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Home My WebLink AboutMiscellaneous - 117 COTUIT STREET 4/30/2018 117 COTUIT STREET 210/023.0-0051-0000.0 v 'own of North Andover ayment Date Monday,March 07,2016 ieposit Number 1603071 ►perator Counter pc 1 t ICR(PLUMBING INSPECTION) $30.50 Y" otal Paid $30.50 ash $30.50 'hange $0.00 receipt Number gov00004584 1712016 9:52:38 AM :ashier Id. treascoll-17 Date... . .....1 c�NOr+rM��o TOWN OF NORTH ANDOVER ° p PERMIT FOR PLUMBING mu Thiscertifies that... ................................:.L.......................................................................... has permission to perform!.` ................................................................................. plumbing in th�"' uildin of......CO, P ........................................................, at...........��...7.... .. 7Y ..................... North Andover, Mass. ... ................. . .....................`� N ...........................Fee...................... ......-'...... ic. o. ..................................................... PLUMBING INSPECTOR Check# �� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ff , CITY N eAmi A'N-DO�12 MA DATE 3 IS 1 16 PERMIT# I JOBSITE ADDRESS 117 C O-T U I—r ST OWNER'S NAME POWNER ADDRESS Ill C O -TvtT S T TEL -7<? to,:Z1 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW: ❑ RENOVATION:011 REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO FIXTURES Z FLOOR— SSM 1 2 3 4 5 6 7 8 9 10 11 12 13 L 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR 1 AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES❑ NO �q IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW 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 , Massachusetts.Gene 1 Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER til AGENT ❑ SIGNATURE OF OWNER OR AGENT I 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 compli with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME M a-r kE:W 0 Cot.-JE-1K \ LICENSE# M 154 a 1 SIGNA MP 10 JP❑ CORPORATION❑# PARTNERSHIP❑# LLC❑# COMPANY NAME ADDRESS SS N CAL ST CITY M,4,\-SEN STATE ZIP TEL FAX CELL EMAIL 1 r' The Commonwealth of Massachusetts z Department of Industrial Accidents 1 Congress Street, Suite 100 t" Boston,MA 02114-2017 �M www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. ApOicant Information Please Print Leeibly Name(Business/Organization/Individual): M 1�111.1�V� W 1\ Address: '�S N EAS. �jr( City/State/Zip: KkL CN MA CQ 1 L4%Phone #: -7 Are you an employer?Check the appropriate box: Type of project(required): l.❑I am a employer with employees(full and/or part-time).* 7. ❑New construction 2. am a sole proprietor or partnership and have no employees working for me in $, &emodeling any capacity.[No workers'comp.insurance required.] 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ❑Demolition ❑ 4.❑lam a homeowner and will be hiring contractors to conduct all work on my property. 1 will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12. Plumbin ❑✓ g repairs or additions 5. I am a general contractor and I have hired the sub-contractors listed on the attached sheet. ]3.E]Roof repairs These sub-contractors have employees and have workers'comp.insurance.: 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have no employees.[No workers'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: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address:_ ill CO"�U i � S City/State/Zip: N1ANZ)64C_z MA, Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify and r thepains andpenalties ofperjury that the information provided above is true and correct. Si nature: Date: / 5 Phone#: 1' 3S1^ boor 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#: RESET FORM 3/7/2016 IMG 0153.PNG Z �} �7 4 t r as a i � � e i n k https://mail.google.com/mail/ca/u/0/Mnbox/1535180db98f942b?projector=1 1/1 Aik Commerce Insurance The Commerce Insurance Ccmpany C� Citation Insurance Company Members of The Commerce Group, Inc. RECEIVED CLAIMS DEPT. 11 Gore Road,Webster,Massachusetts 01570 (508)949-1500 www.Commerceinsurance.com March 18, 2003 MAR 2 ,0 2003 BUILDING COMMISSIONER or Board of Health or BUILDING DEPT. INSPECTOR OF BUILDINGS Board of Selectmen TOWN/CITY HALL Town/City Hall NORTH ANDOVER MA 01845 RE: Our Insured: LOUIS J DETORA/CAROL A DETORA Property Address: 117 COTUI T STREET Policy#: MP6569 Date of Loss: 01/31/2003 (, File#: RM1277-KRP586 Claim has been made involving loss, damage, or destruction of the above captioned property which may exceed $1,000, 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. Please reference the above captioned insured, location, policy number, date of loss, and file number on any correspondence. VICKIE DEVISH Telephone: (508)949-5593 Claim Adjuster Toll Free: 1-800-221-1605,Ext: 5593 On this date,I cause copies of this notice to be sent to the persons indicated above, at the address above,by first class mail. March 18, 2003 (::Tree limb fell on the property. CcmmCrc Ccmpanies....COME GROW WITH us CIC 254 (Rev.4/95) MAIL 026