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Home My WebLink AboutMiscellaneous - 158 BEAR HILL ROAD 4/30/2018 158 BEAR HILL ROAD f 210/064.0.0090-0000.0 r Location /J U m&55iO/' '11"11411 //41 No. — Date • ' TOWN OF NORTH ANDOVER e Certificate of Occupancy $ Building/Frame Permit Fee Foundation Permit Fee $ �' z i:►zX�`l, Other Permit Fee $ TOTAL $ Check# 25818 Building Inspector TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: 7 �` z? l� - Date Received Date Issued: 1671� /2 ORTANT:Applicant must complete all items on this page LOCATION 5 ecu- H-1l Print PROPERTY OWNER 5a/lfc 2., r'1 O ,e &/A Print MAP NO:0D&4_PARCEL:0-09aONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building One family ❑Addition ❑Two or more family ❑ Industrial 0 Alteration No. of units: 0 Commercial 0 Repair, replacement ❑Assessory Bldg ❑ Others: 0 Demolition 0 Other I� Se tic f0 W le 1 I�Flood lain p }_ ' ' Watershe{d District Wetlands W Water/Sewer t w DESCRIPTION OF WORK TO BE PERFORMED: S Identification Please Type or Print Clearly) OWNER: Name: 50./1.s CQ- YY\.0.29el Z-^ Phone: r-766-/&T Address: 6F 8 ea, /�� 12d, CONTRACTOR Name: Geoffou)%S af,ST. Z'n.c. Phone: ZI$ y06 Address: mac/e. "a c 4 AN Supervisor's Construction License: Jr �y9d' Exp. Date: / D— al-13 s Home Improvement License: /1 r7 e7 o Exp. Date: /V/a%A ARCHITECT/ENGINEER Phone: Address. Reg. No. FEE SCHEDULE:BULDING PERMIT:$92.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED ON$925.00 PER S.F. Total Project Cost: $ l�� 93D, Oo FEE: $ �� Check No.: y S Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signatureofi4gent/Ownerx` r `4 _� :' Signature of,contractor .:.: ,_ Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo CopY of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations ns (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Yn all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc: Doc.Building Permit Revised 2008mi Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ 4 TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Swimming Pools A . ❑ Tanning/MassageBody Art ❑ _. _ , , , , Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on Signature f COMMENTS HEALTH Reviewed on Signature COMMENTS ZoningBoard of Appeals: Variance Petition No: Zoning Decision/receipt t submitted yes Pp � 9 p Planning Board Decision: Comments i Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— For department use i El ' I i Notified for pickup - Date Doc:.Building Permit Revised 2008 NORTFI own o 2 ndover - Yto No. 019 �QA No ver, , '4e- Cot«.c„ew.ca U BOARD OF HEALTH a� Food/Kitchen PERMIT T D v Septic System o �0 Q /��, BUILDING INSPECTOR 0 THISCERTIFIES THAT ...... �G�............. :....... .. �1.. .<.......................................................................... A Foundation has permission to erect .......................... buildings on ..1,��. .�f�..f.:l ...�).��.�........................ Rough to be occupied as /� ............................./..../its ��.��Q�............................................................. Chimney provided that the person accepting this perall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and Construction of Buildings in the Town of North Andover. _ PLUMBING INSPECTOR I VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final I PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION STARTS Rough .......... Service ........... ��ry ��j —.................... �”" ' Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. SEE REVERSE SIDE C The Commonwealth of Massachusetts f Department of Industrial Accidents Office of Investigations �l 600 Washington Street w Boston,MA 02111 www.mass.g ov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lel:ibly Name (Business/Organization/Individual): &eo J --c, C-011:5 -T7 Address: 91 4 "Ad City/State/Zip: �l`G[G�c7, �/!�. Phone#: 41� e$kC Sa Are you an employer?Check the appropriate box: Type of project(required): 1.[Q I am a employer with /0 4. ❑ I am a general contractor and I 6. ❑Newconstruction employees(full and/or part-time).