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Miscellaneous - 32 MARBLEHEAD STREET 4/30/2018
�-32 MARBLEHEAD STREET - 09'0000'0 2101009- i I, i i I� 1 i I �1 I I I Location 3oZ M A���e k Y A " { No. © � Date S Qb—oCf NORTIy TOWN OF NORTH ANDOVER 0 9 Certificate of Occupancy $ E Building/Frame Permit Fee $ Mus Foundation Permit Fee $ Other Permit Fee $ TOTAL $ ( 0 9 r - 'Check # a3 l� A' 17329 M Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAI RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER 7 D DATE ISSUED: �!a S D D X SIGNATURE: I/ 1 , Building Commissioner/I for of Buildings Date z SECTION 1-SITE INFORMATION O 1.1 Property Address: 1.2 Assessors Map and Parcel Number: 32- Lle v A , &l a r I /�� Map Number Parcel Num ber dh 'u . �- 1.3 Zoning Information: .L 1.4 Property Dimensions: a- Zoning District Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided R red Provided 1.7 Water Supply M.G.L.C.40.11 54) 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: i Public ❑ Private ❑ Zone Outside Flood Zone ❑ Municipal 0 On Site Disposal System ❑ SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT Historic District: Yes No M 2.1 Owner of Record Name(Print) Address for Service Signature Telephone 2.2 Owner of Record: ra Name Print Address for Service: s Signature Tel hone 9 TION 3-CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Not Applicable ❑ C)I- A""0-r,C k-�o,,A In Licensed Construction Supervisor: / c o'f L A License Number wn Address ic e �� (�) • f (9 a 3 ' �—31/3 Expiration Date Signature Telephone r 3.2 Registored Home Improvement Contractor Not Applicable ❑ v Company;Name m Registration Number Address r z Expiration Date r1 Signature Telephone !� G SECTION WORKERS COMPENSATIO G.L C 152 § 25c(6) Workers Compensabo 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 all applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) Addition ❑ Accessory Bldg. ❑ Demolition Other ❑ Specify Brief Description of Proposed}W-ork: tQ 19 o A '� t csx �sJr c� LD 0- l`A<, Aa j- (` SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be pF)�fCTAI,UEQ ,� Completed by permit a licant -- 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of D Construction 3 Plumbing Building Permit fee(a)x (b) 4 Mechanical HVAC Zoe 5 Fire Protection 6 Total 1+2+3+4+5 ®®© StL Check Number SECTION 7a OWNER AUTHORIZAT1459 TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf,in all mattergre a e to work authorized by this building permit application. ✓`��.C�-ILLI Q ���' -�'��Z —Gt•� Signature of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I> as Owner/Authorized Agent 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 Print Name Mature of Owner/A ent Date NO.OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TRVMERS 1 2 3 SPAN DIMENSIONS OF SILLS DMIENSIONS OF POSTS DM ENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHEMNEY 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: SA L e n, (Location of Facility) Signature of Permit Applicant Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector I 'i I FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and 'Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. *****************************APPLICANT FILLS OUT THIS SECTION ✓APPLICANT U U 01, t7w (_ CLI S4 PHONE LOCATION: Assessor's Map Number Qf2 g PARCEL C Cho SUBDIVISION LOT (S) TREET f'j'IAT�f3G2-15� � S`f2��'T `ST. NUMBER 3 Z I USE ONLY*******'�`�`***��`�`*' ***"*** RECOMMENDATIONS OF TOWN AGENTS: CONSERVATION ADMINISTRATOR DATE APPROVED /J DATE REJECTED COMMENTS TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD INSPECTOR-HEALTH DATE APPROVED DATE REJECTED SEPTIC INSPECTOR-HEALTH DATE APPROVED DATE REJECTED �I COMMENTS ✓PUBLIC WORKS -SEWER/WATER CONNECTIONS DRIVEWAY ER 5LJ'A ✓ IRE DEPARTMENT S RECEIVED BY BUILDING INSPECTOR DATE i Revised 9197 jm ttORT Town of North Andovera Building Department o - 27 Charles Street North Andover, MA. 01845 SMC"v D. Robert Nicetta Building Commissioner (978) 688-9545 (978) 688-9542.Fax HOMEOWNER LICENSE EXEMPTION Please print. DA'`f E f U JOB LOCATION 32-- Number Number Street Address Map/lot "HOMEOWNER Name Home Phone Work Phone