Loading...
HomeMy WebLinkAboutMiscellaneous - 160 COVENTRY LANE 4/30/2018 160 COVENTRY LANE 210/104.C-0124-0000.0 ' I I 4 Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS, Ch. 139, Sec. 3B To: Building Commissioner or Inspector of Buildings 1600 Osgood Street North Andover, MA 01845 RE: Insured: Amir& Mehr Tabassi Property Address: 160 Coventry Lane Policy Number: H017084964 Date/Cause of Loss: 2/18/2015, Water/Ice Dams File or Claim Number: 32352-R 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, CHAPTER 143, SECTION 6, to be applicable. If any notice under MASSACHUSETTS GENERAL 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 or file number. Ryan Werner On this date, I caused copies of this Notice to be se7/1, 77-7/)o d above p bo a at the addresses indicated above by First Class Mail. Signar and Date ANDERSON ADJUSTMENT CO., INC. 50 Nashua Road, Suite 303 PO Box 1098 Londonderry, NH 03053 Date...... .!7. 1....�V.................... �NORTh� TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION Bs�cHus� This certifies that .......1 R. ................... !........t.....:.................................................. f.has permission for gas stallation .`: ✓.?.JA:--,4.,................................... in the buildings of g at.....K00. .w�Q.�........:. ...l .tib.............................. North Andover, Mass. Fee. ........' ...... Lic. No.�........................ GAS INSPECTOR Check# iV of MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY MA DATE �- I PERMIT# i � ' �. JOBSITE ADDRESS OWNER'S NAME JTIj , GOWNER ADDRESS TELFAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL PST ® RESIDENTIAL CLEARLY NEW:01 RENOVATION:0 REPLACEMENT: PLANS SUBMITTED: YES F1 NO E] APPLIANCES 7 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER I _..E:j z:j I I_z:j _ . BOOSTER - - --- - - - -�. -- -_-- �. — = CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT [—V OVEN POOL HEATER ROOM/SPACE HEATER - _.. _ t. r ROOF TOP UNIT TEST UNIT HEATER I j UNVENTED ROOM HEATER r I WATER HEATER [�- OTHER INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL.Ch.142 YES 0,N0 D IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW " LIABILITY INSURANCE POLICIG� OTHER TYPE 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 ONLY: OWNER F 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 a 14X ur a to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in complia t Perti ent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. k PLUMBER-GASFITTER NAME 4& '� `� _j LICENSE# G TURE MPE—"GF[A JP® JGF Q LPGI El CORPORATION©#=PARTNERSHIP[j# LLC[]#r COMPANY NAME: _ ADDRESS ____o CITY o _ STATE MZIP TEL O FAX CELL &j---�_ j �EMAIL j ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES 41 CSP Z-►-� �� �� -P u�� cti vti,. -A Y ry , The Commonwealth of Massachusetts - Department of Industrigl AccMiks Office of.Investigations 600 Washington Street Boston,MA 02111 www.massgov/rlia Workers,Compensation Insurance Affidavit:Buifders/Conk°actors/ElectricianslPlumber$ AAlzeant 7n£ormati�on Please Print Le 'bl Name(Businessiorgaui-zati,),,&di idaal): Lkuz� .Address: o- City/State/Zip: (1 "Phone#: 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(fall and/or part tibae)* have hiredthe sub-contractors 2.KI am a sole proprietor or partner- listed on the attached sheet. `7• ❑Remodeling ship and'have no employees These sub-contractors have ElS. Demolition wanking forme in any capacity. workers'comp.insurance. 9• Building addition LNo workers' comp.insurance 5. ❑ We are a corpora]oa and its 10. Electrical repairs or additions required.] officers have exercised.their 3.E1 I am a homeowner doing all work right of exemption per MGL 1 Plumbing repairs or additions myself.[No workers'comp. c.152,§1(4•),and wehaveno 12 fl Roofrepairs insurancere pir .a�edemployees.[No workers'comp.insurance required.] 13F]Other MAny applicant that checks box#t must also fill outthe section below showingtheir workers'compensaflonpolicy information. t'Homeowners who sabmitthis affidavit indica&gthey ire doing allwork and then No outside contractors must submit anew affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name ofthe sub-contractors and their workers'comp.policy information. am an eraxployer that is providing workers'compensation insurance for my employees low is the policy and job site information. Insurance Company Name% Policy##or Self ins.Lic.ff. Expiration Date: lob Site Address; 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 requiredunder Section 25A ofMGL o.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 maybe.forwarded to the Office of Investigations of the AIA for insurance coverage verification. 