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Miscellaneous - 445 WOOD LANE 4/30/2018
Date.........-.................. TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that::.^..a.....:.:..�..`�:............ .. ............................ has permission for gas installation ......::..::; in the buildings of ................................... at ...... -..<:`.'...':':... `..`. r ................... "..'.' Lic. No. �.... #.e....... Check # .............. North Andover, Mass. !� GAS INSPECTOR 7 Date ... Z?f- ........... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that'.... U� ................................................................................................................ has permission to perform ... ... ........... ) ........ ... ................................................ plumbingin the buildings of ............................................................................................. at ... ...................................... ,North Andover, Mass. .... ... ......... ... .... ........... . . Feel,/' ..... ..... Lic. No. ..................... ............ ................................................................. PLUMBING INSPECTOR Check `I MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 'r"ITY ° � _ MA DATE l T 22 WL51PERMIT# JOBSIT(�ADDRESS Foo &AjOWNER'S NAME K GouvE #A _ POWNER ADDRESS w I TEL 47$-ZS f3-'T2y3 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL Q EDUCATIONAL RESIDENTIAL)a PRINT CLEARLY NEW: Ell RENOVATION: REPLACEMENTS PLANS SUBMITTED: YES FQ NQK FIXTURES Z FLOOR--> BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS101USAND SYSTEM[ DEDICATED GREASE SYSTEM _.._._� �_„ ( __ R _ [ _____ j _ ( ___._ I _ DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM _.._._J ____I [ [ DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER I -.-- __1 ._-_.__.I----�_� FLOOR/AREADRAIN l _! L____ INTERCEPTOR (INTERIOR) KITCHEN SINK LAVATORY R00� DRAIN SHOWER STALL __..._._.f J —1 4 SERVICE MOP SINK TOILET__ 1 ___..__ ___.__ _ _ I M _I _ ._!-_.__._ __ ___-• _-- __, __.�$ ____ -___ URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER INSURANCE COVERAGE: 1 have a current liability 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 INSU NCE POLICY Q OTHER TYPE OF INDEMNITY D BOND 0 OWNER'S INS NCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massach is I signature on this permit application waives this requirement. �i -�-1� CHECK ONE ONLY: OWNER AGENT 10 SIGNATURE 0 0 N OR AGENT >> I hereby certify that all of the details-a-n-cT information I have submitted or entered regarding this application are true and ac rate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in PH t inent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME -bioNNt LICENSE # _ 13772 I SIGNATURE MPN JP 0k CORPORATION 01 #=PARTNERSHIP # _ G LLC COMPANY NAMED10N�z: ADDRESS 12S wi..�:-c a 3 CITY La'il j STATE MA _ ZIP OtBSy I TEL �— - FAX L _ i CELL 7$ lat xall EMAIL IM N ❑ LU M tii w LL The Commonwealth of Massachusetts Department of lndustrialAccidents - 1~ X Congress Street, Suite 100 Boston, MA. 02114--2017 www.mass.gov/dia Workers Compensation Insurance Affidavit-. Builders/Contractors/Flectricians/klumbers. TO BE FILED WITH THE PERWTTING AUTHOR1TY. Name (Business/Organization/Individual)- Jt?9N — Address: 12 q GJk,.14- 5 FL 3 City/State/Zip: uj w e (. Are you an employer? Check the appropriate box: at esti _ Phone #: 9'78- y2i-708) I-01 am a employer with employees (full and/or part-time).* 2.❑ I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself [No workers' comp. insurance required.] t 4. ❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5.❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.' 6. ❑ We are a corporation and its. officers have exercised their right of exemption per MGL c. 152 61(4) andwehave no employees. [No workers' comp. insurance required.] Type of project ()Vequired): 7. ❑ NbVdonstrii'ction 8. Remodeling 9. ❑ Demolition 10 ❑ Building addition 11.❑ Electrical repaixs or additions 12T[] Pliunbng repairs or additions 11 [] Rb6f repairs 14.[] Other *Any applicant that checks box#1 must also fill out the section below showing their workers' compensation policy information. Homeowners who submit -this ; affidaYit 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 (hose entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. X 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. 