PRESENT MAILING ADDRESS /S_ SQ F RA City Town State Zip Code The current exemption for"homedwners"was extended to include owner-occupied dwellings of two units or less and to allow such homeowners to engage an individual for hire who does not possess a license, provided that the owner acts as supervisor. (State Building Code Section 108.3.5.1) DEFINITION OF HOMEWOWNER: Person(s)who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one or two family dwelling,attached or detached structures ac- cessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other Applicable codes, by-laws, rules and regulations, The undersigned"homeowner"certifies that he/she understands the Town of No. Andover Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. I HOMEOWNER'S SIGNATURE . Q i APPROVAL OF BUILDING OFFICIAL i Q 4 a The Commonwealth of Massachusetts - M , d Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 5�lb Workers'Compensation Insurance Affidavit Name W Please Print Name: Location City lU c) Phone # Q 79'- 1-/ 6 2 W6 0 1 am a homeowner performing all work myself. aI am a sole proprietor and have no one working in any capacity aI am an employer providing workers' compensation for my employees working on this job. Company name � gx!i D 91 1 ax-rfM9 C Dvu 5 / Address I D-Y: (_ ld(,/-i� City �% t dN /V Phone 3 Insurance Co. 44-00#J LV LD I IMUS Policy# 10622�2 2 _—� D 0 Company name: n 3 13 r7 / --6`/ / 33 Address City Phone#: Insurance Co. Policv# Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of,a fine up to$1,500.00 and/or one years'imprisonment-as_welLas_civiLpenattiesin the form ofa_STOP WORK_ORDFR..anda fine of.(.$100.00)..aday against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature Date Print name ►U 1(I f Aht /,A Phone.# —I 1 (/ Official use only do not write in this area to be completed by city or town official' ` City or Town Permit/Licensing ❑ Building Dept ❑Check if immediate response is required ❑ Licensing Board ❑ Selectman's Office Contact person: Phone#: ❑ Health Department Other `AC D,. CERTIFICATE OF LIABILITY INSURANCE D05/11/2 04 ' PRODUCERTHIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION 603-890-6439 ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE SANTO INSURANCE& FINANCIAL SERVICES, HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR INC. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 5 ROCKINGHAM ROAD, ROUTE 28 WINDHAM, NH 03087 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURERA: NATIONWIDE INSURANCE COMPANY NORMAND MARTIN INSURERB: TO BE DETERMINED DBA NORMAND MARTIN CONSTRUCTION 19 SCOTLAND AVE INSURERC: SALEM NH 03079 INSURER D: INSURER E: COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR DD'L P0LICYEFFECTIVE POLICYEXPIRATION LTR POLICY NUMBER LIMITS SII GENERAL LIABILITY EACH OCCURRENCE $ 300,000 A X COMMERCIALGENERAL LIABILITY 51 AC 106272 3001 05/11/04 05/11/05 --DAMAGL:IU tu PREMISES RENTrence $ 100,000 CLAIMS MADE X OCCUR MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 300,000 GENERAL AGGREGATE $ 600,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS,COMP/OPAGG $ 300,000 17 POLICY X PRO' LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON>OWNEDAUTOS (Per accident) - PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY,EAACCIOENT $ ANYAUTO EAACC $ OTHERTHAN AUTOONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR FICLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND X WCSTATU, OTH> B EMPLOYERS'LIABILITY PENDING 05/12/04 05/12/05 TORY LIMITS1 ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100,000 OFFICER/MEMBER EXCLUDED? E.L.DISEASE,EA EMPLOYEE $ 100,000 describe under SPECIAL PROVISIONS below E.L.DISEASE,POLICY LIMIT $ 500,000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONSADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL DAYS WRITTEN MARY RAGONESE NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL 215 SALEM ST IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR ANDOVER MA 01810 REPRESENTAT4S. AUTHORIZED ESENTATIVE Crirr� G' <3tl� ACORD 25(2001/08) 'ACORD CORPORATION 1988 ACORD,. CERTIFICATE OF LIABILITY INSURANCE DATE05/11/2004Y) PRODUCER 603-890-6439 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION SANTO INSURANCE & FINANCIAL SERVICES, ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR INC. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 5 ROCKINGHAM ROAD, ROUTE 28 WINDHAM, NH 03087 _ INSURERS AFFORDING COVERAGE _N_A_IC_# _ INSURED INSURERA: NATIONWIDE INSURANCE COMPANY NORMAND MARTIN INSURERB: TO BE DETERMINED DBA NORMAND MARTIN CONSTRUCTION INSURER C: 19 SCOTLAND AVE INSURER D: SALEM NH 03079 INSURER E: COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR" D'L POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTRDATE(MMIDDlYY) GENERAL LIABILITY EACHOCCURRENCE $ 300,000 A I X COMMERCIAL GENERAL LIABILITY 51 AC 106272 3001 05/11/04 05/11/05 pRAEMISES0(Ea EN occurence $ 100,000 I_ !__j CLAIMSMADE E OCCUR MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ _ 300,000 GENERAL AGGREGATE $ 600,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS)COMP/OP AGG $ 300,000 7 POLICY X PRO> I LOCI I _ ----- AUTOMOBILE LIABILITY -- COMBINED SINGLE LIMIT ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY i SCHEDULEDAUTOS (Per person) $ f i --1 HIREDAUTOS BODILY INJURY $ NON,OWNEDAUTOS (Per accident) I _ PROPERTY DAMAGE $ (Per accident) i GARAGE LIABILITY AUTO O NLY,EA ACCIDENT $ ANY AUTO OTHERTHAN EA ACC $ AUTOONLY: AGG $ EXCESSIUMBRELLA LIABILITY _EACH OCCURRENCE $ I I� OCCUR (� CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ � RETENTION $ $ WORKERS COMPENSATION AND XWCSTATU, I OTH> B EMPLOYERS'LIABILITY PENDING 05/12/04 05/12/05 — _TORY LtMfTS ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100,000 OFFICER/MEMBER EXCLUDED? _E.L.DISEASE,EA EMPLOYEE $ 100,000 I If yes,describe under — I SPECIAL PROVISIONS below E.L.DISEASE)POLICY LIMIT $ 500,000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL DAYS WRITTEN MARY RAGONESE NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL 215 SALEM ST IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR ANDOVER MA 01810 REPRESENTAT4S. AUTHORIZED E RESENTATIVE 0C% ACORD 25(2001/08) 'ACORD CORPORATION 1988 x.10RTH ovm 0Andover No. 7409 - �1 LAK dover, Mass., S y COCMICMEWICK ADRATED PP���S `S U BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System �j 1 ) � ... BUILD ING INSPECTOR THIS CERTIFIES THAT ...................................... . . .......... ...... .. .......... . Foundation 0 has permission to erect... ... buildings on...934... ou..... ...... .............t. .............. ......... .... to be occupied as lir�, .t...Dly w.•... v�..K� ...: xm.....;..*......lR4pyij*actChimney ..... . .................... provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relatin to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. a' Of &10 � PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTIONT S ........ jut...... . . Rough ...... ................... Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove RoughFinal No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner s Street No. SEE REVERSE SIDE Smoke Det. f \ THE C0A1H0NGVE4LTH0FM4S94CHUSE7TS Office Use only DEPARTNmVTOFPUBIlCS MY Permit No. Q` BOARDOFF=PREVENHONRLGUTATIONSM7CW]2.VO Occupancy&Fees Checked Mk + 0 APPLICATTONFOR PE TO PERFORM ELECTRICAL WORK ALL WORK TO BE PERFORMED IN ACCOR ANCE H THE MASSACHUSSTS ELECTRICAL CODE,527 CMR 12:00 d /�^ , (PLEASE PRINT IN INK OR TYPE ALL INFORM TION Date `'/ Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the ele t ' al work described below. Location(Street&Number) Plir 1e Owner or Tenant S ' ' Owner's Address ( if,�,� 1 �1-r' H A)�I.t�l.&PI 1"i F��(/� Is this permit in conjunction with a building permit: Yes . No (Check Appropriate Box) t2 6 5-788 Purpose of Building peS%ci ev, ��`L ( Utility Authorization No. Existing Service 6 AmpsOO /rya Volts Overhead Underground No. of Meters ice 00 Amps /�� �//lVolts Overhead Underground No.of Meters f Feeders and Ampacity nd Nature of Proposed Electrical Work /Sf' p dti- 060x— fn as'' up ting Outlets O No.of Hot Tubs O No.of Transformers 0 Total KVA ting Fixtures I NSwimming Pool Above Below Generators KVA round round tacle Outlets No.of Oil Burners No.of Emergency Lighting Battery Units 0 h Outlets O No.of Gas Burners U j No.of Air Cond. 0 Total FIRE ALARMS No.of Zones - Tons 1 _ als O No.of Heat O Total . Total � No.of Detection and Pumps Tons KW Initiating Devices shers Space Area Heating KW Nq.of Sounding Devices 0 No-Jbf Self Contained Dei6ction/Sounding Devices t Heating Devices D KW Local Municipal Other 1 Connections eaters / KW No.of No.of 0 Signs 6 Bailasis sage Tubs O No.of Motors Total HP ParmarA$DdiemquiraneniSofNiq&wh lsott3C* aallaws hmuancelblicymch>�gComplele Covaoritssubt;tantialegtlivai�t YES NO st>brnt>edvafidptoofofsarnetotheO&Z YES Ifwuhavediad®dYES,plea9eirldicatethetypeofco ageby angthe box 1RANCE BOND r7 OrIHER F-1 (Please Specify) EVkati�onDate E VahreofEechicalWotk$ to Start hTectionDateRequested Rough Final i urxlerTie lames ofpajtay. NAME Lia=No. =e �'Iq�f'�Q�J 13ernc►rc/1 Sigrolure LicenSeNo n/� M i� BlmxmTel No. 975(- 6/ — X69 y►1lcerx+ live ry)R 0/"Ll1tTe1Na 9?Jl' �R'SINSURANCEWAIVER;Iamawaietha drLi�doesnothav�etheinstaarlmcovaageoritssuf alegtuvamasm4medbyMaesxinisettsGeralLaws t my sig mnm on this pe it application waives this reg meffo t e check one) Owner ® Agent Telephone No. PERMIT FEE$ rgna ure of Owner or gen �iw�f-L- o� 3- �� - a s P�'r''� �c�ev� ��� O1-� 3 - � 9- 0 � �✓ � ` Date... .../.. F .i °4- TOWN OF NORTH ANDOVER F: p PERMIT FOR WIRING AT 0 ,SSACMUS� This certifies that ......'..'.d..... .................... ...f ..................................... A has permission to perform . .............. ......« wiring in thce�building of at..... . North Andover,Mass. ? 01 Fee. .`.......... Lic.No %-/pgC�f ,�, / ELECTRICAL NSPECTOR Check # 5296 Office Use only ThECOAMOArR LTHOFAMS ACHU,S'�+M DEPAITAIEVTOFPUBLICSAFETY Permit No. � �` :• ' BOAR_DOFFIR_ EPREVENT70NREGULAHONS527CM -12.W Occupancy&Fees Checked APPLICATTONFOR PETO PERFORMELECTRICAL WORK ALL WORK TO BE PERFORMED IN ACCOR ANCE W H THE MASSACHUSSTS ELECTRICAL CODE,527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORM TION Date Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the ele t ' al work described below. Location(Street&Number) 3�- (1 ra-9 e ,Qcl j �p0-1 `A Owner or Tenant OLfl, S Owner's Address /� 1 Hn C'� A d)�m A.D.( : Yl/if/: n 1 L e� Is this permit in conjunction with a building permit: Yes= No (Check Appropriate Box) Purpose of Building ��5� C� �� Utility Authorization No. Existing Service6� Amps/01'0 /01y0 Volts Overhead © Underground � No. of Meters New Service /00 Amps /�q(�Voits Overhead Underground No. of Meters / Number of Feeders and Ampacity Locatioil and Nature of Proposed Electrical Work /Sf ahs /-/ook— lln 13r'!4 uP t) No.of Lighting Outlets O No.of Hot Tubs 0 No.of Transformers 0 Total KVA No.of Lighting Fixtures Swimming Pool Above Below Generators 6 KVA round ground No.of Receptacle OutletsNo.of Oil Burners No.of Emergency Lighting Battery Units 0 No.of Switch Outlets O No.of Gas Burners No.of Ranges No.of Air Cond. O Total FIRE ALARMS No.of Zones Tons No.of DisposalsO No.of Heat Total Notal` No.of Detection and Pumps Tons KW Initiating Devices No.of Dishwashers Space Area Heating KW Nq,of Sounding Devices 0 No':of%Self Contained Detection/Sounding Devices No.of Dryers ' Heating Devices D KW Local Municipal Other Connections .-No.of Water eaters , KW No.of No.of 0 Signs 6 Bailasis No.Hydro Mat-sage Tubs 0 No.of Motors Total HP 'IT-IER �unli�Covaage.Ptust>ar>rmthet�tmti�ltsofMass�ln�.�tsGeneialLaws aveaamentLiabflitybsrmxelblicyirkidingCompim Covaageoritsmbsta d e#vala>t YES NO ,iie,%bnz edvandproofofsameto&Offim YES Ifvoubavndrd dYO,pkmftdicaiethetypeofoDNaageby Xking alebox S'URANCEE BOND F7 OTHER F-1 (Please Spa*) rr f FVirationl)& ':k to Snit l� ' �'O—1 Estinaled Vahle ofFkchit�l Wotk$ h>SpedionDateRegtresled Rough Final ned under-Ti,analties of pajtuy. MNAME Li No. nsee /hg4+keo 1 e-rnmrcA Signattue IicenseNo y00\61 L' tBusiness Tel No. X17�— (�`,Sl" �9 3 V Htev,7 �ve - ��e�► P ®"`l Alt Tel No. 'NQ 'SINSURANCEWAIVE[2 Iamawmdiattheliomg--doesnothavetheinstuaricecovm,-eoritssut alffpvalerltasogmedbyNbssachusenCu)edLaws Thatmysignature onthispm6tapplicationwaives thisrequirernent F/ . :ase check one) Owner ® Agent Telephone No. PERMIT FEE$ lgna ure of Owner or Aorent a r u The Commonwealth of Massachusetts d . Department of Industrial Accidents Office of Investigations �R Boston; Mass. 02111 5,1b '� Workers'Compensation insurance Affidavit Name Please Print Name: Location: City Phone # I am a homeowner performing all work myself. 0 I am a sole proprietor and have no one working in any capacity I am an employer providing workers' compensation for my employees working on this job. Company name: Address. City: Phone#: Insurance.Co. Policv# Company name: Address ' City: Phone#: Insurance Co. Policy# Failure to secure coverage as required.under Section 25A or MGL 152 can lead to the imposition of criminal penalties of,a fine up to$1,500.00 and/or one years'imprisonment_as_welLas_civil..penatties in.-ffie farm cf-a_STOP WORK ORDER.-and a.fine_of.(.$1I10.00)a day against.me. I 1 understand that a copy-of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature Date Print name Phone.# Official use only do not write in this area to be completed by city or town official' City or Town Permit/Licensing Building Dept ❑Check if immediate response is required Licensing Board p Selectman's Office Contact person: Phone#: � Health Department ❑ Other O ^N017Th qti O 39 os.+vo F�t°i TSacNas CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Permit Number Io Date THIS CERTIFIES THAT THE BUILDING LOCATED ON 3Q M A R b A- f A D s � MAY BE OCCUPIED AS S)'v, rA /y D w e IN ACCORDANCE WITH THE PROVISIONS OF.THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY/"PLY. .. CERTIFICATE ISSUED TO '1 1j 01_ o Ck.) A- /D . Building Inspector tAORTH Town of =. -F_ `oo ; dover, Mass., C OC HIC HE WICK 4BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System ),�(M BUILDING INSPECTOR THIS CERTIFIES THAT........ /+ .....a ....................................... .................... ..............................................: Foundation f �! 04+ 1 �...: .A. .b 1a.. .a. ... ... Rough has permission to erect... .................................... buildings on..93d;? , A 1M �� + �� It* qL Chimney to be occupied as.. . ............ ........................I................f..................... ....................1.......................................................... / provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relatin to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. Bj i e, ` PLUMBING INSPE� VIOLATION of the Zoning or Building Regulations Voids this Permit. ou V —a—ckr- PERM17F EXPOS IN 6 MONTHS in ELECTRICAL INSPECTOR UNILESS •CONSTRUCTIONiTlAiFt �Ts Rough A /a ........................... .. ....................................... Service BUILDING INSPECTOR Occupancy Permit Regtdred to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final IS4 No Lathing or Dry Wall To Be,Drone FIRE DEPARTMENT Until Inspected and Approved by the R aiding Inspector. Burner i7" Street No. C SEE REVERSE SIDE Smoke Det. r Date. .?-. HORTM of —to 1.0 TOWN OF NORTH ANDOVER ,f I � PERMIT FOR PLUMBING . � ; . ,SSACNus �?This certifies that . . . . .r, . . .� . . . . . . . . . . . . . . . . . . . . . . . . . . has permission to perform . . . .h. s-.4p <<.- . . . . . . . . . . . . . plumbing in the buildings of . .( °'!7.G""�'- . . . . . . . . . . . . . . . . . . . at. 3 ?. .!4� � �:. l:. :`. . . . . . . . . . . , North Andover, Mass. Fee. s.3 . .` .Lic. No.. . . . . . . . . . . . . . . . PLUMBING INSPECTOR Check # U 6683 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBIN (Type or print) NORTH ANDOVER,MASSACHUSETTS Date Building Location, 4 Owners Name a Permit# O Amount Type of Occupancy (I d� New Renovation Replacement 0 Plans Submitted Yes ❑ No FIXTURES H w c � 4. S RFERVK M MOOR zn 4M H-" J$MROM MK 9M11-OCIR (Print or type) !