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HomeMy WebLinkAboutMiscellaneous - 110 QUAIL RUN LANE 4/30/2018 110 QUAIL RUN LANE 210/060.0-0135-0000.0 9800 Fredericksburg Road San Antonio,TX 78288 us" 04664. 1TKH2.JSS1025789176 . 01 . 01 . 3600 ATTENTION: BUILDING COMMISSIONER March 30, 2015 TOWN OF NORTH ANDOVER 120 MAIN STREET NORTH ANDOVER MA 01845-2420 Reference: MASSACHUSETTS GENERAL LAWS, CHAPTER 139, SECTION 3B Attention Building Commissioner, I am writing regarding the claim referenced below. Policyholder: Rosalie M Pulverenti Reference #: 002821008-19 Date of loss: March 4, 2015 Location of loss: North Andover, Massachusetts A claim has been made involving loss, damage or destruction of the property located at 110uail Run Rd. North Ando, MA 01845-5326 which may either exceed $1000.00 or cause (e1A-55'�CCHUSETTS 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 number. You may submit correspondence or questions to me. My contact information is: Address: P.O. BOX 659461 SAN ANTONIO, TEXAS 78265 Fax: 1-800-531-8669 Phone: 1-618-409-6868 Sincerely, Christopher S Kelley Central Region United Services Automobile Association P.O. Box 33490 San Antonio, TX 78265 Phone: 1-618-409-6868 Fax: 1-800-531-8669 JFF/CSK 002821008 - DM-04664- 19- 7326 - 59 54577-0914 Page 1 of 1 Date....� Z. . 1..... NORTH TOWN OF NORTH ANDOVER p PERMIT FOR WIRING CHU This certifies that .............................t..........� ....../../.�........ \ has permission to perform !' so C � �n , wiring in the building of.......... ....... .G.............. . � / at...............................NO 00 ........................................... ... North Andover Mass. Fee��©C7 Q ......... Lic.No. . .....Cf.............4664 . :. . . . . LE C L INSPECTO �• t Check # ���7 "10509 s Commonweakk o f Wamackusefts Official Use Only �\ c� Permit No. f G`d o O 2epartment ol3ire Services Occupancy and Fee Checked \ BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leaveblank) 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: City or Town of: _dol` /�.� P� f To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) I IoQ�i L Quin Roa I Owner'or Tenant OSCLLi e I_LtL,\Je_r e.,n4 f Telephone No. &R,S v601� Owner's Address 118 Q(A Q—i L. Qi,u RA rA Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Lei Purpose of Building1_o S f Utility Authorization No. � L Existing Service Amp ` / �t{Q Volts Overhead ❑ Undgrd® No,of Meters f New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: PenlaCi✓lG _)_Om l+yl� f SOC�I Completion of thefollowing table may be waived by the Inspector 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 No.of Luminaires Swimming Pool Above ❑ In- ❑ o.o Emergency Lighting rnd. rnd. Batte Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones` No.of Switches No,of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons g No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: "' """'"""".""""""""I"""".".....' 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 KW No,of No.of Data Wiring: ` Heaters Signs Ballasts No.of Devices or Equivalent No. Hydromassage Bathtubs No.of Motors Total HP- Telecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail if desired, 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, under the pains and penalties of perjury,that the information.on this application is true and complete. FIRM NAME: LIC.NO.: Licensee: Ge-nPcP L Maglr i, j Signature , __ LIC.NO.:J11f 99t (Ifopplicable enter ''' xempt"in the license number line.) Bus.Tel.No. ��3 Of Address: .2 7 U ��3 Alt.Tel.No.:E�.� S"3�-f 61 S f *Per M.G.L. c. 147,s'5 -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 signatureBelow,I hereby waive this requirement. I am the(check one)K owner ❑owner's a ent. Sin Agent /� r Telephone No. /r/� PERMIT FEE: $ Signature � /G'��-�'—t 6C.��L��s� p '�D '!�;d'S`�?L'L�� r..f3d The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street y` Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leeibly Name(Business/Organization/Individual): Gr „� L-. nu�lay)i' GV Address: Za nc�c•%�;1 -� f�t'y Q City/State/Zip: Sej e*ln N q. Q30� Phone#: X 03 8&)14th. 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 employees(full and/or part-time).* have hired the sub-contractors 2.[r I am a sole proprietor or partner- listed on the attached sheet. 7. []Remodeling ship and have no employees These sub-contractors have g, E]Demolition workingfor me in an capacity. employees and have workers' y p n'• # 9. ❑Building addition [No workers'comp.insurance comp.insurance. required.] 5. We are a corporation and its 10. Electrical zepairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I L Plumbing repairs or additions myself. [No workers' comp. right of exemption.per MGL . 12.❑Roof repairs insurance required.]t c. 152, §1(4),and we have no employees.[No workers' 13.❑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. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp,policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and. job site information. Insurance Company Name: w 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 S 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. 1 do hereby certify under the pains andpenalties of perjury that the information provided above is true and correct: Signature: Date: Phone#: 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#: