HomeMy WebLinkAboutMiscellaneous - 21 PEMBROOK ROAD 4/30/2018BUTTERWORTH & O'TOOLE, INC.
ADJUSTERS/APPRAISERS
FOR INSURANCE COMPANIES ONLY
P.O. BOX 8294
SALEM, MA 01971-8294
TEL. (978) 741-5731
FAX (978) 740-9109
claimsgbutterworthotoole.com
09/11/2014
FORM OF NOTICE OF CASUALTY LOSS TO BUILDING
UNDER MASS. GEN. LAWS, CH. 139, SEC. 3B
TO: Building Commissioner or Board of Health or
Inspector of Buildings Board of Selectmen
City/Town Hall
ADDRESSES
North Andover, MA 01845
RE: Insured: Richard Redman
Address: 21 Pembroke Road
Policy No.:
Loss of:
City/Town Hall
North Andover, MA 01845
North Andover, MA 01845
3061670
09/06/2014 Wind
File or Claim No.: 041-1026
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.
If no reply is received from your office within ten days, we will assume
you have no liens of any type against this property and we will recommend to the
insuring company that this claim is paid.
Brad Doherty
Adjuster
Member of
`� National Association of Independent Insurance Adjusters
i
a
u
C
u
c
f
M C
N N L
z z c
0 O t
G
W W
N N L
w > > L
p 0 0 i
in J J
F LL LL �
0 N L
m w w
w l7 [7 L
in a a i
F
o
z
wa
O
t7
w
LAI
Q
0
a
a
rn
iK
0
a
S
-,
m
Y
�
0
W
M
m
z
W
Z
b�
z
LL
0
z
m
p
x
LL
f.
O
z
W
Q
O
Q
7
Q
<
a
O
z
w
c
z
m
N
z
--
Ln
IL
W��
NS
0
LL
y
C\
N
d
m
LL
Z
W
w
w
m
m
u
m
LU
Z
m°
0
It
i
N
o
O
ft
w
\
D
W
Z
Z
ILL
O
oIn
Q
i
0
Q
O
J
z
J
H
2
a
m
m
to
O
O
U.
F
0
0
0
u
O
0
W
W
Ln
Z
Z
a
L,
w
LL
0
d
6d
IL
Ir
O
w
N
N
Z
6
®
N
a
z
m
N
N
U J
J
J
V
d
m
z
m
O
F:
t=
�
m
F-
M
aj w
w w
N
(aa
ad
LU
CL
w
O
aL
Z
_O
L
O
Z
V
F-
l0
�
0
b
z
a1
0
m
U)
W
i
w
Z
w
i
E
O
a
Z ao
Z
Q
m
z
O
O N
N
F
WK
N
Z
w
Z
a w
w~
a
u
d
IL
u z
z
J
Q
OO
O
rp F
M
NNJ
a
m
r:
i
a
u
C
u
c
f
M C
N N L
z z c
0 O t
G
W W
N N L
w > > L
p 0 0 i
in J J
F LL LL �
0 N L
m w w
w l7 [7 L
in a a i
F
o
z
wa
O
LAI
Q
0
a
rn
iK
0
S
m
a
I
W
0
z
W
Z
b�
z
LL
0
z
m
p
m
LL
f.
O
z
W
Q
O
Q
7
<
a
O
a
w
z
m
a
z
Ln
IL
a
0
LL
m
LL
Z
°
m
m
m°
0
It
i
o
a
W
IL
O
z
0
a
o
0
w
F
0
u
u
u
f
a.
d
6d
a
w
a
0
a
U J
J
J
V
m
z
m
m
F:
t=
�
m
M
aj w
w w
N
(aa
i
a
u
C
u
c
f
M C
N N L
z z c
0 O t
G
W W
N N L
w > > L
p 0 0 i
in J J
F LL LL �
0 N L
m w w
w l7 [7 L
in a a i
F
wa
O
Q
0
rn
iK
O
S
a
0
w
b�
z
3
p
m
LL
f.
O
z
W
Q
7
f
a
w
z
t7
w
Ln
IL
a
Oa
a0
wN
w w.
UI
Z
a�
o �0
N p,
oe 0
W Q � Z
a
°L puna
t7 J O �-.
LL o
Z O�a
D N
ZEN
OUJ
mU
m WOa
2Nw.