* have hired the sub-contractors 2.EJI am a sole proprietor or partner- listed on the attached sheet. ❑ 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 10.0 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' 131-1 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 andjob site information. / Insurance Company Name: Policy#or Self-ins. Lic.#: t-✓C 06 `7 Ll 91f3 Expiration Date: Job Site Address: �� !� � /Gv' 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$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 nder the pains and penalties ofpetjury that the information provided above is true and correct. Si nature: Date: Phone#: ��lj �"L/06 c� 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#: i r f Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three aparhnents and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or-on the grounds or building appurtenant thereto shall not because of such,employment be'deeined to be an employer." MGL chaptef 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s) of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confinnation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be.sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the pen-nit/license number which Will be used as a reference number. In addition,an applicant that must submit multiple pen-nit/license applications in any given year,need only submit'one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future pen-nits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or pen-nit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not,hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 5-26-05 www.mass.gov/dia Q. C"(1iN4'�'i)TT�'+'!�'TfIXT "J10" � '�ct7i3't✓Y.si.=s i\it iji-g.��c3._."a�'a. �.ii r:�i�+mr✓'l.:i 96 Arlington Ave. Dracut,MA 01826 ` Al Greene-Estimator 1-978-453-4242 Office 1-978-888-1700 Cell georgoul is 141 @aol.com PROPOSAL I Janice Moegelin 09/27/12 158 Bear Hill Rd. N. Andover,MA 1-978-766-1869 rascaljm@aol.com Job Location: 158 Bear Hill Rd.N.Andover,NU Scope of Work: Remove all layers of roofing down to wood deck on all roofs of the house. Install 6'of GAF Weatherwatch ice/water shield underlayment on all roof eaves,around chimney,in all valleys,and up rakes at all roof to wall locations. Install GAF Shinglemate felt paper over remaining exposed roof deck. Install new 8"heavy duty aluminum drip edge on all roof perimeters,leave hicks vents in place. Install GAF Timberline HD Lifetime Architectural shingles with Timbertex caps on roof. Install new stack pipe boot on plumbing pipe. Install new Coravent V-400 ridgevent on main ridges. Install new lead flashing around existing chimney. Remove all job related debris from property on a daily basis and at jobs completion. $55.00 Per Sheet Extra Cost to replace any damaged plywood decking(if needed). $7.00 Per Lineal Foot Extra Cost to replace any damaged facial,rake,or shadow trim boards(if needed). Entire job includes GAF Systems Plus Warranty. First 50 Yrs.Is non-prorated,full labor and ' material coverage from GAF,against any material defect cause. `-'7P nn0nOGE hereby to furnish material and labor complete in accordance with above specifications, for the sum of. Nt.P�:a �4130.00 C14 @ QS22 t0 a a 8 � � Twelve Thousand Nine Hundred Thirty Dollars $12,930.00 PAYAPIT To RF N4A,T)F AS F01 T.r)tixrc- 54.930.00 PAID IN ADVANCE FOR MATERIAL COST.$8.000.00 PAID IN FULL WHEN JOB IS COMPLETELY FINISHED ACCORDING TO THE ABOVE LISTED PROPOSAL. All material is guaranteed to be as specified.All work to be completed in a substantial workman like manner according Com. to specifications submitted per standard practices.Any alteration or deviation from above specifications involving extra costs will be executed only upon written orders,and will become an extra charge over and above the estimate. All agreements contingent upon strikes,accidents or delays beyond our control.Owner to carry fire,tomado and other necessary insurance.Our workers are fully covered by workers compensation insura qce. Georgoulis Authorized