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HomeMy WebLinkAboutMiscellaneous - 340 WOOD LANE 4/30/2018_NgO N I � O NO N � _ 0 ."i v 00 8s b z o fir" gm 0 0 Cunningham Lindsey U.S., Inc. P.O. Box 703689 Dallas, TX 75370-3689 Telephone (888) 738-8714 Facsimile (214) 488-6766 CLCAT@CL-NA.COM ***********************AUTO**3-DIGIT 018 768 T3 P1 95000058958 Building Commissioner or Inspector of Buildings 120 MAIN STREET N Andover, MA 01845 Cunnin fiham �% l�Lindsey Form of Notice of Casualty Loss to Building Claim has been made involving loss, damage, or destruction of the above captioned property, which may either exceed $1,000 or cause Massachusetts General Laws, Chapter 143, Section 6, to be applicable. If any notice under Massachusetts General Law, Chapter 139, Section 36 is appropriate, please direct it to the attention of the writer. Kindly include a reference to the captioned insured, location, date of loss and claim number. Section 3B. No insurer shall pay any claims (1) covering the loss, damage, or destructions, to a building or other structure, amounting to the 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 the 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. Under MASS. GEN. LAWS Ch. 139, Sec 3B Claim Number: 646802 Policy Number: 646802 30 m Company Name: MERRIMACK MUTUAL FIRE INS LO Cause of Loss: ICE DAM co F Date of Loss: 2/18/2015 Insured: James Roche 0 Property Location: 340 Wood Ln Claim has been made involving loss, damage, or destruction of the above captioned property, which may either exceed $1,000 or cause Massachusetts General Laws, Chapter 143, Section 6, to be applicable. If any notice under Massachusetts General Law, Chapter 139, Section 36 is appropriate, please direct it to the attention of the writer. Kindly include a reference to the captioned insured, location, date of loss and claim number. Section 3B. No insurer shall pay any claims (1) covering the loss, damage, or destructions, to a building or other structure, amounting to the 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 the 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 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. Cunningham Lindsey Catastrophe Department cicat(o)cl-na.com 800-867-3885 ` Date .... ...... ............................ NOR7h o? •`` ' ' °°9 TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION Thiscertifies that �.................................................................................... ' ....................... has permission for gas installation ...... G:...... `?:..?'.� in the buildings of ...............'....................:................. Poe �e- at ....- w l—*' ........................ . North Andover, Mass. ................................................................ . MK Fee..... Lic. No. ........................................................ Check # ( b r GASINSPECTOR y1 X219 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK r CITY I North Andover MA DATE 3/24/2014 PERMIT #—iTl JOBSITE ADDRESS L340 Wood Lane OWNER'S NAMEono ue GOWNER ADDRESS I Same I TE 978 685 5403 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL[] EDUCATIONAL ® RESIDENTIAL❑ PRINT CLEARLY NEW:❑ RENOVATION: ❑ REPLACEMENT: ® PLANS SUBMITTED: YES❑ NO❑ APPLIANCES 1 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM /SPACE HEATER ROOF TOP UNIT .FEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER Replace Gas Meter x and Pioin as Needed INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES [JNO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ OTHER TYPE 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: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT 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 knowledge and that all plumbing work 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. PLUMBER-GASFITTER NAME I Joseph Marino LICENSE #�PARTN 36 SIGNATURE MP 0 MGF F-1JP[jJGF ❑ LPGI ® CORPORATION [1# 3285C SHIP ®# LLC ®# COMPANY NAME: RH White Construction Co ADDRESS 41 Central St CITY I Auburn I STATE MA ZIP 01501 TEL 1(508) 832-3295 FAX 508-926-4347 CELL 508-832-46144IEMAIL JMarino@RHWhite.com r l Im w H 0 z z 0 H U W W d z w a Zo❑ z O H� d O � W O w O H n W 3 W a a a W a Pro W a V o a a � U J F,. a a w X: w � a O \ � O \ F U W a z unH v x x 0 x mi --�-7­-:-'""-- : Olt A::;f'4 n�g L>- WLU LL .0 0=) > ti z 0 Ln 'j < < " cii: 2C3 U),qC < k LU w (.D IX Au LA mi 04/03/2014 14:04 5088326751 RH WHITE CONSTRUCT PAGE 02/02 AC ® GATE (MMlDDryyYY) � CERTIFICATE OF LIABILITY INSURANCE rage 1 0� 08/29/2013 THIS CERTIFICATE IS ISSUED ASA 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(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the Certificate holder is an ADDITIONAL INSURED, the policy(ios)muct be endorsed. If SUBROGATION IS WAIVED, subject to theterms and conditions of the policy, certain policies may require an endorsement. A statement on this certifleate does notconferrights to the certificate holder in lieu of such endorsement(s), A IB Willia of Massachusetts, Inc. c/o as CAAtvey Blvd. R. 0. sax 305195 NaChville, TN 37230-5191URER(9 77-945•-7378AxNO), 888-467-2378 eAIL te��•e.c0m SUE 4FI,1 AFPORDINGCOVERAGE NAICttChartOr oak Fire Insuranco Company 25615-001 .� t4hite Construction Company, Inc. 41 Canrral Street: P. 0. Box 257 lgx2 Property Casualty Company of ]mt 25674-063 nAl Union Fir,) Inevranco Company of 7.9445-001 INSURERD;Travelera Indmmrzty Company 25658-DOl Auburn, MA 01501 UVLKAGES CERTIFICATE NUMBER: 20287680 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSUR INDICA7ED. NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER I CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRI13E EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. t TYPEOPINSURANCE DD' SUE pOLICYNUMBER GENERALUABILITY .� 300 _000 MEDEXP(Anyone arson) VTC2000 977X9948-13 X COMMERCIAL GENERALLIAFAIL17Y CLAIMS -MADE OCCUR 000 GENERAL AGGREGATE $ 4, 000 000 PRODUCTS-COMP/OP AGO GEN'LAGGREGATF LIMITAPPLIES PER; X8 OM8NN1 eDSINGLFnt),LIMIT POLICY 51 PRO -LOC 2,000,000 BODILY INJURY(Peroemon) $ AUTOMOBILELTABILITY 130DILY I NJ URY(Per accident) VTaCAP 977K955P.-13 X ANY AUTO AUITOS NEI) SCHEDULED EACH OCCURRENCE 5 $ 5' 000, 000 AGGREGATE $ 9.000,000 X wos ° - 7DRY LI, E.L. EACH ACCIDENT 5 .$ 11000 000 X HIREDAUTOS X MON-OWNED AUTOS X Co Defl X _C 11 Ded aroo UMBRELLAUAB Ix OCCUR $£8766140 EXCESS LIA6 CLAIMS -MADE DEC) I $ RETENTIONS 10,000 WORKERS COMPENSATION 7z>�17� 82 0 5A7.8 5 -13 AND EMPLOYERS' LIABILITY Y!N - ANY PROPRIETORIPARTNERIFXECUTIVEI_ I NIA VTC21mB A203A71A-13 < OPPICERIMEMOEREXCLUDED? I`JJ Mandetory In NH) U 'uKIII UNu UPURATIONSbelew Evidonce of InmuXAnce 1/1/2013 •9/1/2014 /1/2013 19/1/2014 /1/207,3 )9/1/2014 /1/207.3 19/1/2014 9/1/2014 /1/2013 u,ui,wu-piRamarKeacneaviu,amoreepgab REVISION NUMBER: :D NAMED ABOVE FOR THE POLICY PERIOD IOCUMENT WITH RESPECT TO WHICH THIS HEREIN IS SUBJECT TO ALL THE TERMS, LIMITS EACH OCCURRENCE 'F 2,000,QOD r� TORENTED ��� IS�,B�Eeoceumncrl .� 300 _000 MEDEXP(Anyone arson) 101 000 PERSONAL&ADV INJURY 000 GENERAL AGGREGATE $ 4, 000 000 PRODUCTS-COMP/OP AGO E_4, 0 0 0 000 X8 OM8NN1 eDSINGLFnt),LIMIT & 2,000,000 BODILY INJURY(Peroemon) $ 130DILY I NJ URY(Per accident) ereccldenl $ EACH OCCURRENCE 5 $ 5' 000, 000 AGGREGATE $ 9.000,000 X wos ° - 7DRY LI, E.L. EACH ACCIDENT 5 .$ 11000 000 E.L. DISEASE- EAEMPI,pYP.E $ F,L,DISEASE. POLICY LIMIT 1,000,000 110001000 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES SE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZEDREPRESENTATNH UQA1:42N7bU4 ` PI:1694012 Ce7:t::20287680 ®1988-2010ACORDCORPORATION,A11 rights ACORD 25 (2010!05) The ACORD name and logo are registered marks of ACORD Af d NORr 0.1,a74, p P SA US Date..�.'3l'.. f',� TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .... ................. -U........ has permission to perform......_.... +'................. wiring in the building of 4-' L�/ at `f �i' .. ......�"°'(1......,_,................................ . rth Andover, -Mass. c�912 Fee ............. Lic. No. �'.......................� ..����r .. ELECrIC INS ECr0 Q Check# 1,11P 8224 W Commonwealth of Massachusetts Official Use Only Department of Fire Services o. baa BOARD OF FIRE PREVENTION REGULATIONS cy and Fee Checked °� (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT ININK OR TYPE ALL INFORMATION) Date: ( r C, ( 0 City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) 1,41 Owner or Tenant tF Owner's Address S�rJt Is this permit in conjunction with a building permit? Purpose of Building f Existing Service i / 0 © Amps / /C / Z"fOVolts New Service `l 6 Amps / � /i� Volts Number of Feeders and Ampaeity Location and Nature of Proposed Electrical We Brae � P -Ate . - e-1 C-,/ l`T of Recessed Luminaires No. of Luminaire Outlets No. of Luminaires No. of Receptacle Outlets No. of Switches No. of Ranges No. of Waste Disposers No. of Dishwashers No. of Dryers Heaters KW No. Hydromassage Bathtubs a Telephone No. Yes ❑ No L7 (Check Appropriate Box) Utility Authorization No. Overhead Undgrd ❑ No. of Meters ' Overhead Undgrd ❑ No, of Meters I 'motif 'a the ollowinR table may be waived by tho T"r—i— „r m: No. of Cell.-Susp. (Paddle) Fans No. of Hot Tubs Swimming Pool m.nd Above Ep �' en No. of Oil Burners No. of Gas Burners No. of Air Cond. Total Tons Totals: I- Space/Area Heating KW Heating Appliances KW No. of No. of Signs Ballasts . No. of Motors Total HP Estimated Value of Electrical Work: Attach additional detail if desired, or as required by the Inspector of Wires. .(When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such cov a is in force, and has exhibited proof of same to the permit issuing office., CHECK ONE: INSURANCE [BOND ❑ OTHER ❑ (Specify:) I certify, under the ns and penalties /perjury, thaf he is ormadon on this application is true and complete, FIRM NAME •". �L s'� / �� ,-�, LIC. NO.: i! I 7 Licensee: �� -3 i. Signature r Q_ (If applicable, enter "exempt " in the license nuipber line.) IC. NO.: 77 Address: Li J �� ®� Bus. TeL No.:10 *Per M.G.L c 147, S. 57 61, security work re vires D Alt. Tel No.: �' q apartment of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage no rmally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑owner ❑owner's agent Owner/Agent Signature Telephone No. PERMIT FEE: $ Total Transformers KVA Generators KVA —me d. o. o E rmgency tg g Battery Units 'TIRE ALARMS INo. of Zones No. of Detection and Initis ' Devices No. of Alerting Devices 71!sgi�er edDevicesg on ❑ Other Security Systems:* No. of Devices or E uivalent Data Wiring: No. of Devices or Equivalent Telecommunications firing: No. of Devices or Equivalent Estimated Value of Electrical Work: Attach additional detail if desired, or as required by the Inspector of Wires. .(When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such cov a is in force, and has exhibited proof of same to the permit issuing office., CHECK ONE: INSURANCE [BOND ❑ OTHER ❑ (Specify:) I certify, under the ns and penalties /perjury, thaf he is ormadon on this application is true and complete, FIRM NAME •". �L s'� / �� ,-�, LIC. NO.: i! I 7 Licensee: �� -3 i. Signature r Q_ (If applicable, enter "exempt " in the license nuipber line.) IC. NO.: 77 Address: Li J �� ®� Bus. TeL No.:10 *Per M.G.L c 147, S. 57 61, security work re vires D Alt. Tel No.: �' q apartment of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage no rmally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑owner ❑owner's agent Owner/Agent Signature Telephone No. PERMIT FEE: $ I Lp' The Common wealth of Massachusetts k� ! Department of Industrial Accidents lk Office of Investigations Ulf s r 600 Washington Street Boston, MA 02111 www mast gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Eiectriciaus/Plumbers Applicant Information Name (Businessibrgaoirdtion/Individual): Address:_ City/State/Zip:_ Are you an employer? Check the appropHate box: ` 1. ❑ l tun a employer with 4. ❑ 1 am a general contractor and I ployees (full and/or part-time).* . have hired the sub -contractors 2. I am: e.sole proprietor or partner- listed on the attached sheet t ship and have no employees These sub -contractors have working for mein any capacity, workers' comp. insurance. [No workers' comp, insurance S. ❑ We are a corporation and its . required..] 3. ❑ I air a homeowner doing officers have exercised their all work right of exemption per MGL myself. [No•worke'rs' comp, c. 152, § 1(4), and we have no insurance required:] t employees. [No workers' •d,,. e.. N ­ o, comp. insurance required..] (C. �7SYys/lrG Type.of project (required): 6. [] Now construction 7. ❑ Remodeling 9. Q Demolition' 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.0 Plumbing repairs or additions 12.[] Roof repairs 13. ❑ Other .., w ,u, out ure wean below showing their workers' bomponutioci policy information t Homeowners who submit this affitlavit indicating they are doing all work and then hire outside conuactors must submit a new affidavit indicating such. ;Contractors that check this box must attached an additional sheet showing. the name of the sub,coi n eton; and their worker 'comp, polies information. I am an employer thar.is.providing:workers' compensation insurance for my employees: information Below is the policy and job site insurance Company Name: Policy # or Self -ins. Lie. #: 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 penaltits of a fine up to $4500,00 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 here c fP % �' hereby elder the pains and penalties er u .that the information provided above is true and correct Si tune Date: `Z 7.� tJ Phone #: /' q Ofriciat use only. Do not write in this area, to he completed by city or town officio( City or Town: Permit/License # Issuing Authority (circle one): I. Board of Health Z Building Department 3. City/Town Clerk 4. Electrical Inspector S. Plat mbing Inspector Contact Person: Phone #r Information. and Instructions V4 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" An employer is defined as "an individual, partnership, assodiation, corporation or other legal entity, or any two or more ofthe'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 licensing agency shall withhold the issuance or renewal of a license or permit to operate 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, MOL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter irno any contract far 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' compmsation 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 certificates) 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 may be submitted to the Department of industrial Accideri s 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 numberlisted 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 permitllicense. number which %vilI be used as a reference number. in addition, an applicant that. must submit multiple permit/licame 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 aff davit 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 at permit to bum leaves etc.) said parson is NOT required to complete this affidavit The Office of Investipations 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. 9 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-Q5 Fax 4 617-727-7744 rvww.mass.gov/dia