HomeMy WebLinkAboutMiscellaneous - 125 OLD VILLAGE LANE 4/30/2018 / 125 OLD VILLAGE LANE J 210/046.0-0090-0000.0 Date. : /Yl../..!....................... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION CHU This certifies has permission for gas installation ...... inthe buildings of(................................................................................................................... at./ -T.D(d r)34fe.. ................................ No thWndover, Mass. Fee�j............ Lic. No. .G.......... ... ................................. �- GASINSPECTOR Check# fs Date�*� ...... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that, .....................�" f.............................................. 'It shas permission to perform....6.1 ...................................................................... plumbingin th b *ldi gs of............................................................................................. at...«f.f> q. 3,&'14- ............ ...... Andover, Mass. Fee!�............. �.f�....... ......................... ............................. S.CV...L i c. ....................... P MBIN L INSPECTOR Check# MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY 1�C �v r� J MA. DATE Jt l 5 'I L+ PERMIT# JOBSITE ADDR S A6 1/ 4 I c, �G(�_ OWNER'S NAME 00q C fy 14A1d4 POWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE: COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL{j- C PEARLY RINT NEW:El RENOVATION.-❑ REPLACEMENT: ] PLANS SUBMITTED: YES El NO EJ FIXTURES Z FLOOR BSMT 1 2 1 3 1 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE f DEDICATED SPECIAL WASTE SYS DEDICATED GA S/OIUSAND SYS DEDICATED GREASE SYS DEDICATD GRAY WATER SYS DEDICATED WATER RECYCLE SYS DRINKING FOUNTAIN DISHWASHER FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL S RVICE/MOP SINK TOILET U INAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES i WATER PIPING OTHER INSURANCE COVERAGE: I have a current fi-abilitV insurance policy or its substantial equivalent which,meets the requirements of MGL Ch. 142. Yes YNo❑ IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY g' 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 General Laws,and that my signature on this permit application waives this requirement. CHECK ONE BOX ONLY: OWNER ❑ AGENT ❑ Signature of Owner or Owner's Agent 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 of the Massachusetts State Plumbing Code.and Cha r of the General Laws. PLUMBER NAME S'TEW6I.3 C_ GALIPSK+( SIGNATURE LIC# 10311S MP 2 JP❑ CORPORATION X# -319 fc PARTNERSHIP ❑# LLC ❑# COMPANYNAME 61U40SKY Pc.0M0jAjb *- HVWr11443 ADDRESS: P.O. GGX 1701 CITY f1iAVEfLk1LL STATE r ZIP 01'931 EMAIL Wyyw. ri)ryrAbef(9Q , Caw, TEL Ci"� -371- 17N 3 CELL 501a-_60q-5'9Q'4 FAX 97$'5';i-s113i 4 gar. ROUGH PLUMBING INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL fNSPECTIQbbNQTF.,q Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE; $ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY: 1Lq&t%+ MA. DATE: 2- _� 5 1� PERMIT# JOBSITE ADDRESS: l 6 6 (d Qj(1 4, ",e_ OWNER'S NAME: GOWNER ADDRESS: TEL: FAX: TYPE OR OCCUPANCY TYPE: COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL Iff PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENTS PLANS SUBMITTED: YES❑ NO❑ APPLIANCES? FLOOR Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCK MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACHEHEATER ROOF TOP UN TEST UNIT HEATER UNVENTED RWATER HEAT INSURANCE COVERAGE I have a current liabili insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO ❑ If you have checked YES,please indicate the type of coverage by checking the appropriate box below. LIABILITY INSURANCE POLICY [J' OTHER TYPE INDEMNITY ❑ BOND ❑ OWNER'S INSURANCE WAIVER:1 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 ❑ 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 accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will top in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ZVZL�_� - PLUMBER/GASFITTER NAME: STEPHEN C. G A ii r NS KY LICENSE# 10 a y rS SIGNATURE COMPANY NAME: &A L W s Kq PILOM AJ OC -t 14041-W&& ADDRESS: P.D- W X 1-701 CITY: OAVE—r.HiLL STATE: Yn-14• ZIP: OIS31 FAX: q79- 5a1-14131 TEL: q78-37q- 17143 CELL: moi - Ste- 590 EMAIL: WVV'W. M1''plpmbeff MASTER V JOURNEYMAN❑ LP INSTALLER❑ CORPORATION[r# ;3,c PARTNERSHIP❑# LLC❑# O ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL TNSPECTX0N NOTES Yes No 3h (mZY/ THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE; $ PERMIT# PLAN REVIEW NOTES Date....