160 liereby cert! lie ain penalties fperlury tliat the information provided aabove is tree d'correct. Si - _ Date: / stare• Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License 0 Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk d.Electrical Inspector 5.Plumbing Inspector 6.Other - - - Contact Person: Phone M Information and Instructions , Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuazii to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express ox implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,ox any two ox 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 apartments 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 deemed to be an employes." MGL chapter 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 chapterhave beenpresented to the contracting authority." Applicants Please fill.out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if n0cessary,supply sub-contractor(s)name(s),addresses)andphone 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 notrequired to cavy workers'compensation insurance. If an LLC or LLP does have employees,apolicy is required. De advised that tbis affidavit maybe submitted to the Department of Industrial Accidents for confirmation 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 andpriated 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 inthe pennit/license number whichwill be used as a reference number. In addition,an applicant thatmust submitmultiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(ifnecessary)and under"Job Site Address"the applicant shouldwrite"alllocations 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 asproof that a valid affidavit is on file for suture pemlits or licenses. Anew affidavit must be filled out each year.Where a homo owner or citizen is obtaining a license or p ermit not related to any business or commercial venture (i.e.a dog license orpermit to burn leaves ate.)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 Go wnweaTthofMassaclivsetE Depaftent~ofludwWaj AccidelIts offioe QUAVestigAtt ass. 60 Wasb-gw stxe-t Bosun}MA 02111 td,#617-7.2-7,49OQ OA 406 ox-1-877,M Revised 5-26-05 FU 0 617"727-7749 WWW.Musi,go-VAa :>COMMONWE `LTH OF M SS USETT.S::;:;: ' • , • °< ISS �ASFITTERS;;;.:;> I UES TH`: F0LLOWIr j NG L1.:1rEfdSE . I LIC 1+15E.. AS A MASTER MARTLN F CALLA HAN JR 931 H IG >> HLA:ND' 17.46-168.7> , 222987 >««COMMONWEALTH OF M;.'SSAC7=IUSETTS. ' • • - • • L01:4 0 Rill ol LUMBERS 4'RESF ITTERS,,;' ISSUES THE FOLLOW1tdG,..;L.1.1;ENSE L I C.EX EVAS.; A JOURNEYMAN :PL-UMBEL# ' .0 � t CS - 2 MART,I:N F CALLAHAN "''`JR. rt W' v- UJ 931 H IH`LAIH"STlu `. lCfla>L>I`S7 N 0Ao1746 16 : 88 3 .1 i 7 Date..�'.. :.).. . .. .`..... r F NORTI{ TOWN OF NORTH ANDOVER A tipL ry o PERMIT FOR GAS INSTALLATION i • gj 7SgACMUSEt This certifies that . . ?. .. . . . ... ... . . .. . .`. . . . . . has permission for gas installation . . 1.. . . `. . . . . . . . . . . . . . . . .� in the buildings of . '. . .... . . . . . . . . . . . . . . . . . . . . . . . at .: . . . . . . . . . . . . . . . :: . . . . . . . .. North Andover, Mass. Fee. . �. ?:. Lic. No.. . . . . . . . ... . . . . . . GAS INSPECTOR WHITE:Applicant CANARY:Building Dept. PINK:Treasurer r' MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING Z. j (Print or Type) o, 3 19 51 Permit # ` 7 Mass. Date � -�'�`— Building locationL-44," ,wner's Name 4� �����✓ Type of Occupancy �� New p Renovation ❑ Replaceme� Plans Submitted: Yes❑ No ❑ H W N P Y Z. it Vl N N U ¢ f. W JN W 0 V m H ` S Vf R fC Z O W g< < Z O O ~ Q W f.. . �� < m of I- ►r W O d c o < W Z V W W < ¢ O I ,I W W frf J < M Q O cc W W W #A - J �� Z < W < C r v1 m• Z O W O t~A = < W > Z W O Z < Q < < O O W O •1 P J V C > p d I^ O SUB—BSMT. BASEMENT t 1ST FLOOR 2NDFLOOR 3ROFLOOR I 4TH FLOOR STH FLOOR 6TH FLOOR 7TH FLOOR 8TH FLOOR Li Installing Company Name Check one: Certificate Address ❑ Corporation ❑ . Partnership Business Telephone lO nn ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter J� INSURANCE COVERAGE: I have a current I' 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 coverage by checking the appropriate box. A liability insurance policy Other type of indemnity O Bond ❑ OWNER'S INSURANCE 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 this permit application waives this requirement. Check one: Owner❑ Agent ❑ Signature of Owner or Owner's 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 and installations performed under the permit issued or this application il,,l be in compliance with all pertinent provisions of the Massachusetts Slate Gas Code and Chapter 142 of the Gene . BY T cense: r Sigifature of Ucen I ber or GasFit—ter Title Purneyman r Ucense Number City/Town APPROVED( IC US .ONL # 4— `A O A BELOW FOR OMCE USE ONLY ` 1 MAL INSPECTION SKETCHES PROOREu ulsmcTIOM N _ s 1 FEE- ; r APPLICATION FOR PERMIT TO 00 GASf1TT1144 N D 3 'NAME S TYPE OF RU1L0►NC! LOCATION OF BUTUDINh ' PLUMBER OR GASFITTER uC.NO. PERMIT GRAlITE9 DATE 19 GAi 114SPECTOII r