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 requited under MGL e. 152, §25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. X do hereby cert under the andpenalties ofperjury that the information provided above is arae an_v. vulle-1 - '� Tl�+o d zo /TABS 978 - 1121- 7081 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 Phone #• Contact Person: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employ"ees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hii , express or implied, oral or written." An employer is defuied as "an individual; partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enferpri'se, 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 ofthe 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 whd has not produced -acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for 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 Pleasb fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub=contractors) 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 Accidents 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 number listed 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 permit/license number which will be used as a reference number. In addition, an applicant thai must submit multiple permit/license 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 affidavit 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 or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT . TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES [3 NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW ",- LIABILITY INSURANCE POLICY11 OTHER TYPE INDEMNITY 0 BOND OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts ner .Laws; an'd'tty signature on this permit application waives this requirement. ✓—(— CHECK ONE ONLY: OWNER( AGENT SIGNATURE 0 WNER AGENT ereby certify that all of the details rmation 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 P inent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME I J1930- rieA#JCbiS LICENSE#� SIGNATURE MPI MGF 0 JP ® JGFJ LPGI © CORPORATION ©# © PARTNERSHIP [3#= LLC ®#� COMPANY NAME: J 7�o��E_ ADDRESS 129 �wR `4-- 5, Fl- CITY Z CITY L.Ga.>ul �� STATE -ZIP TEL FAX CELL 5"78 `�?�?? EMAIL _ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY"u`Jav _ MA DATE Srri'Iv�v'IPERMIT# JOBSITE ADDRESS tied-) 1-d OWNER'S NAME r-,1;Zon-JK Vt s� GOWNER ADDRESS 141145 W o n it E,J, TE 9-78- 25$ -_-7 FAX TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ® RESIDENTIAL CLrARLY NEW: 0. RENOVATION: REPLACEMENT: El PLANS SUBMITTED: YES 0 N0tg APPLIANCES Z 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 t;Rll I F f I I III 111 1111 mill 11 1111 INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT . TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES [3 NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW ",- LIABILITY INSURANCE POLICY11 OTHER TYPE INDEMNITY 0 BOND OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts ner .Laws; an'd'tty signature on this permit application waives this requirement. ✓—(— CHECK ONE ONLY: OWNER( AGENT SIGNATURE 0 WNER AGENT ereby certify that all of the details rmation 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 P inent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME I J1930- rieA#JCbiS LICENSE#� SIGNATURE MPI MGF 0 JP ® JGFJ LPGI © CORPORATION ©# © PARTNERSHIP [3#= LLC ®#� COMPANY NAME: J 7�o��E_ ADDRESS 129 �wR `4-- 5, Fl- CITY Z CITY L.Ga.>ul �� STATE -ZIP TEL FAX CELL 5"78 `�?�?? EMAIL _ H z H U W a� d W i . o� z O NEl W r � ~ W U w � f- r3 W � � Q w co a W w U a 0 a a a U J E. a a a �r � w M: w 1-- LL H Z O _ F-1 U w PL-( C7 a I The Commonwealth of Massachusetts Department of IndustrialAccidents I Congress Street, Suite 100 Boston, MA 02114-2017 oM SyVo www mass.gov/dia Walkers' Compensation Insurance Affidavit-. Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHO'RITY' Name (Business/Orgahization/tndividual): -J6AlJ_ f'�F1��ES rpnYr+3 Address: 12-1 t °4 • 3 City/State/Zip: Are.you an employer? Check the appropriate box: Phone #: 9 _7& qz t - ©$ I l.[] I am a employer with employees (full and/or part-time).* 2.M I am a sole proprietor or partnership and have no employees Working for mein any capacity. [No workers' comp. insurance required.] 3.Q I am a homeowner doing all work myself. [No workers' comp. insurance required] t 4.❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole ±. proprietors with no employees. 5.❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub contractors have employees and have workers' comp. insurance.$ 6.FJ We are a corporation and its, officers have exercised their right of exemption per MGL c. 152, §1(4), and'we have no' empldydes. [No workers' comp. insurance required.] Type of project (required); 7. ❑ New'd6nstr66 ion 8. [] Remodeling 9. ❑ Demolition 10 ❑ Building addition 11.0 Electrical repays or additions 12. (.plumbing repairs or additions 110 Rbof repairs 14.� Other 6M r iTraJ *Any applicant that cheoks box 91 must also fill out the section below showing their workers' compensation policy information: 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 (hose entities have employees. If the sub -contractors have employees, they must provide their workerscomp. policy number. , X ant an employer that is providing workers' compensation insurancefor my employees..8elow is the policy and job site information. Insurance Company Policy # or Self -ins. Lic. #:, 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 ate).Failure to secure coverage as required under MGL c.152, §25A is a criminal violation punishable by a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORD ORDER and a fine of up to $250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. X do hereby certify under thafandpenalti�qfperrjut the information provided above is true and correct: n:......