�..�..G.J.-.. ....... TOWN OF NORTH ANDOVER O 9 PERMIT FOR WIRING ,SS•�CMUS�t This certifies that ............. YA ............... .............................................has permission to perform ...... i.le..t....................................................................... O wiring in the building of....... .f flur.. .t)........................................................... at ....2..<......Ol j....V I...)fj..�.. .......1 AQ.IV ,North Andover,Mass. Fee...!� � ...........Lic.No�). ............f..^ . .. . /.. . ................................................. LECTRICAL INSPECTOR Check# `� 3 7 Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. Occupancy and Fee Checked 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: 16 City or Town of: NORTH ANDOVER 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) 1a; D�tX lh.\\„�e -0.A OwnerorTenant Toy[t- �,,, (�,g,4,, Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No [9, (Check Appropriate Box) Purpose of Building S;� \� �u,;\ Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No.of Meters New Service Amps ! Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: 1 Jif 1,k e d" o rXcl CO/ c,rv.c1LC Completion ofthefollowing 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 Above In- o.o mergency Lighting No.of Luminaires Swimming Pool rnd. ❑ rnd. ❑ Battery 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 Pum Number Tons W.. No:of Self-Contained 9 Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KWLocal❑ Municipal F1Other Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water , 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: "]Sy (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. d 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 cover a 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: �e �cc*J:G �vrC• LIC.NO.: Licensee: Qt`o,,� \,)c��t Signature _ �J LIC.NO.: (If applicable,enter"exempt"in the li ense number line. p Bus.Tel.No.•�( '7 13U Address: '� \ �,u\A &c a� ��� MA. ()l 35 Alt.Tel.No.: �i 1S?-37G-116a *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 a Owner/Agent Signature Telephone No. PERMIT FEE: $,ST t The Commonwealth of Massachusetts Pant Form 3 M Department of Industrial Accidents 19 - t" Office of Investigations -+ 1 Congress Street,Suite 100 Boston,AM 02114-2017 = www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/OrganizatioMndividual): yy Address: City/State/Zip: 010 35 Phone#:_ U�_ 51 I -"713o 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 employees(full and/or part-time). * have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- Iisted on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g. Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance co p,insurance.t 9. E] Building addition required.] 5. ( e are a corporation and its 10. Iectrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 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 13.❑ Other employees. [No workers' comp.insurance required.] *Any applicant that checks box 41 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: 0, Policy#or Self-ins.Lic.#: WE MAG AG 1 ft A _ ____ Expiration Date:_ Job Site Address: AZ o l A U kk oaa c t o exe City/State/Zip: U, Njr—Je, MA. O($k C 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$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 certify under lthe , in pas and penalties of perjury that the information provided above is true and correct. Si nature: . �✓ - - - - -. -- Date: -a-->1-1 Phone#: 11 E- SM-7i to 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#: fL DATE (MMIDD/YYYY) ACC>R"' CERTIFICATE OF LIABILITY INSURANCE 12/28/2015 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 policy(ies) 