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Reply To
Mansfield, MA 02048
P.O. Box 345
TEL. (508) 337-8058
FAX 1508) 339-5835
NEW ENGLAWn r' AIM SERVICE
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IncorPorated I YOS
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wrandall@lit:vwcllklclllus.laillib.Lum
Form of Notice of Casualty Loss to Building
Under MASS. GEN. LAWS, Ch. 139, Sec 3B
TO: Building Commissioner or
Inspector of Buildings
City/Town Hall
North Andover, MA 0 1845
RE: Insured: Elizabeth Wilson
Address: 293 Mass Ave
North Andover, MA 01845
Policy No.: 0356634
Loss of. November 21, 2013
File No.: 0356634
Origin: Water Damage
X
Reply To
131 Dodge Street, Suite 6
Beverly, MA 01915
TEL. (9781'927-3000
FAX (9781927-3002
Board or Health or
Board of Selectman
City/Town Hall
North Andover, MA 0 1845
14CV- C, 2 2014
TOWN OF NUR -1 H ANDOVj:R
HEALTH DFPARTMENT
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.
Section 3B. No insurer shall pay any claims (1) covering the loss, damage, or destruction to abuilding or other structure,
amounting to one thousand dollars or more, or (2) covering any loss, damage or destruction of any amount, which causes the
condition of a building or other structure to render section six of chapter one hundred and forty-three applicable, without having
at least ten days previously given written notice to the building commissioner or inspector of buildings appointed pursuant to the
state building code, to the fire department or arson squad of the city or town and to the board of health or board of selectmen of
the city or town in which the same is located. If at any time prior to payment the said city or town notifies the insurer by certified
mail of its intent to initiate proceedings designed to perfect a lien pursuant to section three A, or to section nine of chapter one
hundred and forty-three, or section one hundred and twenty-seven B of chapter one hundred and eleven, the said payment shall
not be made while the said proceedings are pending; provided, however, that said proceedings are initiated within thirty days of
receipt of such notification.
Any I ien perfected Pursuant to section three A, or to section nine of chapter one hundred and forty-three or section one hundred
and twenty-seven B of chapter one hundred and eleven, shall extend to and may be enforced by the city or town against any
casualty insurance policy or policies covering any loss, damage, or destruction pursuant to which the proceedings to perfect the
lien were initiated,
No insurer shall be liable to any insured owner, mortgagee, assignee, city or town, or other interested party for amounts disbursed
to a city or town under the provisions of this section, or for amounts not disbursed to a city or town under the provisions of this
section.
On this date, I caused copies of this Notice to be sent to the persons named above at the addresses indicated above by First Class
Mail.
ou,
7bobiert L. WSmith, r.
Adjuster
I—
Ful
Reply To
Mansfield, MA 02048
P.O. Box 345
TEL. (508) 337-8058
FAX {5081339-5835
NEW ENGLAMn r' AIMS SERVICE INC.
1117cowraw 1 ?85
wrandall@.
Form of Notice of Casualty Loss to Building
Under MASS. GEN. LAWS, Ch. 139, Sec 3B
TO: Building Commissioner or
Inspector of Buildings
City/Town Hall
North Andover, MA 0 1845
RE: Insured: Elizabeth Wilson
Address: 293 Mass Ave
North Andover, MA 01845
Policy No.: 0356634
Loss of. November 21, 2013
File No.: 0356634
Origin: Water Damage
7E
Reply To
131 Dodge Street, Suite 6
Beverly, MA 01915
TEL. (978) 927-3000
FAX {978) 927-3002
Board or Health or
Board of Selectman
City/Town Hall
North Andover, MA 0 1845
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.
Section 3B. No insurer shall pay any claims (1) covering the loss, damage, or destruction to abuilding or other structure,
amounting to one thousand dollars or more, or (2) covering any loss, damage or destruction of any amount, which causes the
condition of a building or other structure to render section six of chapter one hundred and forty-three applicable, without having
at least ten days previously given written notice to the building commissioner or inspector of buildings appointed pursuant to the
state building code, to the fire department or arson squad of the city or town and to the board of health or board of selectmen of
the city or town in which the same is located. If at any time prior to payment the said city or town notifies the insurer by certified
mail of its intent to initiate proceedings designed to perfect a lien pursuant to section three A, or to section nine of chapter one
hundred and forty-three, or section one hundred and twenty-seven B of chapter one hundred and eleven, the said payment shall
not be made while the said proceedings are pending; provided, however, that said proceedings are initiated within thirty days of
receipt of such notification.
VW
Any lien perfected pursuant to section three A, or to section nine of chapter one hundred and forty-three or section one hundred
and twenty-seven B of chapter one hundred and eleven, shall extend to and may be enforced by the city or town against any
casualty insurance policy or policies covering any loss, damage, or destruction pursuant to which the proceedings to perfect the
lien were initiated.
No insurer shall be liable to any insured owner, mortgagee, assignee, city or town, or other interested party for amounts disbursed
to a city or town under the provisions of this section, or for amounts not disbursed to a city or town under the provisions of this
section.
On this date, I caused copies of this Notice to be sent to the persons named above at the addresses indicated above by First Class
Mail.
A T
0 Smi
Idjuster
Date..00.�.
,ORTH
6
6
TOWN OF NORTH AN /OVER
X PERMIT FOR GAS INSTALLATION
This certifies that
has permission for gas installation
in the buildings of .... .................
at ... .3 ........... North Andover, Mass.
Fee. Lic. No.. ��3. � - �--)
Check 9
I
MASSAMUSEM UNWORMAPPUCAJONFORPERM To DO GAS FnTING
(Type or priq)
NORTH ANDOVER, MASSACHUSETTS Date _4,,Ll
Building Lo�ations
Owner's Name
New Renovafion Replacement
!S U B - B A SEM —EN T
B A S E M E N T
I ST.
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(Print or type)
Name
Address
7u s Min —es s— T �ee—,'
Peffnit #
Amount S
Plans Submitte�d[]��
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Name of Licensed Plumber'or Gas Fitter
WIL
Ch e k
c. One: Certificate Installing Company
Corp.
.4 Partner.
Firm/Co.
1 00-
RANCE COVERAGE
I have a current liability Insurance, policy or it's substantial equivalent Check one:
If You have checked ves, please indicate the type coverage by checking the apprODri Yes NoO
Liability insurance policy r71— ate bnv
A�M= type of indemnity
Owner's Insurance Waiver 13 Bond
. I Am aware that the licensee does -n 0
Mass. General Laws, and that MY signature on this E I �have the Insurance coverage required by Chapter 142 of the
Permit application waives this requirement
Signature of Owner or Owner's Agent Check one:
Owner
I hereby certify that all of the details and informati ............. 1-3 Agenill
naVesubmitte ....... .. ............................ ............ .......... . .....
(or entered) in above appIicj:ji!j-0_—n are true and accurate to the
best of my knowledge and that all plumbing work and installations Performed under Permit is 11 - 13
syed f 11, H
), �br t Iypp ication will be in
cOmPliance with all pertinent provisions of the Massachus?e02e VG(Cock and Colapter 14 r
e 9#eral Laws.
Illy, SignatUre of
71itie P1 umber
City/T� E3 Gas Fitter
PPR6V, ED (OFFICE USE ONLY) 17 Master
1:3 Joumeyman
Neu flumber Or Gas Fitter --------
License urn er
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Name of Licensed Plumber'or Gas Fitter
WIL
Ch e k
c. One: Certificate Installing Company
Corp.
.4 Partner.
Firm/Co.
1 00-
RANCE COVERAGE
I have a current liability Insurance, policy or it's substantial equivalent Check one:
If You have checked ves, please indicate the type coverage by checking the apprODri Yes NoO
Liability insurance policy r71— ate bnv
A�M= type of indemnity
Owner's Insurance Waiver 13 Bond
. I Am aware that the licensee does -n 0
Mass. General Laws, and that MY signature on this E I �have the Insurance coverage required by Chapter 142 of the
Permit application waives this requirement
Signature of Owner or Owner's Agent Check one:
Owner
I hereby certify that all of the details and informati ............. 1-3 Agenill
naVesubmitte ....... .. ............................ ............ .......... . .....
