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Home My WebLink AboutMiscellaneous - 11 PEMBROOK ROAD 4/30/2018 11 PEMBROOK ROAD 210/021.0-000000.0 J .,wv—, Safety Insurance 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: MATTHEW LACOLLA Property Address: 11 PEMBROKE ROAD,NORTH ANDOVER, MA Policy Number: HMA 0249622 Claim Number: BOS00043653 Date of Loss: 6/6/2014 Company: Safety Indemnity 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. Holly Coughlin Claim Examiner 8/25/2014 Safety Insurance Company Homeowners Claims Unit P. O. Box 55098 Boston, MA 02205-5098 Phone: (617) 951=0600 EXT 3026 Fax: (617)-531-6684 Email: HolfyCoughlin@Safetylnsurance:com Safety Insurance : 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: MATTHEW LACOLLA Property Address: 11 PEMBROKE ROAD,NORTH ANDOVER, MA Policy Number: HMA 0249622 Claim Number: BOS00043653 Date of Loss: 6/6/2014 Company: Safety Indemnity 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. Justin Murphy Claim Examiner 6/17/2014 Safety Insurance Company Homeowners Claims Unit P. O. Box 55098 Boston, MA 02205-5098 Phone: (617) 951-0600 EXT 5436 Fax: (617) 535-5869 ; Email.: JustinMurphy@Safetylnsurance.com Date..... ............... f HO oTM-4ti C `- OCG TOWN OF NORTH ANDOVER p PERMIT FOR WIRING 'This certifies that-.- :........ ............................................................... .c� has permission to performs ............................................... wiring in the-building of f � North An ass . . .. aFee..................... Lic.No..... ........ ............. yy'f................. ELEC`rRICAflNSP14MR Check # 68.3 7559 Commonwealth of Massachusetts Official Use Only Permit No, c5`� Department of Fire Services Perm �L Occupancy and Fee Checked 15 r BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] 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 INFORMATION) Date: 0 -7 City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice ce of his or her intentioWo. erfo the electrical work described below. Location(Street&Number) // brio-ok A.,J Xl vel- IM 0/8-(S- Owner /8-(SOwner or Tenant Telephone No. &yo f$3 Owner's Address SA-MO A6 A-$6 k/E. Is this permit in conjunction with a building permit? "� Yes No ❑ (Check Appropriate Box) � - Purpose of Building � t�p,� P/-.S9," 0C.F-��,to ` Utility Authorization No. Existing Service p?,,oV Amps o61 /,gyp Volts Overhead Eg""' Und rd t g ❑ 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: Completion o the ollowin table ma be waived b the/ns ector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA u No.of Luminaires Swimming Pool Above ❑ In- ❑ o.o mergency ig ing rnd. rnd. Battery Units No.of Receptacle Outlets /57 No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches ? No.of Gas Burners No.of Detection and Initiatin Devices No.of Ranges No.of Air Cond. Total No.of Alertin Devices Tons g No.of Waste Disposers Heat Pum Number Tons KW No.of Self-Contained Totals Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Devices.or Equivalent No.of Water No.of No.of Heaters KW Data Wiring: Si ns Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent A- OTHER: t Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: r S-3-V (When required by municipal policy.) G� Work to Start: 0 S' a7 In ections 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:) A/0 1`f `Z/t'.s� '`69 I certify,under the pai�r,�andff enalties of perjury,that the information on this application is true and complete. FIRM NAME: �'e�/G� .4 L t`8,e—,44 LIC.NO.: Licensee: Signature LIC.NO.: (If applicable, enter -exempt-in the license num*r line.) Bus.Tel. No.: �� 7� - �- Address: (f Alt.Tel. No{�� S! Z *Per M.G.L c. 147,s. 57-6Y,security work requires Dep&fment 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 this requirement. I am the(check one)❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ Date .?. . OORfq T ! R 0'<,��° .1�o TOWN OF NOR H ADO PERMIT FOR PLU ING w 7Y 'O�•no.A�•(�7 ,S.7 USES This certifies that . . (.G. H,! „� „ . • • . • • • . . . . . . • • „ has permission to perform . . . . . ., e-- . . . . . . . . . . . . . . . . . . . . . . . plumbing in�the buildings of <0. <- . . . . . . . . . . . . . . . . . at . . . ./. ,/. . .r. t g.�G. : . . . . . . . . . . . . . North Andover, Mass. Fee. . . . . .Lic. No../ }i.0 . �_.t •'•'!. �-� PLUMBING INSPECTOR Check # / � i1L MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS Date Building Location I �zv Owners Name L,LZG 0/,/0 Permit# ?uv� Amount y -- Type of Occupancy .� New E] Renovation LTJ Replacement E Plans Submitted Yes El No 11 FIXTURES W CC W W2 A SU118 C REM M FLOM MKO R SIH E OM GIIiFIDQt 7IH ROQt MH FMM (Print or type) Check one: Certificate Installing Company Name X,L . s l/ Corp. Address --� Partner.' 0 El Business Telephone "— Finn/Co. Name of Licensed Plumber lA ic; L e,/V` C Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy 3 Other type of indemnity 1:1 Bond Insurance Waiver. I,the undersigned,have been made aware that the licensee of this application does not have any one of the above three insurance rgnature Owner El Agent 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 Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbing Code d Ch ter 142 of the General Laws. By: Signalure of Occriseafumm'Ser Type of Plumbing License Title �� l City/Towniliccme INUU10cr MasterJoumeyman ❑ APPROVED(OFFICE USE ONLY ET Date.. ?A. .. ..... . x NpRTM ,,,h0L TOWN OF NORTH ANDOVER 10 5 P • - PERMIT FOR GAS INSTAL LATI,A �*c +�9SSACHUSEt�y♦ This certifies that . . . . . S.c.. . ..!. . . . . . f.`. . . . . . . . . . . . . . . . . . has permission for gas installation . . .. . f . .�'.?.� :. . . . . . . . . . . . . ` in the buildings of . . . at . . . . .�! . . ./.'.?'.� �!'.` `. . . , North Andover, Mass. Fee. . .�.. . . . Lic. No..). 3.t .`. . . . . f GAS INSPECTOR Check# 6085 MASSACHUSETTS UNIFORM APPUCATON FOR PERIVIIT'I'O DO GAS FITTING (Type or print) Date KZ Lf 0,7 NORTH ANDOVER,MASSACHUSETTS Building Locations / / //Q/��60� /d t`7 G1 ,.� Permit# Amount$ u Owner's Name New❑ Renovation Replacement ❑ Plans Submitted ❑ z z o F x w ¢ s a a w d x z w x (A w a p a > w z w d a F m z " f�0 H w w > w z a z x O v� s o x 3 a a °a > SUB-BASEM ENT BASEMENT 1ST. FLOOR 2ND . FLOOR 3RD . FLOOR 4TH . FLOOR 5TH . FLOOR 6TH . FLOOR 17T H . F L O O R 8TH . FLOOR (Print or type) facd-,1-5 /� Check one: Certificate Installing Company Name _ ❑ Corp. Address C, —� ScU S Partner. 0 usmess a ep one ® Firm/Co. Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE Check onepe' I have a current liability Insurance policy or it's substantial equivalent. Yes ® No❑ If you have checked yes,please in a the type coverage by checking the appropriate box. 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 ❑ Agent ❑ 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 Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Coed Chapter 142 of the General Laws. By. Signature of Licensed Plumber Or Gas Fitter Title ❑ Plumber 4 3 3,.? f City/Town ❑ Gas Fitter License Numoer GyMaster APPROVED(OFFICE USE ONLY) 0 Journeyman