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HomeMy WebLinkAboutMiscellaneous - 38 COLUMBIA ROAD 4/30/2018North Andover Board of Assessors Public Access �J cc Page 1 of 1 pORTh North Andover Board. -of Assessors OE spa . 4� t � �.(°� ,SSACHUSEt _ roperty Record Card . Click Seal To Return n.,.---1 m .7t nine,t n nnen nnnn n Search for Parcels Search for Sales Summary Residence Detached Structure Condo Commercial httn://csc-ma nc/PR SKETCH PHOTO Click on Sketch to Enlarge Click on Photo to Enlar e 1; 38 COLUMBIA ROAD Location: 38 COLUMBIA ROAD Owner Name: DELGADO, MARIA FATIMA Owner Address: 38 COLUMBIA ROAD City: NORTH ANDOVER State: MA Zip: 01845 Neighborhood: 5 - 5 Land Area: 0.23 acres Use Code: 101-SNGL-FAM-RES Total Finished Area: 1084 sqft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 266,900 264,000 Building Value: 105,600 99,600 Land Value: 161,300 164,400 Market Land Value: 161,300 Chapter Land Value: TOWN OF NORTH ANDOVER Office of the Building Department Community Development and Services 1600 Osgood Street, Bldg. 20, Suite 2035 North Andover, MA 01845 978-688-9545 Gerald Brown, Inspector of Buildings Fatima Delgado 38 Columbia Road North Andover, MA 01845 i Re:38 Columbia Road Dear Ms. Delgado, February 14, 2013 The inspection follow up regarding the gas furnace brought to light other outstanding issues that need to addressed. The basement has been renovated to contain two bedrooms and a bathroom. This renovation has been done without proper building, electrical, plumbing and gas permits. Other issues were noted in the inspection, including improper ceiling height and an impaired egress. To be in compliance with Massachusetts State Law under 780 CMR State Board of Building Regulations and Standards, R105.1 states that changes to a structure must begin with a written application with the building official to obtain the required permit. You and your contractors must come to the Building Department Office as soon as possible to file the proper permits to correct the above violations. Sinc rel G raid Brown, Building Commissioner Town of North Andover MetLife Auto & Home® Homeowner Operations Field Claim Office Attention: Claims P.O. Box 6040 Scranton, PA 18505 (800)854-6011 February 19, 2015 North Andover Building Inspection 1600 Osgood St, Suite 2035 North Andover, MA 01845 Our Customer: Claim Number: Date of Loss: Maria F. Delgado JDE91100 OG February 14, 2015 Dear North Andover Building Inspection: Pursuant to M.G.L. 139 § 313, please be advised that a property loss at the address referenced below has been estimated to have damage to the dwelling or other structures that will exceed one thousand dollars. Please let us know within ten (10) days if there is a pending or existing lien against the property as provided by M.G.L. 139 § 313, or if there is an intent to initiate proceedings to perfect such a lien. Loss Location: 38 Columbia Rd, North Andover, MA Sincerely, Home Ops CAT Team Sarah Lackey Metropolitan Property and Casualty Insurance Company Claim Adjuster (800) 854-6011 Ext. 7440 Fax: (855) 411-6689 Email: MetLifeCatTeam@metlife.com MetLife Auto & Home is a brand of Metropolitan Property and Casualty Insurance Company and its affiliates, Warwick, RI. MPL MA-REGDEPT Printed in U.S.A 0698 09882 Date.�t�1.1.�,' ... TOWN OF NORTH ANDOVER PERMI _ OR PLUMBING This certifies that .. . .... Al. Rm�' has permission toperf rm ... .. .... , . , , , , .... , . . plumbing in th buildgs o , ..... a .. .. . , .. . at ... �--� ?N- t VVI6! &- .) J, ,North over, Mass. Fee ......... Lic.1........ . VV Pw BING INSPECTOR Check # ACORLr CERTIFICATE OF LIABILITY INSURANCE �--� DATE(MM/DD/YYYY) 7/20/2012 THIS CERTIFICATE IS ISSUED AS A 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(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER ACT NAME:. Lori A. Cote EA Stevens Company, Inc. 389 Main St. PHONE('181)322-2324 A/CNo:(781)397-7672 E-MAIL ADDRE.loric@eastevensins.com P. 0. BOX 188 Malden MA 02148 INSURERS AFFORDING COVERAGE NAIC # INSURERA-Acadia Insurance Company INSURED INSURERB:TWin City Fire 9459 WILLIAM: MOGLIX- INSURER C : 3 GOODRIDGE STREET INSURER D: INSURER E: X COMMERCIAL GENERAL LIABILITY LYNN MA 01901 INSURER F : (:UVtKAC7t5 CERTIFICATE NUMBERi4ASTER 12-13 REVISION Nl1MRER-- THIS IS TO CERTIFY THAT 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDLSUBR POLICY NUMBER POLICY EFF MM/DD POLICY EXP MM/DD LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Ea occurrence $ 50,000 A CLAIMS -MADE F OCCUR OA5054737-10 6/21/2012 6/21/2013 MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,000 X POLICY PRO LOC $ AUTOMOBILE LIABILITY EOMBIINdEeDtSINGLE LIMIT 1,000,000 BODILY INJURY (Per person) $ A ANY AUTO ALL OWNED X SCHEDULED AUTOS AUTOS 054891-10 6/21/2012 /21/2013 BODILY INJURY Per accident $ ( ) X HIRED AUTOS X NON -OWNED AUTOS PROPERTY DAMAGE $ Per accident Medical payments $ 5,000 X UMBRELLA LIABOCCUR HCLAIMS-MADE EACH OCCURRENCE $ 1,000,000 A EXCESS LIAB AGGREGATE $ DED I I RETENTION$ $ A5055181-10 6/21/2012 6/21/2013 B WORKERS COMPENSATION I WC STATU-OTH- AND EMPLOYERS' LIABILITY Y / NT. E.L. EACH ACCIDENT $ 500,000 ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory In NH) N / A BWECLE5233 /27/2012 /27/2013 E.L. DISEASE - EA EMPLOYE $ 500,000 If yes, describe under E.L. DISEASE - POLICY LIMIT I $ 500,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more sl' �jt I I I I VY 1v1� \ � � CERTIFICATE HOLDER CANCELLATI( �4 qualitycon@verizon.net SHOULD ANY( THE EXPIRAT Quality Construction ACCORDANCE. 11 Ingleside Rd Lexington, MA 02420 AUTHORIZED REW Thomas Pete: k AGURD 25 (2010105) ©!`' INS025 r7m nnFi m Tho ARrion noma anti Innn nra ranieforarl m'r4c nvaf _f1Rn ACORffCERTIFICATE OF LIABILITY INSURANCE �--� D /DDIYYYY) x//20/20/ 2012 THIS CERTIFICATE IS ISSUED AS A 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(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER EA Stevens Company, Inc. 389 Main St. P. 0. BOX 188 Malden MA 02148 CONTANAME: CT Lori A. Cote PHONE (x$1)322-2324 FAX AJC. No (781)397-7672 E-MAIL ADDRESS: loric@eastevensins.com INSURERS AFFORDING COVERAGE NAIC It INSURERAAcadia Insurance Company INSURED WILLIAM_ MOGLIA-- 3 GOODRIDGE STREET LYNN MA 01901 INSURERB:TWin City Fire 29459 INSURER C : INSURERD: INSURER E: INSURER F : COVERAGES CERTIFICATE NUMBEWHASTER 12-13 REVISION Nt1MRFR- THIS IS TO CERTIFY THAT 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDLSUBR POLICY NUMBER POLICY EFF MMIDDrrrfY) POLICY EXP 1MMIDDYYYY1 LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE FX] OCCUR OA5054737-10 6/21/2012 6/21/2013 DAMAGE TO RENTED PREMISES Ea occurrence $ 50,000 MED EXP (Any one person) $ 5,000 PERSONAL 8 ADV INJURY $ GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,000 X POLICY PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident 1,000,000 BODILY INJURY (Per person) $ A ANY AUTO ALL OWNED X SCHEDULED AUTOS AUTOS 054891-10 6/21/2012 /21/2013 BODILY INJURYPer accident $ ( ) X NON -OWNED HIRED AUTOS X AUTOS PROPERTY t DAMAGE Per acciden$ Medical payments $ 5,000 X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 1,000,000 A EXCESS LIAB CLAIMS -MADE AGGREGATE $ DED I I RETENTION$ $ A5055181-10 6/21/2012 6/21/2013 B WORKERS COMPENSATIONWC STATU- OTH- AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under N/A 08WECLES233 /27/2012 /27/2013 E.L. EACH ACCIDENT $ 500,000 E.L. DISEASE - EA EMPLOYEE $ 500,000 E.L. DISEASE - POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) CERTIFICATE HOLDER r_ANr.Fl I ATInN qualitycon@verizon.net SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Quality Construction ACCORDANCE WITH THE POLICY PROVISIONS. 