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 lieu of such endorsement(s). PRODUCER Phone: 978-688-4474 Fax: 978-327-6558 CONTACT NAME: DEGNAN INSURANCE AGENCY DEGNAN INSURANCE AGENCY PHONE FAX 85 SALEM STREET ac No Ezt: 978-688-4474 iaG.Nor 978-327-6558 E-MAIL naninsurance.comd cde nan e LAWRENCE MA 01843 ADDRESS: g � g INSURER(S)AFFORDING COVERAGE NAIC p INSURER :MOUNT VERNON FIRE INSURANCE COMPANY 26522 INSURED INSURER B VALLEY ELECTRIC INC. 21 HYATT AVENUE INSURERC HAVERHILL MA 01835 INSURER D: INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: 25830 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, TERM 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. INSRR TYPE OF INSURANCE INSR ADULSWVD POLICY NUMBERUBR POLICY EFF POLICY EXP LIMITS A GENERAL LIABILITY CIL 2651542A 11/14/15 11/14/16 EACH OCCURRENCE $ 1,000,000 COMMERCIAL GENERAL LIABILITY DAMAGES(RENTED 100,000 PREMISES(Ea oceurence) $ CLAIMS-MADE OCCUR MED.EXP(Any one person) $ 5,000 PERSONAL$ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 PGEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY P LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY Per accident $ AUTOS AUTOS ( ) HIRED AUTOS NON-OWNED PROPERTY DAMAGE UTOS (per accident) $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I RETENTION$ $ WORKERS COMPENSATION TORY LIMITS ER $ AND EMPLOYERS' LIABILITY WC STATU- OTH ANY PROPRIETOR/PARTNER/EXECUTWE YIN E.L.EACH ACCIDENT $ OFFICEMMEMBER EXCLUDED? N I p E.L.DISEASE-EA EMPLOYEE $ (Mandatory in NH) If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION Town of North Andover SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 120 Main Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN N.Andover,MA 01845 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Attention: �v Carla M. Degnan ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD � , J DATE (MMIDDNYYY) A�f' CERTIFICATE OF LIABILITY INSURANCE 12/28/2015 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 policy(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 lieu of such endorsement(s). PRODUCER Phone: 978-688-4474 Fax: 978-327-6558 CONTACT DEGNAN INSURANCE AGENCY DEGNAN INSURANCE AGENCY NAME: PHONE FAX 85 SALEM STREET we No Ext: 978-688-44741C.Not: 978-327-6558 E-MAIL naninsurance.comd cde nan e LAWRENCE MA 01843 ADDRESS: g � g INSURER(S)AFFORDING COVERAGE NAIC# INSURER :NORFOLK AND DEDHAM INSURED VALLEY ELECTRIC INC. INSURER 21 HYATTAVENUE INSURER HAVERHILL MA 01835 INSURER D: INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: 25829 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, TERM 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. INSIR LTR TYPE OF INSURANCE ADO ' SUBR wvD POLICY NUMBER POLICY EFF POLICY EXP LIMITS MM/DD MMIDD GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ PREMISES(Ea oocurence) CLAIMS-MADE I]OCCUR MED.EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ PRO- POLICY J C LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNEDAUTOSULED AUTOS BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE UTOS (per accident) $ $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I RETENTION$ $ WORKERS COMPENSATION WE132614A 11/13/15 11/13/16 WCSTATU- OTH A AND EMPLOYERS' LIABILITY TORY LIMITS ER $ ANY PROPRIETOR/PARTNERIEXECUTIVE YIN E.L.EACH ACCIDENT $ 500,000 OFFICERIMEMBER EXCLUDED? (Mandatory in NH) N/A E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,H more space is required) CERTIFICATE HOLDER CANCELLATION Town of North Andover SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 120 Main Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN N.Andover,MA 01845 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Attention: � / �� (�1C_ yzRlC Carla M.Degnan ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD v<.COMMONWllt OF MASSACHUSETTS • • - • • BGIARA lyF E,L,E CTR I CI ANS ISSUES THE ;FOLLOWING l>I CE*SE AS A ! REGISTERED MASTER ELECTRICIAN VAG:L 8 ELECTRIC... INC N BRIAN A WR(&LEY' , 21 HYATT.:<aE::. RRADFDRD ... .. MA 018 3 35-82.21 , .. , 20186',; 07/31/:<16 63131 ammmap....,F,.._� ,. . Cunningham Lindsey U.S.,Inc. OA 7rA P.O.Box 703689 C nnin am va Dallas, 75370-3689 