(or entered) in above appIicj:ji!j-0_—n are true and accurate to the
best of my knowledge and that all plumbing work and installations Performed under Permit is 11 - 13
syed f 11, H
), �br t Iypp ication will be in
cOmPliance with all pertinent provisions of the Massachus?e02e VG(Cock and Colapter 14 r
e 9#eral Laws.
Illy, SignatUre of
71itie P1 umber
City/T� E3 Gas Fitter
PPR6V, ED (OFFICE USE ONLY) 17 Master
1:3 Joumeyman
Neu flumber Or Gas Fitter --------
License urn er
I ne (,Onznwfz
wealth 0
Hassach
Usetts
Deparlment Of Adaltial
Accidents
Off1ce 0
f Invelligalins
600 WaNjrzij2.j0n Street
WerkBrs, compensati,
AADDIBICanj n In'Uran'e.Affidavit' Runders/Co
f lnformat.ion
N%Me (Busin.-SSIOrganization/indiiidual): ela Is' It Pr r imn LL b j
Addr6m: o
city/stat-�/Zip:
Are y hone
iE��10 I empioyer? Check the appropriate box:
arn
I a employer with 4.71amag TYPe'Of Project (required):
5mPioYets (full and/o__� =erleizal cant -actor and I
rPaTT-tirne).* have hired the sub_ .6. [1 New construction
2.7 1 am a sale Proprietor or partner- COntr=Ors . .
ship and have no listed On the attached sheet 7.
employees The Rem, odelino,
working for me in any capacity. w " sub-cOntractors have
NO workers' camp. insurance Orkers, comp. insurance, Demolition
r qaired-] We art -a cOTPOration and its 9. D 13aciing addition
e
3. F7 have exercised.thei
I arn a homeowner doing ELI] work, right of ex- CIT 10-0 EleciTical re -pairs or additions
Myself No.work=1 comp. _M�otion Per MGL I I
C. 152 (4), bin- r--pai
insurance required.] t and we have no 12,0 rs or addffions
eml work.
31OYees, [No - "TS5 Roof repairs
*Aw appliumt thal cherks b . ox Camp. insuranct required-] 13.[] Other
t M , 9 1 MUM aiso'fill out the secfion beiow shovving th-ir work
oniwwnerp 40 sublllil.WS a— L
ajdavil
� 11"e'l art L'Oifi-c EV
onr-toa thai L -h=4, this box M.
PaiLl Chm nir.
us' ME hed an nddi�honal sh= �showi - outgidb Cont
r
aou
0 L�O=M t-r� =d t.=r W
tht namt of th.-
'"s[ `6m" nm" affidavir indimring such.
Wor
am an employer Mat isp and th=r work='
rolli&tz.v work= 1-Winpensadopz j..,, `MP, Polic:3, infiormation.
40ormatiorL rancefor ny, cMPj0Yff=. B
Insurance Company Name: e"'.is the Pofi,:y andjoh site
Policy # or Self�ins. Lic. #:
Job 'Sit- Address:
Expirz6on Date:
Attach 2 copy Of the workerg, compen City/Stat_-4Zip:
Failure to sation Poiicy deciaration ( ---------------
SeCure coverage as required under Section 25A Of MGL show'Qu the Policy number and expir-3 , tioll d2te).
fine up to 31,500.00 and/or one-year imprisonment as well IS2 can lea� to the imposition Of criminal penal of E
Of up to S250.00
tr ised that a copy of this forrn of a STOP WORK ORDER and a fine
,ations ofthe DIA for insurance c StatelDent may be forwarded to the -C)ffice, of
Investi, a day against the violator. Be, adv' as civ'l Pendties in the.
average verificatiorl.
