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HomeMy WebLinkAboutMiscellaneous - 200 BRENTWOOD CIRCLE 4/30/2018'7 10322 Date./P`*`/*`*` .3...... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ... 144% 0 ... VIA;� ........... .................... has permission to perform..... �,e .. . ................................ plumbing in the buildings of ............................................................................... at.,? n.. .... ......................... North Andover, Mass. Feel� Lie. No. Check #15%15 CHECK ONE ONLY: OWNER',,_ = AGENT '— SIGNATURE OF OWNER OR AGENT I hernuy 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 l and th& all plumbing work and installations performed under the permit issued for W!s application will be in compliance with all Pertinent provision of t`ie Massachusetts State Plumbing Code and Chapter 142 of the General Laws. LAS i PLUMBER-GASFITTER NAME �� In.w14? � LICENSE # J3 jSry SIGNATURE � MPV ;IGF JP ; JGF LPGI CORPORATION /# 3d(� E PARTNERSHIP .s# LLC COMPANY NAME jYJ I� .�A1ti��p.. �.✓�� .......ADDRESS' CITY /►'Lic�lt- STATE,..ZIP 01v4'TELT-66.?!5 FAX CELL EMAI L Wor-keirs' C Naline (BusinesslOrganization/Individual): Address - The. Coinmonlwea'fth, of All'oSsachuseff.`s Department oflndustriat Accidents Office of lnvestitgatiolIS 600 F`fashington ,Yfreet Boston, JvL4 02.11.1 ivlwiv. rno..ss.gov ldia Insurance Afffid2vitte �uA�l �l�';A'�1�®AA�>r��t���/lE➢c���A n�u�IIA�IL� E>ilAmll��m� CC/ Are t an employer? Check the appropriate box: 1. I afn a employer with -3 4. ❑ I am a general contractor and I employees (full and/or part-time). " have lured the sub -contractors 2. [J I am a sole proprietor or partner listed on the attached sheet. s1lip and have no employees working for me in any -capacity. [No worlters' coanpo insurance required.]. 3. ❑ I am a homeowner doing all work myself. [No workers' compo insurance required.) or I have hired the contractor: listed on the attached slaect These sub -contractor. have employees and have,* workers` compo insurance. t 5. We are a corporation and its officers have exercised theix fight of exemption per MGL c. 152, § 1(4), and we have no employees, [1,Io workers' compo instarance re tq aired.), Type of project (required): 6, lew construction 7. [1 Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or .additionts 11.[_J Plumbing repairs or additions 12.0 Roofrepairs 13.F]Other. Any ap, slieant that checks box Nl must also fill out the section below showing their worker„' compensation policy information, t Homeowners who submit this affidavit indicating they are doing all work and [hen hire outside contractors must submit a new affidavit indicating such. icontractoi's 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' compo policy number. Y ant raga. eutplbyer that is providing workers' compenscatdon ifesuraance for my emplayees. Below is the policy andjob site informatdefa. . Insurance,company Name: Policy 4 Or Self -ins, Lie: Expiration Date, Sob SiteAddress: �o^��� �,.. _r ._.____._city/Statelzip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure ;overage as required under Section 2.5A of MGL e. 152 can lead to the imposition of ciimival 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 WOPK ORDER and a fine of up to $250.00 a day against.the violator. Be advis,d that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance covera>;e verification. I do hereby cer4,tY under the pains and penalties of perjury that the information i)rovided above is true and correct. 3ignatrfre: /3 Date: ��iPi � �(f� -2613 !'hone: fv_IF) O -3 Division of Professional Licensure: License Search The Official Website of the Office of Consumer Affairs and Business Regulation (OCABR) Division -of P-rofessional-L-icensure.) Mass.Gov Mass.Gov Home State Agencies A -Z Topics ONLINE SERVICES Check a License Locate a Licensed Professional Online Address Change Contact the Agency More... I �/���� ^•,•1•i:i�L'lY I.P.J pL 1CC 1.t1IIGL 11VlV Disclaimer Regarding Website License Searches Enforcement Process Glossary Glossary of License Status Codes W17A-3 � More... Page 1 of 1 Home ) Division of Professional Licensure> .............. ............ .... ................... .......-- Check A Professional License By the Division of Professional Licensure 1 t NEW SEARCH .--- - - - - ---- -- - - - - -- - -- - LICENSING BOARD TYPE LIC. # LICENSEE'S NAME CITY/STATE STATUS Sheet Metal Workers Master/ unrestricted ' 13848 ` MARK B MAGNIFICO MIDDLETON, MA Current Plumbers Et Gasfitters Journeyman Plumber 25002 MARK B MAGNIFICO I MIDDLETON, MA Current t - - ergs as Truer MasterPlumbe _ 5� ttt • •__.