HomeMy WebLinkAboutMiscellaneous - 26 CHAPIN ROAD 4/30/2018I
Liberty Mutual®
INSURANCE
February 19, 2016
Town of North Andover
Attn: Building Inspector
120 Main Street
North Andover, MA 01845
Re: Property Address: 26 Chapin Rd, North Andover, Ma 01845
Policy Number: H3S21827168840
Underwriting Company: LM General Insurance Company
Claim Number: 033259818-0001
Date of Loss: 2/3/2016
Attn: Town/City Official
Liberty Mutual Insurance
New England Region Central Property Unit
75 Sylvan Street
Danvers, MA 01923
Tel: (800)566-0323
Pursuant to M.G.L. c. 139, � 3B, please be aware that a homeowners insurance claim has been made
involving loss, damage or destruction of the above captioned property, which may either exceed
$1,000.00 or causes the condition of a building or other structure to render Mass. General Laws, Ch.
143, § 6 applicable. You are required to notify Liberty Mutual by certified mail in accordance with
Mass. General Laws Ch. 175, 599, if you intend to initiate proceedings designed to perfect alien
pursuant to Mass. General Laws, Ch. 139, � 3A & B, or Mass. General Laws, Ch. 143, 5 9, or Mass.
General Laws, Ch. 111, § 127B.
This letter should not be construed as a waiver or estoppel of any of the terms, conditions or
defenses afforded by the policy or applicable law.
Please direct your notice to the attention of the undersigned and include a reference to the above
captioned property address, policy number, claim number, and date of loss.
Sincerely,
Liberty Mutual Support
Liberty Mutual Insurance
New England Region Central Property Unit
1-800-566-0323
Date..?/?�f_J'�.
9399
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
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PLUMBING INSPECTOR
Check # ���G
Date ... //Xw/,�,......
A.'6NOTOWN OF NORTH ANDOVER
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• PERMIT FOR GAS INSTALLATION
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at ..... Z�... �'.�'jr?�'�..!�° ...... North ndover, Mass.
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GAS INSPECTOR
Check #
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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
City/Town:NORTH ANDOVER , MA. Date: 41-x/- /,�— Permit#
Building Location: &6 L"IAM) f t Owners Name:E44/c %)6�1-0 1-06"Q
Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential El
New: ❑ Alteration: ❑ Renovation: ❑ Replacement: Q Plans Submitted: Yes ❑ No 2]
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Check One Only Certificate #
Installing Company Name: HALLORAN PLUMBING
❑ Corporation
Address:826 DALE ST.
City/Town: N.AN DOVER
State: MA
❑ Partnership
Business Tel: 978-685-9504
Fax:
[I Firm/Company
Name of Licensed Plumber/Gas Fitter:TOM HALLORAN
INSURANCE COVERAGE:
I have a current liabilityinsurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes El No ❑
If you have checked Yes, please indicate the type of coverage by checking the appropriate box below.
A liability insurance policy E] Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: 1 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
Signature of Owner or Owner's Agent Owner F1 Agent El
By checking this box ❑; I hereby certify that all of the details and information I have submitted (or entered) regarding this application are true and
aacuraze to me oast or my r%nowieage ana mat an piumdmg wont and installations performed under the permit issued for this application will be in
compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
By �
Type of License:
Plumber
Title
E] Gas Fitter ❑ Master Signature of Licensed Plumber/Gas Fitter
Cityrrown ❑Journeyman License Number: o2 ZZ 33
APPROVED OFFICE USE ONLY) ❑ LP Installer
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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
City/Town: NORTH ANDOVER MA. Date: Y2� /z Permit#
Building Location: 1-4%-/AP!/L1 Ifo Owners Name:ocl'ww AlreaL645 irlfd
Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential 2l
New: ❑ Alteration: ❑ Renovation: ❑ Replacement: R Plans Submitted: Yes ❑ No El
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes 21 No ❑
If you have checked Yes, please indicate the type of coverage by checking the appropriate box below.
A liability insurance policy 2] 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
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
Check One Only
_Signature of Owner or Owner's Agent Owner El Agent El
I hereby 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
mmowleuye anu Enat an pwmomg wont ana mstauations performed under the permit issued for this application will be in compliance with all
Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
By
Title
Cityrrown
APPROVE
USE ONL
Type of License: �214�—
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❑Master 0?
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Installing Company Name: HALLORAN PLUMBING
Check One Only Certificate #
El Corporation
Address: 826 DALE ST.
Cityrrown: NORTH
ANDOVER
State: MA
[:]Partnership
Business Tel: 978-685-9504Fax:
❑ Firm/Company
Name of Licensed Plumber: THOMAS HALLORAN
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes 21 No ❑
If you have checked Yes, please indicate the type of coverage by checking the appropriate box below.
A liability insurance policy 2] 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
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
Check One Only
_Signature of Owner or Owner's Agent Owner El Agent El
I hereby 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
mmowleuye anu Enat an pwmomg wont ana mstauations performed under the permit issued for this application will be in compliance with all
Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
By
Title
Cityrrown
APPROVE
USE ONL
Type of License: �214�—
p Plumber Signature of Licensed Plumber
❑Master 0?
pJoumeyman License Number•.
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The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
veldt Boston, MA 02111
b" www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name.(Business/Organization/Individual): 7//OA,f,S
Address: x2 t-- A.a <
City/State/Zip: it/i flan,
olA
Phone.#: `77ac 655--Y5-0111
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with
4• ❑ I am a general contractor and I
employees (full and/or part-time)-.*ime)-.*
have hired the sub -contractors
2.;ZI am a sole proprietor or partner-
listed on the attached sheet.
ship and have no employees
These sub -contractors have
working for me in any capacity.
employees and have workers'
[No workers' comp. insurance
comp. insurance.
required.]
5. ❑ We are a corporation and its
3. ❑ I am a homeowner doing all work
officers have exercised their
myself. [No workers' comp.
right of exemption per MGL
insurance required.] t
c. 152, §1(4), and we have no
employees. [No workers'
. insurance
Type of project (required):.}
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10..0 Electrical repairs or additiont
1112 Plumbing repairs or additions
12.❑Roof repairs
13.❑ Other
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
I HomeoNriers who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors 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' comp. policy number.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy # or Self -ins. Lic. #:'
Expiration Date:
Job 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 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 under the pains and penalties of perjury that the information provided above is true and correct.
r�
not write in this area, to be completed by city or town official
City or Town:' Permit/License
`/-02 3 l�
Issuing Authority (circle one):
I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector
6, Other
Contact .Person:
Phone #:
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." ; f
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 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 employer."
MGL chapter 152, §25C(6) also states that "every state or local Iicensing agency shall withhold the issuance or
renewal of a license or permit to,opera'te>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, §25CO) 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 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 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 permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple perrnit/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 permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit 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-NIASSAFE
Fax # 617-727-7749
Revised 11-22-06
wFvw.mass.govdia