I do her6j) ccrg6,
"Oreb -erg" Lmr M ains andpen7cs
MA aimv andp=,zWes ofjo,
_rpe zhz
infor'"4rt""Pr011idedabope
IS true
A
Off1c'al =e On#- DO not wrile jj7 &is araa� 10 be co
�0�n#Dv ��novt
or to wj7 OfficiaL
n'P "-led bJ1
Cit�, or Town:
Islquift- Authority (circle one): PermittLicen., 4 ------
e
1. Baar� of Health 2. BuRdina Department 3. CkqVToW11
6. Other Clerk 4. E'ectrical InsPector
'Contact Per -son:
Phone 1�-.
correC4
In
Inspector
iniormanon and instructions
Massachusetts General Laws chapter 1,52 requires all enaTDIpy5rs to provide workers' compensatio r for their employees.
Pursuant to this statute, an employee is defined as "...evtr-y person in the servict. of another under any rontrad of hire,
express or. implied., oral or written."
An employer is den"ned as "an individual, paitnership, aR-
ociation, corporation or other legal entity, or any two or more
of the for:going engaged.in &joint enterprise, and includ-i-n.a the legal mpresentatives of a deceased employer, or the
receiver or trustee of an individual, partnership, associati c:m or other legal entity, employing employees. However th-e
owner of a dwelling house having not mom than three apzirtments and who resides therein, or the occupant of the
dwelling house of another who employs pesoris to & mat-int--nanct, construction 07 repair work on such dwelling house
or on the grounds 07 building appurtenant thertto shall nc>t because of such -employment be deemed to be an =ployemr."
MGL chapter 152, §25C(6) also states that "every state tie- r local licensing agency shall withhold the issuance or
.renewal of 2 license orperTnitUoperate a-bu.§iness or to construct buildings iio the commonwealth for any
applicant who has not produced acceptable evidence cb-*f compliance votb the insurance coverage requireV
Additionally, MOL chapter 152, §25C(7) states "Neither -the commonwealth nor any of its political subdivisions shall
enter into any contact for the performance. of public warl< until acceptable evidence of compliance with the insurance
require:ments of -this chapter have been presented to the 6cnnt-acdng authority. -
Applicants
Please fill out the workers' compens6on affidavit comPl-etely, by checking the boxes that apply to yoir shuation and, if
necessary, supply sub-c6ntractor�s) name(s), address(es) am. d phone number(s) along with their certificate(s) of
insurance, Limited Liability Companies (LLC) or Limittcd Liability Partnerships (LLP) with no employees other than the
members or, partners, am not required to carryworkers' c:�rnpensafion insurance. If an LLC or LLP does have
employees, a policy is required- Be advised that this afficlavit may.be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage.. Aiso lbesu.retosi.ananddittethenfli"vit- Thtaffidavitshouid
be returned to the city or town that the applicatior for the permit or license is being requested, not the Dtpartrnent of
Industrial k =id.-nt&. Should vo I u,have, an), qi�estions reLraxdin-1,, the laltq, or if you am required to obtain a worken'
.r,ompensa:tion policy, please call the Dmpartn ent at the nmir-nbcr,listed below. Self-;
insmmd mmpanies sl�iould enter th--ir
Self-insurance license number an the appropriate line.
City or Town Macinis
Please be sure that th`e1,.'kfi5davit is complete and printed le:sziblv. The Department has provided
a space at the bottom
of the affidavit fOrYDU to fill 'out in the, oveTit the Office of' Investigations has to contact you regarding the applicant
Pie= be sure to fill in. the permit/licenst nurnbcr which v%, -ill be used as a reference number. In addition, an applicant
that must submit multiple permit/license applications in ar-ty given yew, need only submit one affidavft indicating currtnt
policy information (if necessary) and under "Job Site Ad&-ress" the applicant should Write "all locations in
—(City or
town).- A copy of the affidavit that has been officially st2amped or marked by the city or town may be provided to the
arrpliicant as proof that a vaiid affidavit is- on file for future permits or licenses. A new affidavft must be filled out -each
Year. Whe:m a home owner or citizen is obtaining a licens� or permit not related to any business or commercial venture
(i.e. a. dog license or permt to burn'lzaves etc.) said persorl is NOT required to complete this affidavit.