Lindsey Telephonene(888)738-8714 Facsimile(214)488-6766 CLCAT n CL-NA.COM Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS Ch. 139, Sec 3B Building Commissioner or Inspector of Buildings 1600 Osgood St North Andover, MA 01845 Claim Number: 449151 Policy Number: 449151 32 Company Name: MERRIMACK MUTUAL FIRE INSURANCE CO Date of Loss: 02/15/2015 Insured: DONALD &JOYCE ANN CHAMPION Property Location: 125 OLD VILLAGE LN, NORTH ANDOVER, MA 01845 Claim has been made involving loss, damage, or destruction of the above captioned property, which may either exceed $1,000 or cause Massachusetts General Laws, Chapter 143, Section 6, to be applicable. If any notice under Massachusetts General Law, Chapter 139, Section 3B is appropriate, please direct it to the attention of the writer. Kindly include a reference to the captioned insured, location, date of loss and claim number. Section 3B. No insurer shall pay any claims (1) covering the loss, damage, or destructions to a building or other structure, amounting to the one thousand dollars or more, or (2) covering any loss, damage or destruction of any amount, which causes the condition of a building or other structure to render section six of chapter one hundred and forty-three applicable, without having at least ten days previously given written notice to the building commissioner or inspector of buildings appointed pursuant to the state building code, to the fire department or arson squad of the city or town and to the board of health or board of selectmen of the city or town in which the same is located. If at any time prior to the payment the said city or town notifies the insurer by certified mail of its intent to initiate proceedings designed to perfect a lien pursuant to section three A, or to section nine of chapter one hundred and forty-three, or section one hundred and twenty-seven B of chapter one hundred and eleven, the said payment shall not be made while the said proceedings are pending; provided, however, that said proceedings are initiated within thirty days of receipt of such notification. Any lien perfected pursuant to section three A, or to section nine of chapter one hundred and forty-three or section one hundred and twenty-seven B of chapter one hundred and eleven, i shall extend to and may be enforced by the city or town against any casualty insurance policy or policies covering any loss, damage, or destruction pursuant to which the proceedings to perfect the lien were initiated. No insurer shall be liable to any insured owner, mortgagee, assignee, city or town, or other interested party for amounts disbursed to a city or town under the provisions of this section, or for amounts not disbursed to a city or town under the provisions of this section. On this date, I caused copies of this Notice to be sent to the persons named above at the addresses indicated above by First Class Mail. Cunningham Lindsey Catastrophe Department cicat@cl-na.com 800-867-3885 FR. T I E 447 Boston Street,Suite 9 Topsfield,MA 01983 JUSTERS (978)887-8112 FAX(978)887-8113 Craig McDonald/Owner-Operator December 1, 2011 FHWEAITH �� 1 `� `1n11 O7 NORTH ANDOVERTown of North Andover DEPARTMENT Town Hall North Andover, MA 01845 Building Commissioner or Board of Health Inspector of Buildings Board of Selectmen Policy: HP0449151 Insured: Donald&Joyce Ann Champion Loss Location: 125-N6�hh'Village Lane Date of Loss: October 29, 2011 File No.: 168P-11-5872CM 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 CH. 143 Sec. 6 to be applicable. If any notice under Massachusetts General Laws CH. 139, Sec. 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 file number, � C ims Representative On this date, I caused copies of this notice to be sent to the persons named above at the addresses indicated above by first class mail. l � � 1' Date Main Office: 447 Boston Street, Suite 9;Topsfield,MA 01983 (978)887-8112 0(978) 887-8113 FAX Boston,MA • Boston/Lynn,MA Gloucester/Beverly,MA • Framingham,MA •New Bedford/Fall River,MA Providence,RI • Cranford,NJ • Toms River,NJ • Philadelphia/Bensalem,PA Shenandoah,PA • State College,PA • Williamsport,PA • Winston-Salem,NC