Signature rr This proposal may be withdrawn by us if not accepted within 30 days. A,^Tcr !Pc-^f f)—r_zal-The above prices,specifications are satisfactory and are hereby accepted You are authorized to do the work as specified. Payment will be made as outlined above. Sig tore Signature Date of acceptance to Ub 2 The following is part of this contract: Contractor Registration All home improvement contractors must be registered with the Commonwealth of Massachusetts. Contractor Registration#117870 and Construction Supervisor License#058498.Inquires about registration should be made to: Director, Home Improvement Contractor Registration,One Ashburton Place,Room 1301,Boston,MA 02108(617)727-8598.Better Business Bureau,Inc. Georgoulis Construction,Inc. member ID#35522. Contact the Better Business Bureau (508)652-4888 or at memberservicesgbosbbb.org. General All outside work areas will be left rake clean.Roofing may result in dust or debris falling into the attic. This contract does not include clean up or protection of the contents in the attic.In the event a satellite dish should have to be removed to complete project, Georgoulis Construction,Inc.will not be responsible for repositioning after re-installation, should it be necessary. Payments The maximum down payment or advanced deposit allowed by Massachusetts law is limited to whichever is larger: (A)One third of the total contract or(B)the entire cost of any special order materials. Final payment is not required until the date of completion of the project.Payment must be made within seven days from completion date.All Credit Card Sales over$1,000.00 are Subject to a 2.0%Convenience Fee. Work Schedule The owner agrees the scheduling date is approximate.The contractor agrees to show good faith in meeting deadlines but are not responsible for delays caused by weather. Suppliers,subcontractors, building officials.asbestos abatement,hidden damages or conditions,accidents,acts of God or anything beyond our control. Change Orders The owner is aware that the work may contain hidden damage,defects,or conditions such as decay, insect damage,or substandard construction practices,that may require additional work not included in this contract.In this case, Georgoulis Construction,Inc.will contact the owner and agree on an additional charge to the original contract price.In the event the owner can not be contacted,and it is crucial that work continue to protect the residence from the elements,(rain, snow, ect.)photographs will be taken to document the necessity of the additional work.The owner understands that any additional work will delay the completion of the project. Warranly The contractor, Georgoulis Construction,Inc.agrees to correct any work that fails to conform with the contract or workmanship that is defective within Five(5)years from the substantial completion date of f the project at NO CHARGE to the homeowner.The homeowner agrees to notify Georgoulis Construction,Inc. specifying the nature of any workmanship defect, immediately.No warranty is provided for ordinary wear and tear,fading,abuse,neglect or casualty,or minor cracking/shrinking of concrete or caulking.No warranty is provided for materials not directly supplied by Georgoulis Construction,Inc. or for used,re-installed materials,(including skylights not installed by Georgoulis Construction Inc)or work done by others. This warranty excluded consequential and incidental damages. Contract Acceptance Upon acceptance of the authorized parties at Georgoulis Construction,Inc.this contract and all work described herein will constitute the entire agreement between Georgoulis Construction,Inc. and the Homeowner. ACCPRv CERTIFICATE OF LIABILITY INSURANCE "� " 10/0512012 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 po6cy(ies) must be endorsed. N SUBROGATION IS WAIVED, subject to the terns 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)263-3500 Fax:(978)2631438 coNTAcT Gallant Insurance Agency,Inc. GALLANT INSURANCE AGENCY,INC. �L et): 978 263-3500 No; (978)263-1438 199 GREAT ROAD/P O BOX 975 E-AIIA& ACTON MA 01720 ADDRESS` PRODUCER 36702 cusroMER ID: INSURER(S)AFFORDING COVERAGE NAIC# INSURED GEORGOULIS CONSTRUCTION INC. irlsuRERA :Seneca Specialty Ins Co C/O SCOTT GEORGOULIS INSURER :Chartis Insurance Company 96 ARLINGTON AVENUE INSURER DRACUT MA 01826 INSURER D: INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: 31434 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, ITR TYPE OF INSURANCE SSR s,� POLICY NUMBER �-1G4� Poucr ExP LIMns A GENERAL LIABILITY BAG4001034 03/05/12 03/05/13 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Ea oaaee as $ 100,000 CLAIMS-MADE I X I OCCUR MED.EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GE N'L AGGREGATE LIMn APPLIES PER PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY 0 PRO LOCAFrT $ AUTOMOBILE UAEI.ITY COMBINED SINGLE LIMIT (Ea accident) $ ANY AUTO ALL OWNED AUTOS BODILY INJURY(Per person) $ BODILY INJURY(Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE HIRED AUTOS (Per accident) $ NON-OWNED AUTOS $ $ IsUMBRELLA UAB OCCUR EACH OCCURRENCE EXCESS UAB HCLAIMS-MADE AGGREGATE $ — DEDUCTIBLE RETENTION $ $ WC009774283 09/25/12 09/25/13 T�nA 0TH PR $ WORKMIS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPMETORPARnERIEXEcurne E.L.EACH ACCIDENT $ 100,000 OFFIC�1®EN EXCLUDED? El N/A ((Ms,M�ry In f" E.L DISEASE-EA EMPLOYEE $ 100,000 ff yes,DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(Attach ACORD 101,Additional Ran ft Schedule,N 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 North Andover,MA ACCORDANCE WITH THE POLICY PROVISIONS. AUniORIZED REPRESENTATIVE Attention: Fax 978-458-9997 Ray Gallant ACORD 25(2009109) 01988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Office of Consumer Affairs andusiness Reguiafiion 10 Park Plaza- Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration - Registration: 117870 Type: Private Corporation = - Expiration: 12/12/2012 Tr# 206063 GEORGOULIS CONSTRUCTION, SNC;;= = SCOTT GEORGOULIS - 96 ARLINGTON AVE DRACUT, MA 01826 Update Address and return card.Mark reason for change. . DPS-CAS si SON-04/04-G101216 FlAddress ❑ Renewal 71 Employment [] Lost Card --° �L, Office of Consumer Affairs siness ega aUoa License or registration valid for individul use only .,-- HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: w Registration: ,;117870 Type: Office of Consumer Affairs and Business Regulation EER � Expiration: 12/12/2012 Private Corporation 10 Park Plaza-Suite 8170 Boston,MA 02116 GEORGOULIS CONSTRUCTION,INC. 1 SCOTT GEORGOULIS 96 ARLINGTON AVE N DRACUT,MA 01826 `s UndersecretaryNotveli without sig re Dvpartmcnt of Puhiir tiatct: 4 Board of Buildim-, Re,-ulationN jtntl `+t.iettfarti> 1-onst:ruction Supervisor License License: CS 58498 SCOTT C GEORGOULIS 96 ARLINGTON AVE DRACUT, MA 01826 Expiration: 10/21/2013 {•minii..i,;ncr Tr=: 4384 4� Michael Winston & Associates, LLC Innovative Risk Specialists ®i'%, POB 10721 Bedford,New Hampshire 03110 Tel: 603-494-2366 - Fax: 603-889-0241 - E-mail: michaelwinston@comeast.net March 24, 2011 rVrg -- Building Commissioner/Building Inspector Board of Selectman/Board of Health 400 Osgood Street APR '12 Z011 North Andover, MA 01845 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT RE: Charles&Janice Moegelin 158 Bear Hill Road North Andover, MA 01845 Type of Loss: Ice Dam/Water Date of Loss: February 4, 2011 Policy: HO17023449 Claim number: HC172267 Our File#: MW1 I-161 Location of Loss: Same To whom it may concern: The above captioned clam has been made involving damages or destruction of property which may exceed $1,000.00 or cause Massachusetts General Laws, Chapter 143,Section 6 to be applicable. If any notice under Massachusetts General Laws, Chapter 139B is appropriate, please direct it to the attention of the undersigned and include a reference to the captioned insured, location, policy number, date of loss, cause of loss and claim or file number. On this date, I caused copies of this notice to be sent to the persons named above at the addresses indicated above via first class mail. Sincerely, Michael Winston Adjuster