Agent/Owner Signaturew of contractor Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits L3 Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan l ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2007 Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— For department use i ❑ Notified for pickup - Date Doc.Building Permit Revised 2007 Plans Submitted Plans Waived Certified Plot Plan. Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/Massage/Body Art Swimming Pools Well Tobacco Sales Food Packaging/Sales Private(septic tank,etc. Permanent Dumpster on Site THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS DATE REJECTED DATE APPROVED CONSERVATION COMMENTS DATE REJECTED DATE APPROVED HEALTH COMMENTS Zpning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes 1 i Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Con nection/Sig nature &Date Drivew ermit Located at 384 Osgood Street F'IRE DEPARTMENT Temp1Dumipster;on site Vires " nor .. Located -at h24"Main Street ' " :F re Department stgnaturg ate * , t F ,COMMENTS Tom- k Location No. Date r NORTH TOWN OF NORTH ANDOVER � w 9 Certificate of Occupancy $ •►cMus E<� Building/Frame Permit Fee $ s .. Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 2 Q 6 � 4 'IT��----- Building Inspector TkORTH T0 0Andover No. a �� K � 0 r o , dover, Mass., lid Q LAKE COCMICKEWICK 7��oRATED P' �� N BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT........ ......... ..e......... ..... .000.0................................................................... Foundation has permission to ere buildinrn ..�.......;..rw� ...... ... R....................................... Rough to be occupied as:.. i... � ........................................................................................................ Chimney f provided that the person acceptin is permit shal n every respect conform to the terms of the application on file in Final this office, and to the provisions 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 2 sow PERMrr EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS . ONSTRU S 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. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ky 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): f-a 0 r Address: C_ City/State/Zip: /1 Phone #: '7 7 C, $� / C% Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction ear 1.plo-yees(full and/or part-time).* have hired the sub-contractors ®' listed on the attached sheet. �• E] Remodeling 2. I am a sole proprietor or partner- ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.E] Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL 1 1.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' 13.0 Other comp. insurance required.] *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. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins. Lic.#: 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 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 DIA for insurance coverage verification. I do hereby ce under the pains and penalties of perjury that the information provided above is true and correct. Si nature: Date: Phone Official use only. Do not write in this area, to be completed by city or town officiab 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#: rDpoalPage# of pages Proposal Submitted To: Job Name Job# Address Job Location Date Date of Plans Phone# / Fax If Architect i Wehereby submit specifications and estimates for:.____............................_._.__.....___._..._.....____..._........___...__...._.._.........................................._......_._.........._._.._._.._.-._._..___..-.---__.____._...._._...._.._..._._.....__:..__.._._.__.__...__.__. . _... . -147 .._r .......... I _........................._............_____...._.........._._..__...._.......__............._____.___.........____.__.__.._.___.__.__.._.__.________................___..........._.__..__.__._.._____ ._._ ............_ _ ------------- ___ __........_.... --_ ___ .........._._.........__.-.......... __.. ......_ ........ ___.._,..._.............__. ........_._............._--__.__. ._.._._..._..._............................__........ We propose hereby to furnish material and labor—complete in accordance with the above specifications for the sum of: $ Dollars with payments to be made as follows: Any alteration or deviation from above specifications involving extra costs will be Respectfully executed only upon written order, and will become an extra charge over and submitted above the estimate.All agreements contingent upon strikes,accidents,or delays beyond our control. Note—this proposal may be withdrawn by us if not accepted within days. 2cceptance of J)ropoda-[--- The above prices,specifications and conditions are satisfactory and are Signature / hereby accepted.You are authorized to do the work as specified. / L ments will be made as outlined above.e of Acceptance Signature NC3819 MADE IN USA ✓lie-Po rr�rwozusnaal�.a�✓�uasa8� ,� llcard of lluildinf;Regulat�u.sa.ln� 11t"a cts .. a HOM lb1PROVc r1ENTCCGNTRkL OR � € agrstration 105523 m Expp_m } t Type `ndividual T RAYP IOND VBERUBc tlick6luig Rd Le NJ p � earULAT10N �uer , - F fie �o�rnniaa _ "7'r� BOARD OF BUILAING REt3S . TRUCTIQN Licenser CON$ SUPE15�R x , 035867 f�thdate 1M7l511941 Bir " . • Expires'�12115%2007 � =rtr no•'9812 0}� 9 d Restncte00 k � xl x n I RAYMOND V BERUBE c k 361 CHICKERWG RD k . I 01845 Commissi N�NDOVER MA. 84 -W