The Office of Investigations would like to.thank you. in advanae for your co*
please do not hesitate to give us a . call. op--mtion and should you have . any questions,
The Departm --rit's address, telephone and fay. number:
The CornrnonwtaLfth of Massazhus--tts
DC-Partmont of lmdustrial Accidents
Office of lEirvestiventions
600 Wasbdngton Str----t
BOSWI� MA G21 11
T51. 4 617-727-4900 fj� 406 or 1-9. 77-MASSkFE
Revised 5-26-� . 05 Fay, � 617-7-7-7749
The COMmonwealth Of MOSSachusetts n(itce Let Only
rvrait NO.
0CPCnMCr1f Of Public Safery
BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 1= occullan9v 4 fee Owckad W
3/90 (leave blank)
APPLICATION FOR PERMIT TO 'PERFORM ELECTRICAL WORK
All %mik to bq performed ir% agc9rdsn" *"h 'he M64"Chustru Vectrical Code, $27
(PLEASE PFaXT IN nM OR TE XINFOMUZION) . . J?4�
n, Date
City or Town of 1.
1he undersigned applies fo Aaj�� To the Inspector
r a permit to perform th electrichi work described Wow.
LO"CiOn (Street 6 uumber� 2— 1�� e
Owner or Tenant
Owntr's Address
15 this Permit in conjunctiom.. with a buildin& permit: Yes 0 No
Purpose of Building (Check Appropriate Box)
Utility Authorization No. 70
Existing Service 0 Am s Zo -vf%l 0.. Overhead i47U dgrd(] Mo. of Meters'
New –u—mic—a /Qj Amps / a "40
Volts Overhead B-/Undgrd C3 NO- Of haters
..Nlmber Of readers and Ampacity, n
Location and Nature of Proposed Electrical Work .41Y I 7� 717
NO* Of Lizhtint Ouri.r.
No. of Lighting Fixtures
NO* of Receptacle OUtler.2
N** of Switch outlets
No. of Disposals
NO- Of Dishwashers
NO- Of Water He2cars
No. Hydro Massate Tubs
TIFA ALARMS MO. of Zones
No. of Detection and
Initiating Devices
NO. Of Sounding Devices
NO- Of Self Contained
Detection/Sounding Devices
Loca 1 13 Municipal
:Z:L�=��ctionoOther
---------------
INSURMCE COVERAGE: Pursuant to the requirements Of Massachusetts General Laws
I have Al current Liabili.Ey Insurance Policy including Completed Operati6l`ls. Coverage or its substAncial
equivalent. YESff NO U I have submitted valid proof of same to this office. YES Ej NO (3
If you have checked YES, Please indicate the typ a Of�,�rage by 4*ecking the appropriate box.
INSUpANCE Tj BOND'[3 (P (please Spec,fy)-�2
3,
Estimated Value of Electrical Work S
I rat on te
Work to Start 4 Inspection Date Requested& Rough — — — — — Final
Signed under the alties o6erjuriy:
FIRM NAME
Licensee IC. NO.
Address ................... Signature M NO.
&. us To R o�. �
5-- -3 — 7 7—
OWNER'S INSURANCE wAIVER: Alt Tel. No. T 7 7
stantial equivalent a I am aware that the Licensee does not hove the insurance coverage or its sub -
required by Massachusetts General -n�
a -EFws, L"a-j;,t my signature on this permit
application waives this requirement. Owner Agent (?lease check one)
(signature of er or Agenc Telephone No. PERMIT FEE S
Date...,-� d
. .................... I .......
927
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that
..... ..... ...... ......
has permission to perfor .... .... .. ... . ... . ..............
wiring in the building f .... ... . ......... ... r!' / ........................
at.c'�..?) ..... . . ' . ..i ................ . North Andover, Mass.
Fee.15�..-77 ....... Lic. ................................. .....................
ELECTRICAL INSPECTOR
'tM- 00 PAID
04to �w -/ L/
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer I
Location Q'�3 1�,A—,s5 A
No. 00 8 —
Date
TOWN OF NORTH ANDOVER
bertificate of Occupancy
$
Building/Frame Permit Fee
$
Foundation Permit Fee
$
Other Permit Fee
$
TOTAL
Check # 36�-45
'jY, —
3571 111mf (�,,
Building Inspector
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