Z
UN=
Qz�
waw
Som
1 ILU
NwW
D a
�Z(n
ZQN
O (n
Uww
w Z
N
N �0<
NII
z
0
I
I
f-1-1-
I
TTT
w
T
Z
W
T 1 TTT
z
U
a
W
t7
Z
z�x'
LL_IIF-71
O
O
h
--ITf
m�e
z
m 0"
oO�
d Z
Z
-
p
F
i
O
O
"
Z
T
�
LL
:1 1 1 I
I 1 TTTT
Z0
Y
W W
Q
U
Q~
°a
3
w
OZ
�
O
m
N
U<
a
m
C�Ow
Z
C
Z
<
W
W
w w
0
JO
LL
O 10000
Z
K
O
.�
K S
u u
OOma
�- U
F
Y
2
m
w=
D
w
-_'
m
d d
v
O<
Z
LL
:EQ
U
<�OZ=
3
7 z
o
a l
a
o
m W
O
?.
S
<>w
000
W
7
<3�<�
z
�_<
a
r
�Z
0
ZZ�O
0)
0<<0
nmm.uv'v'
a
2 a
=)
W W
W
u
W x
u<
<
N Q
m
NII
z
0
I
I
f-1-1-
I
TTT
w
T
Z
W
<
z
U
a
t7
Z
z�x'
Z Q
O
O
h
r
�
m�e
z
m 0"
0 0
ZD
a <
�E
O
o x
F
J
O0N
z0a
Z
v
,nx
�
0ua
UQ
�x
Z0
Y
W W
'-
:
Q~
Q
3
w
OZ
zz v�i��F-
�
O
m
N
U<
a
m
C�Ow
Z
Z
W
W
w w
0
JO
LL
O 10000
< o
K
N
K S
u u
OOma
Y H
m
w
m
m
d d
1
Z Z
Z
<�OZ=
i
�O W
o
NII
00
w
Z
W
<
z
J
a
t7
Z
z�x'
Z Q
K
o���
O
h
r
�
m�e
z
m 0"
0 0
ZD
a <
�E
O
o x
J
O0N
z0a
o
O
v
,nx
NZi-<
0ua
UQ
�x
O
o
W W
'-
Q~
w
w
OZ
zz v�i��F-
�n000ZZO0O
ZZ
a�u�-im<<.t
U<
C�Ow
cN
J
a
t7
Z
O
0
z
Z
0<<00
r
�
m�e
z
O
ZD
a <
�E
J
O0N
o
O
v
Z
W
�O0
LL
K
O
Z
ee
wv,
�n000ZZO0O
ZZ
U<
w
O 10000
J�
00
Z Z
Z
m
i
�O W
O
m W
O
~
<>w
000
N
a<allo�ao
<3�<�
�0
0
:�o
n
��
nmm.uv'v'
Location c>? F)e r co(:D t -PQ
No. 3 Date
�0,. TOWN OF NORTH ANDOVER
9
41
Certificate of Occupancy $
�,a '+nO • E1�' Building/Frame Permit Fee $
s�►CHus
' Foundation Permit Fee $
Other Permit Fee $
TOTAL $ L/O
Check # 9(.. 7 9
15722
Building Inspector
NA
s
SIGNATURE: C
Building Commissioner/I for of Buildings Date
SECTION 1- SITE INFORMATION
I.1 Propert Address:
1.2 Assessors Map and Parcel
Map Number
Number:
Parcel Number
2.2 Owner of Record
Name Print Address for Service:
1.3 Zoning Information:
Zoning District Proposed Use
1.4 Property Dimensions:
Lot Areas
Frontage ft
1.6 BUILDING SETBACKS ft
Not Applicable ❑
V�
Front Yard
Side Yard
3.2 Registered Home Improvement Contractor
Rear Yard
Required Provide
Required Provided
Required
Provided
Ad4ress7-'� / • er sow
Expiration Date
-Signature Tele hone
1.7 Water Supply M.GL.C.40. 54)1.5.
Public ❑ Private ❑ . S } Zone
Flood Zone Information:
Outside Flood Zone ❑
1.8
Municipal
Sewerage Disposal System:
❑ On Site Disposal System ❑
SECTION 2,- PROPERTY OWNERSIIIP/AUTHORIZED AGENT
2.1 Owner of Record
Name (Print) 'M ress or Service :
Signature Telephone
2.2 Owner of Record
Name Print Address for Service:
Si nature Telephone
SECTION 3 - CONSTRUCTION SERVICES
3.1 Licensed Construction Supervisor:
7—t Z/97�Ai Z4
Licensed Construction Supervisor:
13Y43e� 6 SI -7-16e
Address L
V"/f�C/ Vi" � L' �
Signature Telephone
Not Applicable ❑
V�
License Number
y 2d
6.