11 Ingleside Rd AUTHORIZED REPRESENTATIVE Lexington, MA 02420 Thomas Peter Cares Jr, CIC AGURD 25 (2070105) INS025 oninnsi m ©1988-2010 ACORD CORPORATION. All rights reserved. Tho annRn name and Innn nra raniafarari mnrlra of ArnRr1 Gblumti a Gas - of Massachusetts A NiSource Company 995 Belmont Street Brockton, MA 02301 February 28, 2013 Ms. Fatima Delgado 38 Columbia Road North Andover, MA 01845 Dear Ms. Delgado: During a recent visit, our service technician detected a safety problem with your gas heating system at 38 Columbia Road — North Andover, MA 01845 — boiler room has no make-up air. Accordingly, we have issued a Warning Tag because of this situation. Under the circumstances, we strongly urge you to correct the code violation. In addition, the Massachusetts code pertaining to the installation of gas appliances and gas piping, established under Chapter 737, Acts of 1960, requires that the condition be remedied. If you have any questions, please call our Service Department at 1-800-677-5052 and ask to speak with the Service Supervisor. Please disregard this notice if the condition has been corrected. Sincerely, Customer Service Department Columbia Gas of Massachusetts TOWN OF NORTH ANDOVER Office of the Building Department � pORTF� q o , ti Community Development and Services 1600 Osgood Street, Bldg. 20, Suite 2035 North Andover, MA 01845 978-688-9545 Gerald Brown, Inspector of Buildings Fatima Delgado 38 Columbia Road North Andover, MA 01845 Re:38 Columbia Road Dear Ms. Delgado, February 14, 2013 The inspection follow up regarding the gas furnace brought to light other outstanding issues that need to addressed. The basement has been renovated to contain two bedrooms and a bathroom. This renovation has been done without proper building, electrical, plumbing and gas permits. Other issues were noted in the inspection, including improper ceiling height and an impaired egress. To be in compliance with Massachusetts State Law under 780 CMR State Board of Building Regulations and Standards, R105.1 states that changes to a structure must begin with a written application with the building official to obtain the required permit. You and your contractors must come to the Building Department Office as soon as possible to file the proper permits to correct the above violations. Sinc rel G rald Brown, Building Commissioner Town of North Andover ru Ir M 11111 illilililillill MINI 11111 1111111 N IJ "g, Ln C3 Postage $ $0.46 0845 r-9 $3.10 Certified Fee 09 rq 0 Return Receipt Fee Postmark Here $2.55 C3 (Endorsement Required) M Restricted Delivery Fee $0.00 C3 (Endorsement Required) $ $6.11 rq M Total Postage & Fees r -:i nj Sent To r -q ---------------------------- Street, Apt. No.; or PO Box No. - ----------------------- ---------------------------- I ------ --- MA City,= Certified Mail ProAdeC ■ A mailing receipt o A unique identifier for your mailpiece a A record of delivery kept by the Postal Service for two years Important Reminders: ' f+'• o Certified Mail may ONLY be combined with First -Class Mail® or Priority Mail®. ® Certified Mail is not available for any class of international mail. ■ NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For j valuables, please consider Insured or Registered Mail. © For an additional fee, a Return Receipt may be requested to provide proof of delivery. To obtain Return Receipt -service, please complete and attach a Return Receipt (PS Form 3811) to the article and add applicable postage to cover the fee. Endorse mailpiece "Return Receipt Requested". To receive a fee waiver for a duplicate return receipt, a USPS6,postmark on your Certified Mail receipt is required. a For an additional -fee,,,deliveryrmay.- be restricted to the addressee or addressee's authorized agent. Advise the clerk or mark the mailpiece with the endorsement "Restricted Delivery". o If a postmark on the Certified Mail receipt is desired, please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed, detach and affix label with postage and mail. IMPORTANT. Save this receipt and present it when making an inquiry. PS Form 3800, August 2006 (Reverse) PSN 7530-02-000-9047 ■ Complete items 1, 2, and 3. Also complete item 4 if Restricted Delivery is desired. ■ Print your name and address on the reverse so that we can return the card to you. ' ■ Attach this card to the back of the mailpiece, or on the front if space permits. 1. Article Addressed to: VY) 1 l o A. S' nature X Agent Addressee B. Received by ( Printed Name) Cn t off] elivery D. Is.delivery address -different from Item 1? ❑ Ye /if YES; ente del ery�address below: -1 No 0� N 3. SeaOiCe Type �V / Ce fied-MaiiI ❑ Express Mail ❑ Registered ❑ Return Receipt for Merchandise ❑ Insured Mail ❑ C.O.D. 4. Restricted Delivery? (Extra Fee) ❑ Yes E 2. Article Number (?012 1010 0001 1056' ?392 Transfer from service /a! UNITED STATES PO s I 4th r s` • Sender: Please print your name, address, and ZIP+4 in this box • t 2z3, L' fl 'N IORTH ANooVER BRANCH NORTH ANDOVER, 8459998achusetts 2445930845-0097 02/15/2013 (800)275-8777 08:19:15 AM Sales Receipt Product Sale Unit Final Description Qty Price Price A 01845 Zane -0 First -Class Letter 'N Total: $12.22 Paid by; Debit Card $12:22 Account #; XXXXXXXXXXXX0683 Approval #: 141096 Transaction #; 235 23903240646 Receipt#: 001406 @@ For tracking or inquiries go to USPS.com or call 1-800-222-1811. Order stamps at usps.com/shop or call 1-800-Stamp24. Go to usps.com/clicknship to print shipping labels with,postage. For other information call 1 -800 -ASK -USPS. Get your mail when and where you want it with a secure Post Office Box. Sign up for a box online at usps,com/poboxes. Bill#:1000301512025 Clerk:09 IORTH ANooVER BRANCH NORTH ANDOVER, 8459998achusetts 2445930845-0097 02/15/2013 (800)275-8777 08:19:15 AM Sales Receipt Product Sale Unit Final Description Qty Price Price NORTH ANDOVER MA $0.46 01845 Zane -0 First -Class Letter 0.50 oz. Expected Delivery: Sat 02/16/13 Return Rcpt (Green $2.55 Card) @@ Certified $3.10 Label #; 70121010000110567408 Issue PVI: $6,11 NORTH ANDOVER MA $0.46 01845 Zone -0 First -Class Letter 0.50 oz, Expected Delivery: Sat 02/16/13 Return Rcpt (Green $2.55 Card) v- 00 Certified $3.10 Label #: 70121010000110567392 Issue PVI: $6.11 Total: $12.22 Paid by; Debit Card $12:22 Account #; XXXXXXXXXXXX0683 Approval #: 141096 Transaction #; 235 23903240646 Receipt#: 001406 @@ For tracking or inquiries go to USPS.com or call 1-800-222-1811. Order stamps at usps.com/shop or call 1-800-Stamp24. Go to usps.com/clicknship to print shipping labels with,postage. For other information call 1 -800 -ASK -USPS. Get your mail when and where you want it with a secure Post Office Box. Sign up for a box online at usps,com/poboxes. Bill#:1000301512025 Clerk:09 4 TOWN OF NORTH ANDOVER Office of the Building Department Community Development and Services 1600 Osgood Street, Bldg. 20, Suite 2035 North Andover, MA 01845 978-688-9545 Gerald Brown, Inspector of Buildings Fatima Delgado 38 Columbia Road North Andover, MA 01845 Re:38 Columbia Road Dear Ms. Delgado, February 14, 2013 The inspection follow up regarding the gas furnace brought to light other outstanding issues that need to addressed. The basement has been renovated to contain two bedrooms and a bathroom. This renovation has been done without proper building, electrical, plumbing and gas permits. Other issues were noted in the inspection, including improper ceiling height and an impaired egress. To be in compliance with Massachusetts State Law under 780 CMR State Board of Building Regulations and Standards, R105.1 states that changes to a structure must begin with a written application with the building official to obtain the required permit. You and your contractors must come to the Building Department Office as soon as possible to file the proper permits to correct the above violations. Sfrald Gown, Building Commissioner Town of North Andover Leathe, Brian From: Sent: To: Cc: Subject: Good morning Brian, Weir, John Wednesday, February -13, 2013 6:09 AM Leathe, Brian McCarthy, Fred 38 Columbia The address we were at last evening is 38 Columbia (off Sutton St). We were called for an odor of gas (found 0 readings with Columbia gas to confirm. The gas furnace was tagged out by gas company. My concerns for building dept were no hard wired (or any detectors CO/smoke) with the exception of the furnace closet (which was disconnected and on the floor, no makeup air/clearances around furnace, and exit window sizes. Lt John Weir North Andover Fire Dept Please note the Massachusetts Secretary of State's office has determined that most emails to and from municipal offices and officials are public records. For more information please refer to: http://www.sec.state.ma.us/pre/preidx.htm. Please consider the environment before printing this email. F� - aQQ i,�5�ec�-s Leathe, Brian From: Weir, John Sent: Wednesday, February -13, 2013 6:09 AM To: Leathe, Brian Cc: McCarthy, Fred Subject: 38 Columbia Good morning Brian, The address we were at last evening is 38 Columbia (off Sutton St). We were called for an odor of gas (found 0 readings with Columbia gas to confirm. The gas furnace was tagged out by gas company. My concerns for building dept were no hard wired (or any detectors CO/smoke) with the exception of the furnace closet (which was disconnected and on the floor, no makeup air/clearances around furnace, and exit window sizes. Lt John Weir North Andover Fire Dept Please note the Massachusetts Secretary of State's office has determined that most emails to and from municipal offices and officials are public records. For more information please refer to: http://www.sec.state.ma.us/pre/oreidx.htm. Please consider the environment before printing this email. i .3�4 `7`.. . Date.... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION SSACMUSE This certifies that.A ........... /ly . ................ ' 1 4 it &- -i�� -has permission for gas,instAllation,... . ; . ..... ................ in the build)ngs, o ....... at North Andover, Mass. Fee -$4.0. Lic. No. 37�_5 . ............ ............. ! / li� GAS INSPECTOR CI Y'011 lie&# 4'8 4 2 MASSACHUSETTS UNIFORM APPLICATION FOR ERMIT TO DO GASFITTING (Print or Type) TH QW�CSV F fZ ,Mass. Date Permit # Building LocatioOwner's Name FATIMA DFL CADb OV E 12- b'1 AixType of Occupancy 1 l� 1171 L- G New ❑ Renovation ❑ A Plans Submitted: Yes[] No ❑ Installing Company Name BAY STATE GAS COMPANY Address 55 MARSTON STREET LAWRENCE, MA 01840 Business Telephone -68.7-'1105 Name of Licensed Plumber or Gas Fitter Francis X. Corkery Check one: Certificate # HCl Corporation 1862 ❑ Partnership ❑ Firm/Co. !INSURANCE COVERAGE: '.have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. i Yes No ❑ I you have checked res, please Indicate the type coverage by checking the appropriate box. k liability insurance policy X( Other type of indemnity ❑ Bond ❑ JWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by :hapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: signature of Owner or Owner's Agent Owner❑ Agent ❑ hereby certify that all of the details and information 1 have submitted (or entered) in abo plication are true and accuwe to the best of my nowledge and that all plumbing work and installations performed under the permit issu f r this application will n mpliance with all ertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene - S. (j i T of License: itle Plumber Signature of cense Plumber or Gas Gasfitter314.5 4 5 Sty/Tbwn Master License Number PPR(NED FIC S _ ONLY Journeyman O Y • Y • Y • ONE MEMO Naomi ■��l�t v OMNI OMNI oon OMNI Installing Company Name BAY STATE GAS COMPANY Address 55 MARSTON STREET LAWRENCE, MA 01840 Business Telephone -68.7-'1105 Name of Licensed Plumber or Gas Fitter Francis X. Corkery Check one: Certificate # HCl Corporation 1862 ❑ Partnership ❑ Firm/Co. !INSURANCE COVERAGE: '.have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. i Yes No ❑ I you have checked res, please Indicate the type coverage by checking the appropriate box. k liability insurance policy X( Other type of indemnity ❑ Bond ❑ JWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by :hapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: signature of Owner or Owner's Agent Owner❑ Agent ❑ hereby certify that all of the details and information 1 have submitted (or entered) in abo plication are true and accuwe to the best of my nowledge and that all plumbing work and installations performed under the permit issu f r this application will n mpliance with all ertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene - S. (j i T of License: itle Plumber Signature of cense Plumber or Gas Gasfitter314.5 4 5 Sty/Tbwn Master License Number PPR(NED FIC S _ ONLY Journeyman O ZI O H v w 0 - to N Z N N w cr p O CL w w z �t w x wI I 51 a z P h r o a w y. 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