HomeMy WebLinkAboutMiscellaneous - 354 MAIN STREET 4/30/2018Phone: 978-632-2660 Fax: 978-632-2662
JAMES A. TRUDEAU
Adjustment Service Inc.
P. O. Box 7
Gardner, MA 01440
claimsna,trudeauadi.com
Notice of Casualty Loss of Building
Under Massachusetts General Laws, Chapter 139, Section 313
March 6, 2015
)Building Inspector
120 Main Street
North Andover, MA 01845
Board of Health
120 Main Street
North Andover, MA 01845
Fire Department
Dept. of Records
1.24 Main Street
North Andover, MA 01845
Insured:
John & Jaime Phelen
Loss Location:
354 Main Street, North Andover, MA 01845
Insurance Company:
Preferred Mutual Insurance Co.
Policy No.:
PHOO100779907
Date of Loss:
March 5. 201
File Number:
15-13050
Claim Number:
15106738
Type of Loss:
Property Damage
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 3B" is appropriate, please direct it to the writer and include a reference to the
captioned insured, location, policy number, date of loss, and file or claim number.
Claim has been made involving loss, damage or destruction of the above -captioned property, which may
exceed $5000. If any notice under Massachusetts General Laws, Chapter 175, Section 97A is appropriate,
please direct it to the attention of this writer and include a reference to the above -captioned insured,
location, policy number, date of loss and claim number.
On this date, I cause copies of this notice to be sent to the person(s) named above at the address indicated by first
class mail.
Sincerely,
Joshua M. Truheav
Claims Adjuster
10135
Date .... . ` ......1..,
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that..410.01�... ....... R..(/ h....„ /, ....
has permission to perform ..../..............................
wiring in the building of .... T. a. h.
�" �l {� yin
at.......�......................................... "...................... ,North Andover, Mass.
Fee..`j� ............. Lic. No.............. ....................... TRIC..................................
ELECTRICAL INSPECTOR (46
i Check # R31 3
Lj
Commonwealth of massachusetts
Department ®f Fire Services
lug BOARD OF FIRE PREVENTION REGULATIONS
OMcial Use O
Permit No. L G L � S
Occupancy and Fee Checked
Cev. 1/071 (leave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code
(PLEASE PRINTININK OR TTPEALL INFO D
7YON (ME ), 5 7 CMR 12.00
ate:
City or 7['own of: To the Inspector of Wires:
By this application the undersi ed gives no ' e of his or hex ' tention to perform the electrical work described below.
Location (Street �& Number)�K
Owner or Tenant '3til, , ✓6J „ ,a --
Owner's Address
is this permit in conjunction with a building permit? Yes ❑
Purpose of Building ~' / s rmrit
E t' 4pd
Telephone No. 7f- W-704
No P-'FLDG PERWT #
Utility Authorization No.
gis ing Service ® Amps / olts Overhead [-
New- — Service
Amps _ / _Volts
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
N jd
No. of Recessed Luminaires
i 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
No. of Water RW
Heaters
No. Hydromassage Bathtubs
OTHER:
Overhead ❑
X
of Ceil: Susp. (Paddle) Fans
of Hot Tubs
Swimming Pool Above
- grnd
No. of Oil Burners
------------
Ko. of Gas Burners
------------
?To. of Air Cond. To
Totals:I ..........
=e/Area Heating KW
Ing Appliances KW
o.
o. of Motors
No. of
Ballasts
Total HP
Undgrd ❑ No. of meters
Undgrd ❑ No. of Meters
living table maybe waived by the Inspector of Wires
No, of Total,
Transformers KVA
Generators RVA
o. o mergency ig mg
❑ Batte Units
FIRE ALARMS No. of Zones
No. of Detection and
Initiating Devices
No. of Alerting Devices
Local ❑ 1°lunicipal
Connectioi
Security Systems: *
No. of Devices or
Data Wiring:
No. of Devices or
Telecommunications
No. of Devicae nr
❑ Other
uivalent
Attach additional detail if desired, oras required by the Inspector of Wires.
Estimated Value of Electrical Work:
Work to Start: (When required by municipal policy.)
_ Inspections to be requested in accordance with MEC Rule 10, and upon comp
INSURANCE O GE: Unless waived by the owner, no permit for the performance of letion. 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 coverage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE OND ❑ OTHER ❑ (Specify:)
dcwr , under the ains andpenaldes ofperjury, that the information on this application is true and complete
FIRM NAME:
LIC. NO.:�-
Licensee: rG� Signature_
(Ifapplicable, r "exe t" in the cense number line.) � �—� LIC. NO.: )0/ja-s
Address: '' � S .5 v Bus. Tel. No. --C/;7- 552 Z4S1
Alt. TeI. No.:
*Per M.G.L c 147, s. 57 61, security work requires Department of public Safety "S" Licen LIC. NO.:
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner El owner's agent
Owner/Agent
Signature Telephone No. PERMIT FEE: $ ��
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office oflnvestigations
600 Washington Street
,t Boston, MA 02171
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Bui ldeirs/Contractors/JElectriciaus/PZumbears
APPlicant information Please -Print Legibly
Name(B.usiness/Organization/ln(Uviduat):
Address:
City/State/Zip:
Phone #:
Are you an employer? Check the appropriate box:
L ❑ I axn a employer with
4. ❑ I am a general contractor and I
employees (fall -and/or part - time).*
2. ❑ I am a sole proprietor orpartnar
have hired the sub -contractors
listed on the attached sheet. x
ship and have no employees
These sub -contractors have
working for me in any capacity.
[No workers' comp. insurance
workers' comp. insurance.
5. ❑ We are a corporation and its
required.]
3. ❑ I am a homeowner doing all work
officers have exercised their
right of exemption per MGL
myself. [No workers' comp.
c. 152, § 1(4), and we have no
insurance required.] t
employees. [No workers'
comp. insurance required.]
Type ofproject (required):
6. [] New construction.
7. n Remodeling .
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
11.0 Plumbing repairs or additions t
12.❑ Roofrepairs
13.❑ Other
r U11—ALL U1cLL cneous oox III must also rut out the section below showing their workers' compensation policy Mormation.
Homeowners 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 mustaQfached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
lam an employer that is providing workers' compensation insurance for my employees Below is the policy anti job site
information.
Insurance Company N
Policy # or SeIf-ins. Lic.
Yob Site Address:
Expiration Date:
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 r'
of up to $250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
w
I do hereby eert�o under thepains and penalties ofperjury that the informationprovidedabove is true andeorr ect.
Signature: Date
Phone #: r
�ffzcial use orziy. Do not Write in this area, to be complefed by city or town official
City or Town: Permit/License #
rssuing Authority (circle one):
X. Board ofHealth 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6 Other
C ontactPerson: Phone
Location -3 5 `f %1 q c - S1
No. —q7/ Date 6
l
d
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $ k
Foundation Permit Fee $
Other Permit Fee $
Sewer Connection Fee $
Water Connection Fee $
TOTAL
113407 cc,54.
�/f $ / C)
Building Inspector
Div. Public Works
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The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Boston, Mass. 02191
Workers' Compensation Insurance Affidavit
Please Print
Location: 'r' --
City L Phone
am a homeowner performing all work myself.
F -1I am a sole proprietor and have no one working in any capacity
F�`I am an employer providing workers' compensation for my employees working on this job.
Insurance Co. __64/Ji CC _7/— < Policv # LUC"_ l/ ?166 /,P2 <-
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 well as civil penalties in the form of a STOP WORK ORDER and a fine of ($100.00) a day 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 herby certify under th,p pains and penalties of perjury that the information provided above is true and correct.
Signature,
Print name
Official use only do not write in this area to be completed by city or town official'
❑Check if immediate response is required Building Dept
Contact person. Phone A
Date /,
Phone #
❑
Building Dept
❑
Lincensing Board
❑
Selectman's Office
❑
Health Department
❑
Other
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BUILDING DEPARTMENT
DEBRIS DISPOSAL FORM
In accordance withthe provisions of MGL c 40 S 54, a condition of Building Permit Number
Is that the debris resulting form this work shall be disposed of in a properly licensed solid waste disposal facility as
defined by MGL c 11, S 150A
The debris will be disposed of in:
0
Location of Facility
Signature of Pe Applicant
Date
NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of
the Building Inspector
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