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HomeMy WebLinkAboutMiscellaneous - 114 SPRING HILL ROAD 4/30/2018 114 SPRING HILL ROAD 210/107-A-0239-0000.0 PQ Box 55098 Briton,MA 02205=5098 - 617-951-0600 :r r. 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 N ANDOVER, MA 01845 N ANDOVER, MA 01845 RE: Insured: SUMI B DOLBEN Property Address: 114 SPRING HILL RD,N ANDOVER, MA Policy Number: HMA 0262684 Claim Number: BOS00055764 Date of Loss: 2/27/2015 Company: Safety Property and Casualty 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. Coleman Foley Claim Examiner 3/16/2015 Safety Insurance Company Homeowners Claims Unit P. O. Box 55098 Boston, MA 02205-5098 Phone: (617) 951-0600 EXT 5180 Fax: (617) 531-8886 Email: ColemanFoley@Safetylnsurance.com s- L/Z Date.. .. .. .... . .. . MORTPI 3?0ya��ao ,s,tiOL TOWN OF NORTH ANDOVER O P • - PERMIT FOR GAS INSTALLATION SS�1C NUSE4 // M This certifies that . ... . . .'S R��Q'oPa. . . . has permission for gas installation lJ j!P.. .. in the buildings of . . . . . . . . . . . . . . . . . . . . . . . . . . . . at . .,�,7.Sfih�I�Ii�� !�Cl' Nrth dover, ass, Fee3l,�. . Lic.fNo..Flc,`rZ. . !7.!C r!f! GASINSPECTOR Check# 771,'01)w 8160 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY MA DATE L.��,V- PERMIT# JOBSITE ADDRESS _'` SP/L.'1✓l_ I� ���OWNER'SNAMEz GOWNERADDRESS _ TEL _ FAX II TYPE OR OCCUPANCY TYPE COMMERCIAL[j EDUCATIONAL D RESIDENTIAL[ ' PRINT CLEARLY NEW:P RENOVATION:[,� REPLACEMENT:® PLANS SUBMITTED: YES[] NO(J.f APPLIANCES I --FLOORS- BSM 1 2 3 4 5 8 7 S g 10 11 12 13 14 BOILER I f BOOSTER - - -- -- - - - _ -- -- I- -1 ---j E - CONVERSION BURNER COOK STOVE _ DIRECT VENT HEATER DRYER FIREPLACE (-- FRYOLATOR _ FURNACE _ I GENERATOR _-_-- GRILLE INFRARED HEATER _ I LABORATORY COCKS MAKEUP AIR UNIT _ OVEN - POOL HEATER ROOM I SPACE HEATER ROOF TOP UNIT TEST - --- UNITHEATER UNVENTED ROOM HEATER (= .._ WATER HEATER OTHER INSURANCE COVERAGE have a current liablll!y nsurance policy or Its substantial equivalent which meets the requirements of MGL.Ch.142 YES E]NO D I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY 1-71 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 applicationaw lues this requirement. CHECK ONE ONLY: OWNER [_] AGENT SIGNATURE OF OWNER OR AGENT 1 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 compliance with all Pertinent provision Sf the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME --f — �ti7�d�LICENSE#L� az SIGNATURE MP 00'MGF� JP El JGF[j LPGI® CORPORATION[91 PARTNERSHIP EI# LLC[ # COMPANY NAME: S � ._�f._. r✓M- ADDRESS ---------- - - CITY STATERaJZ1Pj. Q TEL . wy - FAXS./riv+' �/. CELL Z2 _ EMAIL Date. ��'r''. ,!7' 7 0. NOR7M TOWN OF NORTH ANDOVER ° p PERMIT FOR PLUMBING 40 SSACMUS� This certifies that . . . .-�-. -.`'•'•�• • .�� ��• has permission to perform... . . t" . . . . . . . . . . . . . . . . plumbing in thef buildings of . ���` _ ."�"'"` '�. . . . . . . . . . . . . • • _ / Pc:% at . . . .`f. . . . . . .;. �. . . ... . . . . . . .. North Andover, Mass. Fee d. . . . . .Lic. No.. �i1Vk �. . . . . . . . . . . . PLUMBINGINSPECTOR Check # 1 3 ��• 7 41.'1 0 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS l Date Building Location / 2 f � k,( Lners Name Permit# %l Amount Type of Occupancy New rl Renovation Replacement 0-1**- Plans Submitted Yes No FIXTURES Ln 1A rA H �a >4 w aW Gn a x w d a wrZ En A x x a A a ca SvR3WAaE B4SMU II' M ROQ4 ZQ FIDQt 3 M HDM 4M HfM 5M I M 6M HIM 7M ROM Mi HIM (Print or type) Q Check one: Certificate Installing Company Name /` -- L—Z�z/lrte ❑ Corp. a Address -P C O Partner; Business Telephone 2 7,F Ko F7, D K--2,0 [3—Firm/Co. Name of Licensed Plumber. y L "e Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy 0"' Other type of indemnity ❑ 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 Signature Owner F1 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 V*mpllations performed under Permit sued for this application will be in compliance with all pertinent provisions of the Mas44dsetotatSLPlumibinv Code and apter 14 the General Laws. By Signature Or rcens er Type of Plumbing License TitlegrD 3 L City/Town rcens Master Journeyman APPROVED(OFFICE USE ONLY u �� DU Date. . . . ".O RT:1�o TOWN OF NORTH ANDOVER ° PERMIT FOR PLUMBING SACNUS� C .. This certifies that . . . . . . . . . . . . . . . . has permission to perform . . . . . . . . . . . . . . . ,dumbing in the buil ings of . . ..1: .. . ... . . . . . . . . . . . . . . . . . . North Andover, Mass. k fete./,.