- B 1u NfF#C i-O�M1— DDt TON FY�it t Plumbers Et Gasfitters _ Plumbing Corporation 3266 �MARRKK=MAGNIFICO MIDDLETON, MA Current Plumbers Et Gasfitters Apprentice Plumber 20301 MARK B MAGNIFICO MIDDLETON, MA Expired The page above has been generated by the Division of Professional Licensure web server on Thursday, September 12, 2013 at 8:59:28 AM. © 2007-2011 Commonwealth of Massachusetts Site Policies Contact Us httv:Hlicense.rea.state.ma.us/t)ublic/i)ubILicsn.ast)?board code=PL&tvne class= M&license numbet 000013559&.cnlor=rerl s1 DEC -13-13 10:43AM FROM -E-A STEVENS CO 1781-397-7672 T-704 P.002/002 F-725 CERTIFICATE OF LIABILITY INSURANCE I 12/12/20131 THIS CERTIFICATE 13 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($), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the Certificate holder Is an ADDITIONAL INSURED, the palicy(las) 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 endomement(s . PRODUCER EA Stevens Company, Inc. 389 Main St. P. 0. Box 188 Malden MA 02148 CONTACT NAME: Bernadette M_ Dava't3, CPCU PHONE (9$1) 322--2324 FAX , (791) 397-7672 EMAIL .bernadetted0eastevensiAl3.Com INSURER(S) AFFORDING COVERAGE NAIC e INSURERA:Hartford Fire Insurance Company 9682 INSURED Magnifico Brothers Plumbing Heating & Ga-& Fitting LLC 31 Forest Street M!Lddlet:011 MA 01949 INSURERe:92fG 7Z* 39454 INSURERC:Twin City Fire 29459 INSURER D: INSURER E: INSURER F: COVERAGES r`FRTICIr:ATr- M1 1MRFq•Maatar 2013-•2014 omsratner wIRRot:D. THIS IS TO CERTIFY THA7 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. (LTR TYPE OF INSURANCE POLICY NUMBER RMIID011JCY EFF PMIDDI EXP LIMITS A GENERALUAB{LITY X COMMERCIAL GENERAL LIABIUTY CLAIMS -MADE XM OCCUR BSBAUQ5370 /24/2013 /24/2014 EACH OCCURRENCE $ 11000,000 a 0aeu CO)S 300,000 MED Exp one n s 10,000 PERSONAL 5 ADV INJURY S 1,000,000 GENERAL AGGREGATE $ 210001000 GEN'LAGGREGAWL[MrrAPPLIES PER: X POLICY 71PRO. LOC PRODUCTS-COMPIOPAGG $ 2,D001000 $ B AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS X SCHEDULED053635 — AUTOS NON -OWNED X HIREDAUTOS X /24/2013 /24/2D14 COM,BIM SINGLE LIMIT(Fa 1 OO D 000 BODILY INJURY (Per person) E BODILY INJURY (PeraccldeM) $ (Par PROPS DAMA E $ a A X UMBRELLA LIARoccUR EXCESS LIAR CLAIMS -MADE BSSAtIQ5370 /24/2013 /24/20i4 EACH OCCURRENCE $ 1,000,000 AGGREGATE S 1,000,000 DED =PETE 10,00 S C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANWTO"ARTNERIEXECLMvE YIN 1'IPRO OFMOCRMMEMSEREXCLUDED7 1:1 (Mandatary In NN) If yes. de541bcundar DESCRIPTION OF OPERA710NS balaw NIA 89M=9050 /24/2013 /24/2014 X WC STATU-0TH- E.LEACHACCIDENT $ 500 000 E.L. DISEASE - EA EMPLOYE $ 500 000 E.L. DISEASE - POLICY LIMIT 1 S 500 1 000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Addllleaef Remarks Schadulq R mart space Is required) a.u�. Irn.ia c tIVLUCIC GANCEL,LATION (978) 465-3064 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES Be CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Newbury ACCORDANCE WITH THE POLICY PROVISIONS, 25 High Road Ne -bury, MA 019551 AUTNOROEDREPRE$ENTATIVE (Thomas Carea, Tr/WV a � III ACORD 25 (2010105) C 1988-2010 ACORD CORPORATION. All rights reserved. IN5025(2D1p051.01 The ACORD name and logo are registered marks of ACORD Oh12v0s0b3T Advantage Claim Services 2100 Lakeview Ave. Dracut, MA 01826 Form of Notice of Casualty Loss to Building Under Mass. Gen. Laws, Ch. 139, Sec. 3B To: Building Commissioner or Inspector of Buildings Town Hall address No. Andover, MA 01845 Re: Insured: Santo Cataudella Property address: 200 Brentwood Circle No. Andover, MA 01845 Policy #: HP2289919 Loss of: 03/01/05 File or Claim No. AD 7318 Board of Health or Board of Selectmen Town Hall No. Andover, MA 01845 Claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or cause Mass. _Gen._Laws,_Chapter_143,_Section_6 to be applicable. If any notice under Mass_ Gen_ 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 or file number. Mark Frechette Title: Adjuster On this date, I caused copies of this notice to be sent to the persons named at the addresses indicated above by first class mail. Signature and date )h12v0s0b3T Advantage Claim Services 2100 Lakeview Ave. Dracut, MA 01826 Form of Notice of Casualty Loss to Building Under Mass. Gen. Laws, Ch. 139, Sec. 3B To: Building Commissioner or Inspector of Buildings Town Hall address No. Andover, MA 01845 Re: Insured: Santo Cataudella Property address: 200 Brentwood Circle No. Andover, MA 01845 ,Policy #: , HP2289919 Loss of: 03/01/05 File or Claim No. AD 7318 Board of Health or Board of Selectmen Town Hall No. Andover, MA 01845 Claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or cause Mass.Gen.-Laws,-Chapter-143,-Section-6 to be applicable. If any notice under Mass Gen 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 or file number. Mark Frechette Title: Adjuster On this date, I caused copies of this notice to be sent to the persons named at the addresses indicated above by first class mail. Signature and date )I C) �)D C-) a j MIN cvt 4 ta w.. q49 i+