HomeMy WebLinkAboutMiscellaneous - 16 POOR STREET 4/30/2018 16 POOR STREET
210/052.0-0066-0000.0
Claims Processing - Arnica Scan Center Toll Free: 1-888-70-AMICA
PO Box 9690 (1-888-702-6422)
a Providence, RI 02940-9690 Fax: 1-988-999-5821
AUTO HOME LIFE
August 2, 2016
North Andover Town Hall - Building Inspector
120 Main St
North Andover, MA 01845
File Number: 60002543901
Date of Loss: 07/30/2016
Owner/ Insured: Nancy C. Campbell-Kollias
Street: 16 Poor Street
Town: North Andover
Type of Loss: Mold
To Whom This May Concern:
Please be advised that we insure the above named individual(s). A claim has been made
for Damage to Real Property and as the insurer, we are presently in the process of adjusting the
loss.
We are mandated to comply with Massachusetts General Laws, Chapter 139 and as such,
if there are any present liens on the above property, please notify us within 10 days of receipt of
this letter. If we do not hear from you, we will be under no obligation to pay you any portion
of this claim.
Sincerely,
(5�all Mem
Eric H. Meister CPCU, AIC
Claims Department
888-702-6422 x21105
EMEISTER@AMICA.COM
AMICA MUTUAL INSURANCE COMPANY AMICA LIFE INSURANCE COMPANY AMICA PROPERTY AND CASUALTY INSURANCE COMPANY
AMICA GENERAL AGENCY,LLC. AMICA GENERAL INSURANCE AGENCY LLC WEB SITE:WWW.AMICA.COM
Date.. . .
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N°RTH
TOWN OF NORTH ANDOVER
• - PERMIT FOR GAS INSTALLATION
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�,SSACNUSEt .
This certifies that . . . . . . . . . . . . . . . . . . .
has permission for gas installation . . . . . . . . . . . .
in the buildings of ". . . . . :h '?/. : . . . . . . . . . . . . . . . . . .
at North Andover, Mass.
Fee :�-. . . . Lic. No: 7: ��1/. . ; 1 ;c`.�r- ... . . . . . . . . . . .
(� GAS INSPECTOR
Check#
3 ; 50
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or Type)���c: ter , Mass. Date 20( Permit#Building Location OOH" Owners Namejq� / Type of Occupancy
New❑ Renovation❑ Replacement(/ Plans Submitted: Yes❑ No❑
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SUB-BSMT j
BASEMENT
IST FLOOR !
2ND FLOOR
3RD FLOOR
4TH FLOOR
STH FLOOR
6TH FLOOR
7TH FLOOR
8TH FLOOR j
Installing Company Name ([�r�� ll .p kyr i1N Check one. Certificate
Address �� �1 1�1'Ivy\ 1� ❑ Corporation.
s
Business
�� �?l � ❑ Partnership
Telephone �/ ct �'6
Name of Licensed Plumber or Cas Fitter (' F1rm/Co.
`(,�ars 'T�f.°�w+�'tSn
INSURANCE COVERAGE:
I have a curre liability 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.
t A liability insurance policy p( Other type of indemnity ❑ Bond ❑
OWNER'S INS URNACE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter
142 of the Mass.General Laws, and that my signature on s perm application waives this requirement
Check one:
Signature of Owner or Owner's Agent Owner ❑ 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 knovNedge and that all plumbing work and installations performed under the permit Issued for this application will be in compliance with
all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gen al aws.
Type of License:
By ❑Plumber a" re of Licensed Plumber or Cas Fitter
Tide ❑Gas fitter
Ciry/Town ❑Mister License Number d
APPROVED(OFFICE USE ONLY) Wourneyman
Y
FJ '� Date.....7.....c� �......
'N
3?�e ``°-:•�"�,� TOWN OF NORTH ANDOVER
A PERMIT FOR WIRING
,SSACHUS�
This certifies that ..... . . ... ......!,..�.�....;. ...... ..!I!G:ck?e; . ...��e
has permission to perform .... /.... ...
wiringin the building of.......................................................:.........................M
at..16........ . .. ,North Andover,Mass.
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Fee... .....-'.. . Lic.NoJ1.L).�/.e............
:.......................................:. ;
ELECTRICALINSPECTOR
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WHITE:Applicant CANARY: Building Dept. PINK:Treasurer GOLD: File
Office Use Only
01 4c LfammDitluralt1 of flaosa`. arflD Permit No.
13¢paTtment IIf Publ-tt 3afttg Occupancy& Fee Checked�J
BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 3/90 (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code, 527 CMR 12:00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date )— ;l S
(M1i or Town of NORTH ANDOVER To the Inspector of Wires:
The udersigned applies for a permit to-perform the electrical work described below.
Location (Street & Number) /�p U
Owner or Tenant /
Owner's Address 16 7P_cc.)r S j
Is this permit in conjunction with a building permit: Yes ❑ No ❑ (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service �O D Amps _J Volts Overhead ❑ Undgrnd ❑ No. of Meters
New Service Amps Volts Overhead ❑ Undgrnd ❑ No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work
f rmers Total
No. of Lighting Outlets No. of Hot Tubs No. of Trans o KVA
No. of Lighting Fixtures I Swimming Pool Above In-
No. grnd. ❑ grnd. ❑ I Generators KVA
No. of Emergency Lighting
No. of Receptacle Outlets No. of Oil Burners I Battery Units
No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones
Total No. of Detection and
No. of Air Cond.
No. of Ranges tons Initiating Devices
No of Heat Total Total
No. of Disposals Pumps Tons KW No. of Sounding Devices
No. of Self Contained
No. of Dishwashers I Space/Area Heating KW Detection/Sounding Devices
Municipal
No. of Dryers Heating Devices KW Local ❑ Connection []Other
No. of No. of Low Voltage
No. of Water Heaters KW I Signs Ballasts Wiring
No. Hydro Massage Tubs I No. of Motors Total HP
OTHER: if, /1 CAJ J C011 CIZ,17 1(rt c
INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts general Laws
I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent. YES -- NO = I
have submitted valid proof of same to the Office. YES = NO _. If you have checked YES, please indicate the type of coverage by
checking the apprgpriate box.
INSURANCE v� BOND OTHER :: (Please Specify)
(Expiration Date)
Estimated Value of Electrical Work S
Work to Start Inspection Date Requested: Rough Final
Signed under the Penalt'es of perjury: / / z
FIRM NAMEJ e1� � C�'�.7.e e1 ` r LIC. NO. � � j��
Licensee �` /�• �' Signature LIC. NO. 14
Address ' 1'4c V J/"1�} U Z a Alt. Tel. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its substantial equivalent as re-
quired by Massachusetts General Laws. and that my signature on this permit application waives this requirement. Owner Agent
(Please check one) /)
Telephone No. PERMIT FEE S V
(Signature of Owner or Agent) x-6565