- . . .Lic. No.. . . .: f� . . � . . . . . . . . . . . . CPLUMBING INSPECTOR Check # �7 74 22 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS l Date 4ners vG ` Name f� < �"t- Permit#Building Location J .�� Amounts Type of Occupancy AC/ New Renovation Replacement Er� Plans Submitted Yes No FIXTURES a arAw �" w �" H a w W W d w a w N 0 a w w F H e� aCAA A aE m SM19a BAS1iN M ]S'1C FLOCR Z.-D FIOM 3M FLOCIt 4M RfM 5M FLOQt 6M ROLR V 7M FLOM 91HRUR (Print or type) ` Check one: Certificate Installing Company Name �� /eri, ✓Ll Corp. Address 9 o x PU © � Partner.' Y� v, u-e -c- P Business Telephone �Firm/Co. a Name of Licensed Plumber. Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy 0/ Other type of indemnity El 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 Signature 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 anms lations pyt3rmed under Permit Issued or this application will be in compliance with all pertinent provisions of the Mas ach efts Stat lu g Cod;td Chapt 42 of the Gen ws. By 1Fa" ceps um er ✓ Type of Plumbing License Title City/Town icens u er Master Journeyman ❑ APPROVED(OFFICE USE ONLY f Date..... .�.��.' .. '... NORTH TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING SSACMUSE� This certifies that ..... t!. E...... ...... fll�l.,C has permission to perform ........... .............�? ./-}��.. ............................ wiring in the building of... l.`UD..�`L22/f...1.�[ i ... ........ at......I./Y PAl ...4b.............. .North Andover,Mass. Z Fee.5�............ Lc.No f.....3..M. ........................... . ... . .. . ..... ELECTRICAL INSPECTOR i Check 'I 7496 v �••v • vr• r • v• • •MV✓MVIIMJVLbJ �/ Department of Fire Services permit No. 7 Occupancy and Fee Checked r` BOARD OF FIRE PREVENTION REGULATIONS [Rev. ]/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: —7/VO 7 City or Town of. NORTH ANDOVER To theIn p ctor 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(q ir`1)..j C. ` 11 (ZJ ZJ Owner or Tenant w J-K © 110 c fJ Telephone No. Owner's Address l(y Sp r` y�i4, �� 11 21 Is this permit in conjunction with a building permit? l Yes ® No ❑ (Check Appropriate Box) Purpose of Building Hyt4er VJapt' Utility Authorization No. Existing Service ZZ70 Amps 120/Z4n Volts Overhead ❑ Undgrd® No.of Meters I New Service Amps / Volts Overhead❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: 1=loa,- Completion of the followingtable ma be waived by the Inspector of Wires. No.of Recessed Luminaires 3 No.of Ceil.-Susp.(Paddle)Fans o.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Z Swimming Pool Above E] In- ❑ o.of Emergency Lighting rnd. grnd. Battery Units No.of Receptacle Outlets / No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners o.of Detection an Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons g No.of Waste Disposers eat ump Number ons o.oSelf-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 KW o.o o.o Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No. Hydromassage Bathtubs i No.of Motors Total HP Telecommunications firing: 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: 71116 7 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:) /certify,under tlee;�ains and Pena ./es of per ury,that the information on this application is true and complete. FIRM NAME: I c� lei �� c ��rvicQtZ301� LIC. NO.: Licensee: ►^crrc c TZ,;c-<11 Signature LIC. NO.: 12 3 k'1 PI- (If applicable, enter "exempt"in the It ense num,(�er line Bus.Tel.No.: 3'�7Z6" n3/ Address: �O i3o X t 2!0 l ,vr�ol'or� �t1S N 14 d 31W.L l y Alt.Tel. No.: (603 1 ENT� *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 this requirement. I am the(check one)❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE. $ L/LL a.,vl//Ilcv/IrvGULb/! V 1111[JJUI;/bLLJC/lJ `7 Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 UT www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): I�1 C-e F, Address: I &x I2 City/State/Zip:4A>.V"rio>J pA-tl S N14 011 Sd Phone #: (OC)-3' '72( " 303 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. 1 am a sole proprietor or partner- listed on the attached sheet. $ E] Remodeling 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.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ 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). 4 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 cern nder the in d pe ties of perjury that the information provided above is true and correct �O Signature: Date: 7 / 6 Phone#: C0o5-423 Official use only. Do not write in this area,to be completed by city or town offzciaz 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#: