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Home My WebLink AboutMiscellaneous - 391 PLEASANT STREET 4/30/2018INSURANCE' February 29, 2016 The Commerce Insurance Companys"' Citation Insurance Companysm 11 Gore Road, Webster, Massachusetts 01570 508.949.1500 jwww.mapfreinsurance.com BUILDING COMMISSIONER or INSPECTOR OF BUILDINGS TOWN/CITY HALL NORTH ANDOVER MA 01845 Board of Health or Board of Selectmen Town/City Hall RE: Our Insured: PETER K MURLEY !SUSAN H MURLEY Property Address: 391 PLEASANT ST Policy#: YT2077 Date of Loss: 02/25/2016 File#: MCMX44-JVPJY6 Claim has been made involving loss, damage, or destruction of the above captioned property which may exceed $1,000, or cause Massachusetts General Laws, Chapter 143, Section 6 to be applicable. If any notice under Massachusetts General Laws, Chapter 139, Section 3B is appropriate, please direct it to my attention. Please reference the above captioned insured, location, policy number, date of loss, and file number on any correspondence. THERESA KALISZEWSKI Telephone: (508)949-1500 Ext: 15846 Claim Representative I, Property Toll Free: 1-800-221-1605, Ext: 15846 On this date, I cause copies of this notice to be sent to the persons indicated above, at the address above, by first class mail. February 29, 2016 wind CIC 254 (Rev. 4/95) MAIL 788 No 9607 Date. I.Q.- A 71:2�! . TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING — 71.kQv .................... This certifies that . V--!� 1% ... k � rq 0 has permission to perform . Wq�� .. .'r. �.. plumbing in the buildings of w4y .............. at ... 3-5.1 ... North Fee3?f �P. . Lic. No..a.v�$.> ... ,Andover, Mass. I N ��'R ... PLUMBING Check # WHITE: Applicant CANARY: Building Dept. PINK: Treasurer MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK -. POWNER TYPE OR PRINT CLEARLY CITY NORTH ANDOVER MA DATE / J.Z PERMIT # JOBSITE ADDRESS 3g'/ )O/e-gS,6,v7- ,S7— OWNER'S NAME ADDRESS 9A rl e TEL FAX OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL RESIDENTIAL% NEW: RENOVATION: Q REPLACEMENT: 5iO PLANS SUBMITTED: YES El NOF -7< FIXTURES Z FLOOR— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOILISAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR I AREA DRAIN INTERCEPTOR INTERIOR KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE I MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES r" NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY Q 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 Ej 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 J„'—' Massachusetts State Plumbing Code and Chapter 142 of the General Laws. � 7A— T, /, PLUMBER'S NAME THOMAS HALLORAN LICENSE # 24833 SIGNATURE MPC JPEI CORPORATION 71# PARTNERSHIP[]# LLC F# COMPANY NAME HALLORAN PLUMBING ADDRESS 826 DALE ST. CITY NORTH ANDOVER STATE ZIP 01845 TEL 978-685-9504 FAX CELL EMAIL f� DO 0 c 0 O D Cn Z Cn a m C) O z z O --i m Cl) m i m � ts► � r = 0 cn O D z +m r CA m D m -„ z < o mDo m — < X � N m 3 -4 c� = m m c-) z 13 -1 o m o X ^' - c cn cn m ai O Z O '< T Z D r z -o m C7 O Z z O m Cn The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, ALL 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name -(Business/Organization/Individual): 11f441- oet Ai+/ pL.i ,m Address: S.22 LX 4 L 4-; y5' i City/State/Zip: /tel%,/ %" Phone.#: Are,you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. [� I am a general contractor and I employees (full and/or part time):* have hired the sub -contractors 2. �9 I am a sole proprietor or partner- listed on the -attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.$ required.] 5. We are a corporation and its 3. ❑ I am a homeowner doing all work officers have exercised their myself. [No workers' comp. right of exemption per MGL insurance required.] t c. 152, § 1(4), and we have no - employees. [No workers' comp. insurance reouired.l Type of project (requir 6. ❑ New construction 7. ❑ Remodeling 8. F-1 Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 1 I.0 Plumbing repairs or additions 12.❑ Roof repairs 13. ❑ Other 'Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees Below is thepolicy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #:' Job 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 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 coveraze verification. I do hereby certify under the pains -and penalties ofperjury that the information provided above is true and correct Sianatuie: �-�G� Date Phone area, to be completed by city or town official City or Town:' Perinit/License # Issuing Authority (circle one): 1. Board of health 2. Building Department 3. City/Town CIerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact. Person: Phone #:. 0 Date . 1A 1!i�-. . . TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ... VV&Uu has permission for gas installation aU. in the buildings of ... r-3 .................... at .... 3. 91 1 ... Fee -90,ev ... Lic. No.. (9HY-P Check I t!To 8348 ........ . North Andover, Mass. GASINSPECTOR If MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY NORTH ANDOVER MA DATE �'—%'7"%2— PERMIT # JOBSITE ADDRESS .311 OWNER'S NAME /0e%�'/t GOWNER ADDRESS TEL FAX TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL EDUCATIONAL'-- EDUCATIONAL'- RESIDENTIAL `A, 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 TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER INSURANCE COVERAGE _ I have a current liabilityinsurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES �_ NO 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 T AGENT i 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 THOMAS HALLORAN LICENSE #�2y i� J 3 SIGNATURE MID.MGF.._ JP,---., _JGF ^ LPGI CORPORATION # PARTNERSHIP # LLC ; COMPANY NAME:HALLORAN PLUMBING ADDRESS 826 DALE ST. CITY NORTH ANDOVER STATE MA ZIP 01845 TEL 97p'-6' FAX 978-208-0840 CELL EMAIL Date .... F? ....... 9-7 T2 738 + TOWN OF NORTH ANDOVER PERMIT FOR WIRING US This certifies that ...... ..................... Id has permission to perform ... . ...... ....... wiring in the building of ............. dover, Mass."o at ,3ql ...... )0/, .......... A— n— ............... T ic. Nomq�.p .................. y Fee. r) �.v .. C R P, WHITE: Applicant CANARY: Building Dept. PINK: Treasurer /,� /o/4 -V x,36 014t (II4auaaawtalt4 of Aassac4uslaw D""" of `ublk .,.yell BOARD OF FIREN I N REGULATIONS PREVE T O U1T10 S 527 CMR 12:00 Office Use Only Permit No. occupancy a. Fre eheckeedD MW (leave blank) or APPLICATION wFOR PERMIT TO PERFORM ELECk to be luirfartrAd in accwdance with the Massachu5m EkKincal Code, $27 CMRITRICAL WORK (PLEASE PRINT IN INK OR TYPE /T ALL IINFORMA ! l / City or Town of --� J/I i /NF7 The undersigned applies for a permit to perforin Location (Street d Number) < 39 c Owner or -Tenant Owner's Address Date t2? , J r To the Inspector of Wires> described below. Is this permit in conjunction with a bui pwmiC Yes LJ No' L:7 ' (Check Appropriate Box) D. r Purpose of Building LL� --- ---------Utiliry Autheritation No. Existing Service ILL Amw _12. v lr,2�4 Volts Overhead 0 Undgrd ❑ No. of Meters New Service —AaW$ / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity I ovation and Nature of Proposed Electrical Work OTHER: C BF 6 1997 INSURANCE COVERAGE: Pursuant to the requinirew of Massachusttes General laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent. YES 1-7 NO 0 1 have submitted valid proof of same to this office. YES U NO LJ If you have checked ES, please indicate the %w d wwage by checking the appropriate box. INSURANCE LJ BOND ❑ OTHER❑ OUM Specify) ,(Expiration Date) Estimated Value of Electrical Work S Work to Start Signed under the oanalties of oeriunr FIRM License lddres Mstpectiort Date Requested: Rough Final LIC. NO. LIC. NO. _ No.��1 Alt. Tel. No. DWNER'S INSURANCE WAIVER: I am aware that the Licensee docs not have the insurance coverage or its substantial equivalent as required by Massachusetts general Laws, and that my signature on this permN application waives this requirement. Owner Agent (Please check one) ``, _ Tclepitortc No. _PERMIT FEES V ((Signature d Owner or App TOTAL No. of l ighling Outlets No. of Hot Tubs No. of Transformers KVA AboveIn- No. of Lighting Fixtures Swimming Pool grnd. 1:1rnd. Generators KVA No. of Emergency Lighting No. of Receptacle Outlets No. of Oil Burners Battery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Detection and /Total No. of Ranges No. of Air Conditioners l Tons Initiating Devices No. of Sounding Devices Heat ota Total No. of Disposals No. of Pumps Tons KW No. of Self Contained Detection/Sounding Devices No. of Dishwashers SpacetArea Heating KW Municipal Local[] Connection 1:1 Other No. of Dryers HeatingDevices KW NO. of No. Of Low Vortage No. of Water Heaters KW Si s Ballasts Wiring No. H deo Massae Tubs No. of Motors Total HP OTHER: C BF 6 1997 INSURANCE COVERAGE: Pursuant to the requinirew of Massachusttes General laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent. YES 1-7 NO 0 1 have submitted valid proof of same to this office. YES U NO LJ If you have checked ES, please indicate the %w d wwage by checking the appropriate box. INSURANCE LJ BOND ❑ OTHER❑ OUM Specify) ,(Expiration Date) Estimated Value of Electrical Work S Work to Start Signed under the oanalties of oeriunr FIRM License lddres Mstpectiort Date Requested: Rough Final LIC. NO. LIC. NO. _ No.��1 Alt. Tel. No. DWNER'S INSURANCE WAIVER: I am aware that the Licensee docs not have the insurance coverage or its substantial equivalent as required by Massachusetts general Laws, and that my signature on this permN application waives this requirement. Owner Agent (Please check one) ``, _ Tclepitortc No. _PERMIT FEES V ((Signature d Owner or App