+.,..o -'4_47Date• �' 20�ZorS Phone #: I ci-70' q2,1- -7081 official use only. Do not write in this area, to be completed by city or town offzciaL City or Town: Permit/License # Issuing Authority (circle one): i 1. Board of Health 2. Building Department 3. City/'I'own Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Information and Instructions 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 ofhire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver'& 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 b6 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-whp has not produced -acceptable evidence of compliance with the insurance coverage xequiired." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for 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' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub=contractors) 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 Accidents 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 number listed 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 permit/license number which will be used as a reference number. In addition, an applicant thai must submit multiple permit/license 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 5Gall 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 affidavit 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 or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number: The Commonwealth of Massa'chusetts Department of Industrial Accidents 1 Congress Street, Suite 100~ Boston, MA 02114-2017. Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 wwwmass.gov/dia Rank Gativaia Jr. YSWbod In North Andover, IVIA 01845 Dear Mr. Hurl", 9M 412015 It has tome to rny attention that rbulfip* projects that I have had completed over the past few years were not carnplotely iollowadthrough, with. For this I am Oxtrarnely stnty. 11 thought that things ware dant they way they were suppose to be done and that averytHng was above ward. The reason things have gone unitnishod. from the point ol in, spe-Mbn Is my'lathor Pirank Gouveia Sr. owned and operated Frank Gouveia Plumbing and Healing in CholawOord MA for dose to 35 years recently passed away and the business closed. Whenever I h, "dad anything done I would have his cornpany come and do the walk and not think Ithice about it. Uniottunalely about 2.5 years ago he gol sick and passed the company, to one of my younger brothers who was not ready to own and operate a company. Suffice to say that as work got done 1 would inquire H evesything was all sot and I would be told nothing to worry about- As [ can now see that was not the case. Since the last pi-oject that was completed (the Navian propane waterheater) my father has passed and my-youngei biothei has had to close the doors of the business he was given. I am left with dealing with the after oflocls in snore ways than just this! I ask that you please torgivo those oversights and I welcome you to corne in and take a look at the work that has been completed to makes sure that it is safe and up to the codes that you represent if you have any questions OT concerns please don't hesitate to contact ma. Best regards, Ffank Gouvaia 445'Wood Ln. North Andover, 'MA 01845 (970)-B94-5716 Date... !.�/i ...... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that .. `.' .. J!"d /� �? .......... . .... _ has permission for gas installation ...... S in the buildings of ....... at!.. ee?, ............ North /Andover, Mass. Fee. A 9 Lic. No...Vc: ... GAS INSPECTOR Check # 2 G31 • MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY NORTH ANDOVER MA DATE JAN. 23, 2012 __ PERMIT # JOBSITE ADDRESS 1445 WOOD LANE OWNER'S NAME `,rank ol►ve OWNER ADDRESS sarne TE 978-994-5715 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL ® EDUCATIONAL E] RESIDENTIAL E] PRINT CLEARLY NEW: E1 RENOVATION: ® REPLACEMENT:E] PLANS SUBMITTED; YESQ NO® APPLIANCES 7 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 I SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER I CONNECT TO A PLUMBERS 1 INSPECTED LINE INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES E] NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITY D BOND E] 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. SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER [D AGENT El 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 co liance with al rtine pr .sion of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME JOHN MARSHALL I LICENSE # 778 SIGNATURE MP ® MGF D JP ® JGF ® LPGI 0 CORPORATION # PARTNERSHIP ®# LLC ®#� COMPANY NAME: EASTERN PROPANE GAS ADDRESS 131 WATER ST. CITY DANVERS STATE MA ZIP 01923 TEL 800-322-6628 FAX CELL EMAIL &, A 2. %010 9:36AV! No.3r�96 P. 2 YWe Commonwealth ofMassachusew Department of Industrial Accidents Dce of Fnvesligations 600 Washington Street Bono& KAI 62111 www.mass.gov/dia-- ixv'oFke�s' Compensatio�;Insurane; �>�'id�ait:]�Cviit3��lContaactorsl�'1e�i�ianslPliaaabe�.,: - Apnlicant Information Phase PtLeeibl Name (Bmmess1[3Vmimnon/lndrvidm4 Address: G4tylStateJZip:y iS� 'Pli®ne #:%�- r .... Are you an employer? Check --tile. appropriate: bog: 1: I am a employervvith 4. ❑ I amF.