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HomeMy WebLinkAboutMiscellaneous - 111 PRESCOTT STREET 4/30/2018 111 PRESCOTT STREET 210/082.0-0001-0000.0 I i i I I Colonial ADJUSTMENT, INC. March 14, 2016 Town of North Andover ATTN: Building/Inspection Services 1600 Osgood Street Building 20, Suite 2035 North Andover, MA 01845 NOTICE OF CASUALTY LOSS UNDER MASSACHUSETTS GENERAL LAWS, CHAPTER 1139, SECTION 3B FILE NO: 161­1100036-MRR POLICY NO: H012061071 CLAIM NO: HC218869 INSURED: George & Claire Fagan DATE OF LOSS: 2/14/2016 LOCATION: 111 Prescott St,North Andover, MA Dear Sir/Madam, A claim has been made involving loss, damage or destruction of the above-captioned property which may either exceed $1,000.00 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 the attention of the writer and include a reference to the captioned insured, locations, policy number, date of loss and claim or file number. Thank you for your cooperation. Very truly yours, I Michael Riesbeck, Adjuster South Portland Office (800) 445-2330 Ext. 231 mriesbeck@colonialadj.com MRR\emc Main Office 111 Wescott Road, South Portland, ME 04106-3437 800-445-2330 . 207-797-9036 • FAX 207-797-6820 " Serving Maine,New Hampshire and Vermont �x Branch Office- Bangor, ME ' Resident Adjusters throughout Maine, New Hampshire and Vermont f Date.................................................: OF &ORTN 4ti o �, TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION s`rACHUS� This certifies that ...�e:e nye ...✓'T ! S ................... ......................................................................... has permission for gas inion ....Vl -.... .... s..I .. ......... in the buildings of............................ .. . ........................................................ at..... .,............... P.x�.... ........... .. North Andover, Mass. Fee.LPU~... Lic. No. .. � .................................................. GAS INSPECTOR Check# J2 0 1 09906 r ^,q ` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM.GAS FITTING WORK N60 z .AA DATE PERMIT � -- JOBSITE ADDRESS / - es co s OWNER'S NAME OWNER ADDRESS I TEI.r— ---�]FAX� ,� TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEWT-1 RENOVATION:Q REPLACEMENT: PLANS SUBMITTED: YES Q NO APPLIANCES'l FLOORS- BSM. 1 23 4 5 6 7 8 9 10 11 12 1 13 1 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE I FRYOLATOR FURNACE GENERATOR �— GRILLE INFRARED HEATER LABORATORY COCKS �— MAKEUP AIR UNIT GVEN POOL HEATER I ROOM/SPACE.HEATER R OF TOP UNIT TES? _ UNIT HEATER UNVENTED ROOM HEATER i WATER HEATER OTHER rfrt widle ov°r- I � INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES [W0 11 I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Eg--* OTHER TYPE INDEMNITY ® BOND Q 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 Q 'SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true and accuro to the be of kno ge and that all plumbing work and installations performed under the permit issued for this application will be in compli erti n r ion Massachusetts State Plumbing Code and Chapter.142.of the General Laws. / PLUMBER-GASFITTER NAME LICENSE# 156Y SIGN RE MP[3,MGF Q JP Q JGF Q LPGI® CORPORATION PARTNERSHIP Q# ( LLC COMPANY NAME: ee 8r® -r, SE2,, e� ADDRESS — CITY STATE' /11 A ZIP Z f Z Z ]TEL FAX�� CELL EMAIL ro O i 4 -�-,. I I r �/� �/ ` /. / U� � `COMMONyN ., • • ALTH pF M • S 1 PLUMBER � ' 5F1TT ISSUES THE FOL3LQW1lVG�hE�ERS ��tICE(�(SE3Q'r= FENS L UM'B uR W GARFIrECa' � 24 W I L T t ,,•2 :'y''�'f co I MA 02301 r 4 51 I � Q7 6 , 22 44.2 w r . COMMONWeWU mOF MAS 1kCHl SE7TS''::' ■ • • � • •I o Fi BOARb"QFC u PLUMBERS A�I� G'ASF�1TrF�RS f sLil}CENSE . � I SSUESF T.NE 'FOLLOWI REGI' TR� D AS A 'PLlMB41r C' OjP PXV,I R 14 GARN EL,'0)' ; } EENLY U-KW L_C Z„ ` v 21 W PLUM'��` � ,�e, � 'BRo t-RTbN ', ¢MA 02301 z 36ET�s ko,y/ot/1a6I$ 221413 i r FEENBRO.01 SMORAN CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY)-- ---.. .. 1130/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the pollcy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In Ileu of such endorsement(s). PRODUCER CONTACT NAME: Rogers&Gray Insurance Agency,Inc. PHONE FAl( (877}81 Ei-2156 434 Rte 134 (A/C.No Ex* ac No South Dennis,MA 02660 E-MADDRESS: INSURER(S)AFFORDING COVERAGE NA1C @ INSURERA:OId Republic General Insurance Corp. 24139 INSURED INSURER B Feeney Brothers Services LLC INSURERC• 103 Clayton St - PO Box 220801 INSURER D: Dorchester,MA 02122 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERRA OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR TYPE OF INSURANCE DD BR POLICYNUMBER MM/D1DYr(YIY M1S�P/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,00 CLAIMS-MADE a OCCUR 2CG07501501 0210112015 02/01/2016 PREMISES Ea occurrence $ 300,00 MED EXP(Anyone person) $ 10,00 PERSONAL&ADV INJURY S 1,000,00 GERLAGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE S 2,000,00 POUCYNJEC LOC PRODUCTS-COMPIOPAGG $ 2,000,00 OTHER: $ AUTOMOBILE LIABILITY - COMBINED SINGLE LIMIT $ ' Ea acc dent ANY AUTO BODILY INJURY(Per person) $ ALLOWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS HIRED AUTOS AUTOS 9VE0 PROPERTY DAMAGE $ 5 UMBRELLALIASOCCUR EACH OCCURRENCE $ EXCESS LIAR HCLAIMS-MAIC AGGREGATE $ DED RETENTION$ S WORKERS COMPENSATION X PER OTH- AND EMPLOYERS'LIABILITY STATUTE ER YIN A ANY PROPRIETORMARTNERIEXECUTIVE 2CW07501501 02/01/2015 02/01/2016[!E ,LEACH ACCIDENT $ 11000,00 OFFICERRME1.18ER EXCLUDED? NIA (Mandatory In NH) E-L.DISEASE-EA EMPLOYEE S 1,000,00 Ivyes,descnbe under DESCRIPTIONOFOPERATIONS bekrn E-L DISEASE-POLICY LIMIT $ 1,000,00 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,maybe attached It more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1600 Osgood Street ACCORDANCE WITH THE POLICY PROVISIONS. North Andover,MA 01845 AUTHORIZED REPRESENTATIVE r :5. ,s ©T088.2014 ACORD CORPORATION. All rights reserved. l ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD