HomeMy WebLinkAboutMiscellaneous - 4 TYLER ROAD 4/30/2018��
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PO Box 55098
Boston, MA 02205-5098
617-951-0600
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WOW -
Form of Notice of Casualty Loss to Building
Under MASS. GEN. LAWS, Ch. 139, Sec. 3B
To: Building Commissioner or Board of Health or
Inspector of Buildings Board of Selectman
City Hall City Hall
NORTH ANDOVER, MA 01845 NORTH ANDOVER, MA 01845
RE: Insured: KATIE FILLIPON and SHONA FILLIPON
Property Address: 4 TYLER ROAD, NORTH ANDOVER, MA
Policy Number: HMA 0408617
Claim Number: BOS00059273
Date of Loss: 3/16/2015
Company: Safety Indemnity Insurance Company
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 attention of the writer and include a reference to the captioned insured, location,
policy number, date of loss and claim number.
Lindsey Hodgens Claim Examiner 4/15/2015
Safety Insurance Company
Homeowners Claims Unit
P. O. Box 55098
Boston, MA 02205-5098
Phone: (617) 951-0600 EXT 3418
Fax: (617) 603-4914
Email: LindseyHodgens@Safetylnsurance.com
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Date- J1z(,.h,1 .......
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TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
. 0W... ...............
This certifies that ... .
-�"�- .......................
has permission to perform ......
plumbing in the buildings
..........................................................................................
at ..... . ............................................ North Andover, Mass.
Fe4a. ....... Lic. No. ��.57 ....... ............................................................
PLUMBING INSPECTOR
Check# 6f, i A
a
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
`
POWNER
TYPE OR
PRINT
CLEARLY
CITY North Andover MA DATE 16 -Jul -14 PERMIT# tba
JOBSITE ADDRESS L4 Tyler Rd. OWNER'S NAME Belford Construction
ADDRESS 130 Marbleridge Rd, N. Andover MA 01845 TEL 508-509-9430 FAX
OCCUPANCY TYPE COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL ZI
NEW: ❑ RENOVATION: ❑ REPLACEMENT: ® PLANS SUBMITTED: YES ❑ NO
FIXTURES 7 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 GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER 1
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR / AREA DRAIN
INTERCEPTOR (INTERIOR)
KITCHEN SINK 1
LAVATORY 2
ROOF DRAIN
SHOWER STALL
SERVICE / MOP SINK
TOILET 2
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER
INSURANCE COVERAGE:
I have a current liabili insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES ® NO ❑
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ® OTHER TYPE OF 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 kngwledge
and that all plumbing work and installations performed under the permit issued for this application will be in cZian with,,a ertinent provision of tv
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. c1'L- /—
PLUMBER'S NAME Robert J. Frazier LICENSE # 13425 /J fGNATURE '
MP ® JP ❑ CORPORATION ❑ # PARTNERSHIP ❑ # LLC ❑ #
COMPANY NAME Bomar Plumbing & Heating ADDRESS PO Box 694
CITY Derry STATE NH zip 03038 TEL 603-325-8958
FAX CELL EMAIL Bob@BomarPH.com
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leuibly
Name (Business/Organization/Individual): Bomar Plumbing & Heating
Address: PO Box 694
Citv/State/Zim Derry, NH 03038
Phone #: 603-325-8958
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. X❑ I am a sole proprietor or partner- listed on the attached sheet.
ship and have no employees
working for me in any capacity.
[No workers' comp. insurance
required.]
❑ I am a homeowner doing all work
myself. [No workers' comp.
insurance required.] t
These sub -contractors have
employees and have workers'
comp. insurance.)
❑ We are a corporation and its
officers have exercised their
right of exemption per MGL
c. 152, § 1(4), and we have no
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10. F] Electrical repairs or additions
I I.❑X 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 the policy and job site
information.
Insurance Company Name: Liberty Mutual Fire Insurance Company
Policy # or Self -ins. Lic. #: WC2-31 S366059-022 Expiration Date: 22 -Apr -15
Job Site Address: 3 Tyler Rd. City/State/Zip: N Andover MA 01845
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 may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct
16 -Jul -14
Phone #: 603-325-8958
Official use only. Do not write in this area, to be completed by city or town officiaL
City or Town: Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
it
North Andover Board of Assessors Public Access
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lilk *, a a. ' 1, r"► is _ M
Elm
Itroperty Record Card
Parcel ID :210/032.0-0026-0000.0 FY:2014 Community: North Andover
SKETCH
Click on Sketch to Enlarge
4 MER ROAD
Location: 4 TYLER ROAD
Owner Name: BALLARD, NATALIE C
C/O N.C. BALLARD REALTY TRUST
Owner Address: 2976 HUNTERS BRANCH ROAD APT 243
City: FAIRFAX State: VA Zip: 22031
Neighborhood: 6 - 6 Land Area: 0.29 acres
Use Code: 101-SNGL-FAM-RES Total Finished Area: 1677 sqft
ASSESSMENTS CURRENT YEAR PREVIOUS YEAR
Total Value: 340,700 349,400
Building Value: 171,500 171,500
Land Value: 169,200 177,900
Market Land Value: 169,200
Chapter Land Value:
http://csc-ma.us/PROPAPP/display.do?linkld=2433421&town=NandoverPubAcc 7/16/2014
Location ]
No.
Date �� 1
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