� 1 Check one: Certificate Installing Company Name Corp. Address Partner. D Business Telephone Fi.VCO. Name of Licensed Plumber: Insurance Coverage: Indicate the type oin urance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity Bond ET . Insurance Waiver: I,the undersigned,have been made aware that the licensee of this application does not have any one of the above three insurance Signature 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 performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbinge and Chap 42 of h General Laws. By: 1gna re o icense um er Type of Plumbing License Title City/Town kensum er Master Journeyman APPROVED(OFFICE USE ONLY 2Z ..2. �� Residential Property Record Card PARCEL ID:210/008.0-0009-0000.0 MAP:008.0 BLOCK:0009 LOT:0000.0 PARCEL ADDRESS:32 MARBLEHEAD STREET FY:2008 PARCEL INFORMATION Use-Code: 101 "Sale Price: 1 Book: '01603 Road Type: T Inspect Date: 06/14/2004 Tax Class: T Sale Date: 09/02/82 Page: 0091 Rd Condition: P Meas Date: 06/ 14/2004 Owner: Tot Fin'Area: _.1168 Sale Type P- Cert/Doc: Traffic: ,rLL1 M 'Entrance: X HADDOW,WILMA Tot Land Area: 0.07 Sale Valid: A Water: Collect Id RRC C/O MARY M.INZERILLI -- -- _ _ _ Grantor; WHITE LEONARD W TR Sewer: Inspect Reas: M Address: 215 SALEM STREET Exempt-B/L% / Resid-B/L% 100/100 Comm-B/LP/o Indust-B/L% / Open Sp-B/L% / ANDOVER MA 01810 RESIDENCE INFORMATION LAND INFORMATION Style: CO Tot Rooms: 5 Main Fn Area: 784 Attic: NBHD CODE: 4 NBHD CLASS: 4 ZONE R4 N 1 P Co S Sq- O.res Influ YIN -Value Class Story Height: 1.50 Bedrooms: 2 Up Fn Area: 384 Bsmt Area: 784 - Seg Type Code _Method Sq-Ft Acr _ 70 _. ... 142,897 Roof: 'd Full Baths:. 1 ''Add Fn Area-' Fn Bsmt Area: Ext Wall: AV Half Baths Unfin Area. Bsmt Grade: VALUATION INFORMATION Masonry Trim: Ezt Bath Fix:""" 0 _Tot Fm Area:7.1__1168 ' Current Total: 230,400 Bldg: 87,500 Land: 142,900 MktLnd: 142,900 Foundation: ST Bath Qual: T RCNLD: 87514.. Prior Total: 170,000 Bldg: 84,900 Land: 85,100 MktLnd: 85,100 -Kitch Qual: T Eff Yr Built;; 1062.' Mkt Adj. Heat Type: ST Ext Kitch Year Built 1910 Sound Value: F,uelType: O " Grade. " Fi4� Cost Bldg;-, 87,500 Fireplace: 0 Bsmt Gar Cap: Condition: FA Att Str Val! Central AC:- N Esmt'Gar SF: 0ct'C6mplete: -Att Str Va12 Att Gar SF: %Good P/F/E/R: //100/69 Porch Tyne Porch Area Porch Grade Factor P 98 SKETCH PHOTO �,A. , 10 ,r s 47 Fl "�.5 t . 6 §qh m 37 26AIM 32 32 `. 32 MARBLEHEAD STREET . 6 54 Sq Ot Parcel ID:210/008.0-0009-0000.0 as of 5/21/08 Page 1 of 1 i I Location No. Date / -�9-- NORTh TOWN OF NORTH ANDOVER O�tt.•o ,•'�q. O F 9 Certificate of Occupancy $ SsncMusEt Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL Check # r 16991 // Building Inspect r TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REM RENOVATE, OR DEMOLISH A ONE OR TWO FAMILY DWELLING BUILDING PERMIT NUMBER: of 2 DATE ISSUED: /� p X I'Taw."Rr SIGNATURE: Building Commissioner/12-5 I�Etor of Buildings Date SECTION 1-SITE INFORMATION O 1.1 Property Address: 1.2 Assessors Map and Parcel Number: L/ Map Number Parcel Nu ber �1✓ � Gy\cam �l$ S 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Areas Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided 1.7 WaterSupply M.G.L.C.40. 54) I.S. Flood Zone Information: 1.8 Sewerage Disposal System: Public ❑ Private ❑ Zone Outside Flood Zone ❑ Municipal ❑ On Site Disposal System ❑ SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT 2.1 Owner of Record 11n ) - R ChaKlQ1 Name(Print) Address for Service Signature Telephone 2.2 Owner of Rec rd: Name Print Address for Service: z Signature Telephone SECTION 3-CONSTRUCTION SERVICES 90 3.1 Licensed Construction Supervisor: Not Applicable ❑ Licensed Construction Supervisor: ' J 3 License Number CRY Wn Adder— / Q Q � 6 Yd �� J Expiration Date Signature Telephone r tstered ome Improvement Contractor Not Applicable ❑ ago Company Name Registration Number rM Address Expiration Date ^ Signature Telephone VI i 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.......0 No.......0 SECTION 5 Description of Proposed Work(check all applicable) New Construction ❑ Existing Building V Repair(s) Alterations(s) ❑ Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify .s-t t Brief Description of Proposed Work: + " �Cv6L c� 1 SECTION 6-ESTIMATED CONSTRUCTION COSTS Item Estimated Cost(Dollar)to be Y C)FFICIAL�7SE�OITI.y O L Completed by permit applicant , ..: 1; � F A,� ...{ _-Z'4', 4k&:• 1. Building (a) Building Permit Fee ' Multiplier 2 Electrical (b) Estimated Total Cost of Construction / 3 Plumbing Building Permit fee(a)x (b) 4 Mechanical(HVAC) fry 5 Fire Protection; 6 Total 1+2+3+4+5 Check Number SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, as Owner/Authorized Agent of subject property Hereby authorize C Oa, CEJ Q n to act on M�behaIf,m all mattrel a to work authorized by this building permit application.0— 1 L/ a�' /� 3 Signature of Owner j'_ Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 1, U 2�,�A Q as Owner/Authorized Agent 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 ;� I� G Print Name 9 2_/D1/63 /D Q/63 Signature of Owner/ ent Date �/ 111MARNM mom NO.OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 2 ND 3 RD SPAN x- DMIENSIONS OF SILLS DIMENSIONS OF POSTS ! f b< Z DRvIENSIONS OF GIRDERS x t HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY JY.� IS BUILDING ON SOLID OR FILLED LAND , 1 e J IS BUILDING CONNECTED TO NATURAL GAS LINE a � �4( i t ✓�ie ZJoarrraoraaseca+!C�i o��aao¢clucaPl7a y, Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration: 123420 Expiration: 2/14/2005 Type: DBA CERMENO CONSTRUCTION EDGAR CERMENO 206 PROSPECT ST. � LAWRENCE,MA 01841 Administrator A i 1 1 i 1 i I i I t I - t1ORTH own of No. O .,�. y iz a 9 2 003 a." dover, Mass., COCHICHEWICK ORATEo p,PCl U BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System THIS CERTIFIES THAT........ BUILDING INSPECTOR .... ... �....... .. .................................................... Foundation ION has permission to erect..........:.................. buildings on ................ Rough .......... ....................................... • to be occupied as. 11� Chimney provided that the person accepting this per sh in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final ELECTRICAL INSPECTOR UNLESS CONSTRUCTION ST Rough .....................................:.........................................................................:.. Service BUILDING INSPECTOR Final Occupancy Permit Required t0 Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove Rough Final No Lathing or Dry Wall To Be Done Until Inspected and Approved by the Building Inspector. FIRE DEPARTMENT Burner Street No. SEE REVERSE SIDE Smoke Det. PROPOSAL I I I PROPOSAL NO. i SHEET NO. DATE PROPOSAL SUBMITTED TO: WORK TO BE PERFORMED AT: NAME ADDRESS ADDRESS 4a. DATE OF PLANS PHONE NO. ARCHITECT 9 - 7v - a '7 id We hereby propose to furnish the materials and perform the labor necessary for the completion of t c I ISI a I I All material is guaranteed to be as specified, and the above work to be performed in accordance with the drawings and specifi- cations submitted for above work and completed in a substantial workmanlike manner for the sum of ? Dollars ($ with payments to be made as follows. e 2 I Respectfully submitted Any alteration or deviation from above specifications involving extra costs will be executed only upon written order, and will become an extra charge Per r t over and above the estimate. All agreements contingent upon strikes, ac- cidents,or delays beyond our control. N to—This proposal may be withdrawn i by us if not accepted within days., I ACCEPTANCE OF PROPOSAL The above prices, specifications and conditions are satisfactory and are hereby ac epted. You are authorized to do the work as specified. Payments will be made as outlined above. v� Signature- DateG► Signature cam.. — NC 3818-50 PROPOSAL MADE IN USA �+ i I INSTRUCTIONS: This form is used to verify that all necessaryapproyals/permifs fromBoards and Departments having jurisdiction have been obtained. This Idoes not the applicant and/or.landowner from compliance with any applicable or requi em.ents relieve APPLICANT FILLS OUT THIS SECTION****i********,**********i ARPL►CANT PHONE i LOCATION: Assessor's Map Number PARCEL_____ SUBDIVISION LOT(S) STREET 3o' ST. NUM13ER OFFICIAL USE ONLY********* I RECOM MEND ATIONS OF TOWN AGENTS: � CONSERVATION ADMINISTRATOR DATE APPROVED DATE REJECTED COMMENTS �► i TOWN PLANNER DAT E.APPROVED. DATE REJECTED COMNIEN T S I FOOD INSPECTOR HEALTH DATE.APPROVED DATE REJECTED__ SEPTIC INSPECTOR-HEALTH DATE APPROVED DATE-REJECTED. x COMMENTS PUBLIC WORKS-SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9197 J'm i NORTH Town ofAndover No. y g ti....., 3 w. .� A K E o dower, Mass., Ito a 9 21o&3 .A COCKICKEWICK A. 00 ATED 7 U BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System BUILDING INSPECTOR THIS CERTIFIES THAT • ....... Foundation has permission 4o erect..................... buildings on ........ Rough .......... ........................................... to be occupied as. ...... ............. Chimney ile in Final provided that the person accepting this permit sh in every respect conform to the terms of the application on f this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EMPIRES IN 6 MONTHS Final ELECTRICAL INSPECTOR UNLESS CONSTRUCTION ST M: Rough .....................................:................................................... ........................: Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove Finalh No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner - Street No. SEE REVERSE SIDE Smoke Det. .M' i Sw � LTi _ K.aed fi- rte.nF•sac,� '� :* -*e� �-`�• �4 �.�+�`�'.;,t�`'�3�aa...11pp it IR I , r r iFl �1 r 1Kpyily �Fa � '� e ..'fj e�x=F` � *��.F,� $^�ka4st+�r+m�r4�. �+�•. `1.��..k ,"J s .1.! •i ,r',,Jr:R I•,.!,/1 d e.6! " a A s rr•+"��G,.,, �r -s"ki'g �; "s'�a�ca � .` e° l` fkMPJA,ws"G.wfi 1 s. aR i. ...9wVP[fe�.. yt th Y .A NEW ENGLAND CLAIMS SERVICE, INC. ReplyTo ❑ Reply To ❑ Reply To ❑ P.O. BOX 345 100 CONIFER HILL DRIVE, SUITE 308 P.O. BOX 578 MANSFIELD, MA 02048 DANVERS, MA 01923 SHREWSBURY, MA 01545 TEL. (508) 337-8058 TEL. (978) 777-9900 TEL. (508) 842-3995 FAX (508) 339-5835 FAX (978) 774-9296 FAX (508) 842-7510 Form of Notice of Casualty Loss to Building Ta7'TaF "oRYF] ec�Ra ofH A�L'ET' H'o' Under Mass. Gen. Laws, Ch. 139 Sec 3D { JUS - 3 2003 TO: Building Commissioner or Board of Health or Inspector of Buildings Board of Selectmen__ addresses RE: INSURED \A) A PROPERTY ADDRESS Yy1&,g?j c k^0 m O&-7" to N,p0y.cel{ 04A © (X q5 POLICY NO.: _ �(3 I LOSS OF: 19 FILE OR CLAIM NO.: ?)QS_ w-1-3L{ C1 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, Chapter 139 Section 3D 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. TITLE 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. / 0 SIGNATURE AND DATE cc : Fire Dept . NEW ENGLAND CLAIMS SERVICE, INC. ReplyTo ❑ Reply To ❑ Reply To ❑ P.O. BOX 345 100 CONIFER HILL DRIVE, SUITE 308 P.O. BOX 578 MANSFIELD, MA 02048 DANVERS, MA 01923 SHREWSBURY, MA 01545 TEL. (508) 337-8058 TEL. (978) 777-9900 TEL. (508) 842-3995 FAX (508) 339-5835 FAX (978) 774-9296 FAX (508) 842-7510 n t A,'! Ist Form of Notice of Casualty Loss to Building Under Mass. Gen. Laws Ch. 139 Sec 3D JUL ' y � TO: Building Commissioner or Board of Health or _ _ __Inspector of Bui.ldin s Board of Selectmen 71�� ,�-, addresses RE: INSURED 1 "I PROPERTY ADDRESS `�� ►N6131C i�c � n t9s�►Ar�v ts+� ✓� b 1 S-+-I POLICY NO.: 1 cl 112-S%-1 j LOSS OF: -30— agg3 19 FILE OR CLAIM NO.: `3173C(8 Claim has been made involving loss, damage or destruction of the above-captioned property which ma .either exceed $1 ,000.00 or cause Mass. Gen. Laws Chapter 143 Section 6 to be applicable. If any notice under Mass. Gen. Laws Chapter r 139 Section 3D 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. TITLE On this date, I caused copies of this notice to be sent to the persons n med above at the addresses indicated above by first class mail. GNATURE AND DATE cc : Fire Dept . NEW ENGLAND CLAIMS SERVICE, INC. ReplyTo ❑ Reply To ❑ P.O. BOX 345 100 CONIFER HILL DRIVE, SUITE- 308P.O. OX 578 MANSFIELD, MA 02048 DANVERS, MA 01923 SHREWSBURY, MA 01545 TEL. . 337-8058 TEL. (978) 777-9900 TEL. (508) 842-3995 FAX (508)508) 339-5835 FAX (978) 774-9296 FAX (508) 842-7510 Form of Notice of Casualty Loss to Building Under Mass. Gen. Laws Ch. 139 Sec. 3D 3 2003 TO: BuildingCommissioner mmissioner or Board of Health or - --- i Inspector of Buildings p g Board of Selectmen Uj addresses _N o&-Tj RE: INSURED PROPERTY ADDRESS -3 �►� ViAft D POLICY NO.: LOSS OF: 19 FILE OR CLAIM NO.: yL)j 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, Chapter 139 Section 3D 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. C VL TITLE On this date, 1 caused copies of this notice to be sent to the persons n med above at the addresses indicated above by first class mail. GNATURE AND DATE cc : Fire Dept .