Expiration Date
3.2 Registered Home Improvement Contractor
Not Applicable ❑
/ ?i
Company Name
----`
Registration Number
Ad4ress7-'� / • er sow
Expiration Date
-Signature Tele hone
U
Mpq
X
Z
0
SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 & 25c(6)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed affidavit Attached Yes .......❑ No ....... ❑
SECTION 5 Descri tion of Proposed Work (check- applicable)
New Construction ❑
Existing Building
Repair(s)
Alterations(s).. . Q
Addition ❑
Accessory Bldg. ❑
Demolition
Other ❑ Specify
Brief Description of Proposed Work:
% -a
SECTION 6 - ESTIMATED CONSTRUCTION COSTS
Item
1. Building
Estimated Cost (Dollar) to be
Completed by permit ap licantW
n�
�f
�i OFF'ICI, CJSE {},y t
(a) Building Permit Fee
Multiplier
2 Electrical
(b) Estimated Total Cost of
Construction
3 Plumbing
Building Permit fee tel X (b)
i
r '
4 Mechanical HVAC
5 Fire Protection
6 Total 1+2+3+4+5
Check Number
SECTION 7a OWNER AUTHORIZ YON TO BE COMPLETED WHEN
OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Owner/Authorized Agent of subject property
Hereby authorize to act on
My behalf, in all matters relative to work authorized by this building permit application.
-Signature of Owner Date
SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION
I> " �L V t LAX, —a/9 as Owner/ uthorized ent of subject
property
Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge
and belief
"Ie-
Print Na e
'L- !, 2, •� C�
Si ature of O A en Date
Sam
NO. OF STORIES SIZE
BASEMENT OR SLAB
SIZE OF FLOOR TIMBERS 1ST 2 ND 3
SPAN
llIMENSIONS OF SILLS
DIMENSIONS OF POSTS
DIWNSIONS OF GIRDERS
IMIGHT OF FOUNDATION THICKNESS
SIZE OF FOOTING X
MATERIAL OF CHIMNEY
IS BUILDING ON SOLID OR FILLED LAND
IS BUILDING CONNECTED TO NATURAL GAS LINE
North Andover Building Department
Tel: 978-688-9545
DEBRIS DISPOSAL FORM
In accordance with the provision of MGL c 40 S 54,'a condition of Building Permit
Number is that the debris resulting from this work shall be
disposed of in a properly licensed solid waste disposal facility as defined by MGL
c11,S150A.
The debris will be disposed of in:
7—'16
--
� 1 6 4�
(Location of Facility
ignatur ermit Applicant
Date
NOTE: Demolition permit from the Town of North Andover must be obtained for
this project through the Office of the Building Inspector
/Y• A
The Commonwealth of Massachusetts
Department of Industrial Accidents
Dfflice or'Investigations
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit
Please Print
am a homeowner performing all work myself. -
01 am a.sole proprietor and have no on6 working in any capacity
Ela"am an employer providing workers' compensation for my employees working on this job.
Company name:
AddressD-2-��-t�
�iampanv-trams: - - -
Address
}
Phone# -
Failure to secure coverage as required under motion 25A or MGL 152 can lead to the Wrpos ,Mon of airrthpenalties. ot a fine up.. to $1:500.00
and/or one years' imprisonment as'well as dva penalties in the farm of a STOP WORK of and a fine of ($100-00) a day against
understand that a copy of this statement may be forwarded to the Office of Mvesb3atim of the DIA for coverage verification.
/do herby certify under pains and ggna*� of perjury that the infonnatko provided above is true and correct
Print name V 4,,' L J e Phone #2e el
Official use only do not write in this area to be completed by city or town official' Building Dept '
p.Gheck iiimmediate response is requked Building Dept El
0 Licensing Board
0 Selectrr an's ice
Contact person. Phone #- 0 Health Department
0 outer
Mf WORKMAN'S COMPENSATION
wad 4
")17 1+ u i 1. (.J -i 1-1 q I u t i i >1-1 c I I -
1. - 11 d tI
kmi(=' I. ilipruveim-, I I I.. j
A
I\IEW EI`\IGL-i-)I\II--)
I.-OWIH.U.-
W1 I MING'roN MA 01,8z::3/
BOARD OF BUILDING REGULATIONS
License: CONSTRUCTION SUPERVISOR
Numbem'.CS
008828
.Birthdate :04/2%;1951
Ex 0442012004 Tr. no: 20132
Reser (;Tecl'.; uu
VALJ LANZA
34 BIXBY ST
REVERE, MA 02151 Administrator
k
Rol 1 1. 1*'111 oil
0?10212002
I ype: Private Corporatio
NEW 11161ANO CUSTOM DESIGN,
Val Lanza
LOUELL 51.
ADMINISTRATOR
t"' H'I'GION MA 011181
7k
Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
Registration: 102467
Expiration: 7/2/2004
Type: Private Corporation
NEW ENGLAND CUSTOMbESIG
Val" Lanza
226 LOWELL ST.
WILMINGTON, MA 01887
Administrator
I
License or registration valid for individul use only
before the expiration date. If found return to:
Board of Building Regulations and Standards
One Ashburton Place Rm 1301
Boston, Ma. 02108
Not valid without signature
w
A
W
V
o
w
cn
v
cn
°
U
z
,r7
co
o
w
o
w
>
'c
U
q
w
E°�
U
E
o
w
C
w
0
w
W
'�°°
o
u:
u
05
w"
a
p
w
a
'ono
o
c4
G
w
w
5
r�
o
2
cn
0
E
cn
•m C
o�
Ch
v
O C
is O
�V
•p,'O
Cl -
m W
m
•
® = OC O
0 L
0 C
:= O
w
o a.
y
SE
1 O m
1: c
0
u �
y . a E
m
O �y
M*
CD
N : CD y.r
cm m \y
CA
= C C
y O O
,Em ev
Q
® cm
CLC..D 4D
g m m
r=.. CD
\R y •_
aC.0 m
m O 0
v h O O~ .
W O.� Of
+••� C C O C
a m N m C •C
= m m re
t
W Cui
•N ==• O C Z
C: E 3 .r CUD •� c
NJ L- CO2:9
m C
y CJ 4D
d O 'O
to .0 ` y •= O
F� t ♦O.■ CLO- m
zIN
0 4
z
U
Cf)
O
•7��r
W cm
i O
y � �
m m
CD C2 CD
CLI--_
Z y .a
3�
CD
IM0
03 L
cc O a
a- cmQ
y C
CD cqo
c
v
.n 0 s
C co
CL
V CO)
C C
C
■ C
cc
CO2
0
_0
U)
U)
CCw
w
w
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that ..� _, . -�-v ...........
has permission to performZ'...
plumbing in the/bufl`8ings of ... !,!�c�n:�, ! ...................
at 75V. :.............. /`-... , North Andover, Mass.
Fee 1' .. Lic. No.. .
" Pi:UMWf.13 SPECTOR
Check # (JJ
5710
MASSACHUSETTS UNIFORM APPLICATION 433,E
AT FOR PERMIT TO DO PLUMBING
(Print or Type) A
U0
U r /77llG�J Ui/Y Mass. Date c Permit #
Building Location 1�fe r Owner's Name
Type of Occu�Kt 5 i 17 E TI
New ❑ Renovation ❑ Replacement gr' Plans Submitted: Yes ❑ No ❑
FIXTURES
Installing. Company Name ',Ow mA•TAefQ Check one: Certificate
Address _ �� ? CDRC N (Y1 r4n) Aj ❑ Corporation
/r E% 4 u fo A o[ f c/L/ ❑ Partnership
Business Telephone- 5t97 ! �/Co,
Name of Licensed Plummer 'r4 6 r=;2 T d • , �A, mpq r 4 con,
INSURANCE COVERAGE:
I have a current I' ility insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes No ❑ '
If you have checked ves, please/indicate the type coverage by checking the appropriate box.
A liability insurance policy fid" 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 Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
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
knowledge and that all plumbing work and installations Derformed under the permit issu for this application will be in compliance with all
pertinent provisions of the Massachusetts State Plum ' g e and apter of the eral Laws.
By ,�j,,U
re of Licensed Plumber
Title
Type. of License: Master �% Journeymah ElCity/Town -
APPROVED (OFFICE USE ONLY) License Number 233 5
z
Q
z
N
V
m
0
9
N
x
m
A
19
m
.v
m
.r
A
O
z
m
0
z
A
m
Z
-1
o
O
Z
N
N
x
m
A
O
m
r
A
V
0
A
m
c
N
m
O
z
19
m
.v
m
.r
A
O
z
m
0
z
m
Z
o
-i.
0
v
O
r
c
c
m
z
O
m
r
A
V
0
A
m
c
N
m
O
z
tir
BUTTERWORTH & 01 TOOLE, INC.
ADJUSTERS/APPRAISERS
FOR INSURANCE COMPANIES ONLY
P.O. BOX 8294
SALEM, MA 01971-8294
TEL. (978) 741-5731
FAX (978) 740-9109
claims@butterworthotoole.com
09/11/2014
'WN��N DEPAR�N�NT
FORM OF NOTICE OF CASUALTY LOSS TO BUILDING
UNDER MASS. GEN. LAWS, CH. 139, SEC. 3B
TO: Building Commissioner or Board of Health or
Inspector of Buildings Board of Selectmen
City/Town Hall City/Town Hall
ADDRESSES
North Andover, MA 01845
RE: Insured: Richard Redman
Address: 21 Pembroke Road
North Andover, MA 01845
North Andover, MA 01845
Policy No.: 3061670
Lo -ss of: 09/06/2014 Wind
File or Claim No.: 041-1026
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.
If no reply is received from your office within ten days, we will assume
you have no liens of any type against this property and we will recommend to the
insuring company that this claim is paid.
Brad Doherty
Adjuster
Member of
National Association of Independent Insurance Adjusters