-general. contractor and I employes (frill and/orpart-tmle}.' ', have hired the,sub-contractors 2. ❑ I am a sole proprietor or partner= listed on the;attached sheet $. ship and have ao. employees Mese sub -contractors have working forme in any Capacity. workers' comp. insurance. [No workers' camp.•insirranct 5- ❑ we are a corporation and its required.] officers have exercised their 3_0 I.am a homeo-wne, doing ail work right of exemption. per MOL myself. [No worker' comp c. 152, :§1(4);.and we have no insuurance required:] t eutployees. [No workers.' comp. insurance recuu-ed_1 Type of project (requdred): 6. ❑ New construction 7. ❑ Retnod�iing . H. O] Demolition 9, ❑ 8wildino addition 10.0 Electri:.al.repairs or additions 11:❑ Plumbing repairs o: additions 12.—M Roof rcPairs 13. Other �as l�� rnG "AayaupHmarmatcbecisb=#1-m=alsofiiloa`twz=oate1c sbowit taes�voris�'. tioapol ytatomsattvn Hmaeovm= who sebmh tars affidavit b% i=* toy an doiq al! woik and ttum hue fid= c=ft m mese aehmtt t der affidavit maiming saz... 1Con==is that chemo this b= MM shct 3bawmg the name of tho sob-cenvactarr and dwi: wotiess' C --F_ P-br_Y iss�ou F mrc an employer that Is -providing workers' compeiisnfiviT iursrarcrnce for my employees Below is th e. pohq,and job..si#e.: infortrlatirr:: / / / Insurance Company Name. Policy t or Self -ins, Lic. n; (yC %— i% y f'6 05l% Exviratio� JZate: F//-5 2,'1'L Job. Site Address:_u 4 �.+acc.J� lA'^� CitylSt-atJ�ap:.�l� 0..`4 t.:�e�rh �e✓� O A ttach:a:copy.af:the worker_7tomveaniign policy dnbxgtjpn.ge, . ho- - the . pae FsaT...t.cy p. utriber ant€;ezptratlon tlet'c). Failure to sacure coveWe.as required under`Se.-tion 25A.ofMGZ.c. 152 can lead to the mpersiti on of.criminal;penslties .Q.i:a fiw up to S 1,500.00 and/or.cure-year imprisonment, as wellas cid pcnaltics in. the f= of a STOP WOW ORDER and. z fin of up to 5250.00 E day aping the.violeto..: Be advised that a COPY of this stat=nt may be forwarded to the Office of Investigations of the DIA for hs=m= coverage vmiffirmtion I dp herebp cantly under:the pains nerd pen {per -Wfaaie infonnadan prvrad d above is, rmcar�d eflnea ' E? cclal use only. Do not r.�s:n this area, to be, completed by city or Powe offIc}al City or'iovrn: 1?erta [eense. Issuing Authority (circle one) - 1. Board of Healtb 2. Building Department 3. Cityrown Clerk 4. Electrical Inspector 5. I'tumbinc Inspertor 6, Other Contact-Person: Date/P zf - �� ...... HORTM ! 0 o= TOWN OF NORTH ANDOVER F A • PERMIT FOR,GAS�4STALLATION • ,' a 4 y 9SS��..SEt This certifies that ...!?. f . �'" " ��?. !�?" .......... . has permission for gas installation ...�'.'.!? ." ':`............. in the buildings of . ��p v 1-t q.! ' .......................... . at . Vii! �!? ` . 1!' `0 ° `` ........ ...... North Andover, Mass. CL Fee .3 �? .�. Lic. No)?.�..'..... .. .... ^....... . GASINSPECTOF� Check # i n , P 4 5839 G MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) NORTH ANDOVER ,Mass. Date 11/1 Building Location 445 WOOD LN Owner Tel# 978 994 5716 2006 Permit# rr3.1 Owner's Name FRANK GOUVEIA Type of Occupancy RESIDENTIAL New a Renovation Replacement Plan Submitted: Ye[j Nt FIXTURES Installing Company Name Eastern Propane & Oil, Inc Check one: Certificate Address 131 Water Street ZCorporation Danvers, MA 01923 Partnership Business Telephone # 800-322-6628 �— Firm/Co. Name of Licensed Plumber or Gas Fitter Jam. Vh V„ INSURANCE COVERAGE: I have a cu liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yesl ✓ I No ❑ If you have c ecked yes, please indicate the type coverage by checking the appropriate box. A 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 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 ❑ I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best Knowieage ana mat au plumbing work and installations performed under the permit issued for this application will be in compliance with all ertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General�L�lors^ ,t1 By Type of License: J Cs. ,_ • �'� E'r lumber Signature of Licensed Plumber or Gas Fitter Title as fitter t �, • -Master License Number 1 Cityrrown • -Journeyman APPROVED (OFFICE USE ONLY) III •.- �������������������������� Installing Company Name Eastern Propane & Oil, Inc Check one: Certificate Address 131 Water Street ZCorporation Danvers, MA 01923 Partnership Business Telephone # 800-322-6628 �— Firm/Co. Name of Licensed Plumber or Gas Fitter Jam. Vh V„ INSURANCE COVERAGE: I have a cu liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yesl ✓ I No ❑ If you have c ecked yes, please indicate the type coverage by checking the appropriate box. A 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 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 ❑ I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best Knowieage ana mat au plumbing work and installations performed under the permit issued for this application will be in compliance with all ertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General�L�lors^ ,t1 By Type of License: J Cs. ,_ • �'� E'r lumber Signature of Licensed Plumber or Gas Fitter Title as fitter t �, • -Master License Number 1 Cityrrown • -Journeyman APPROVED (OFFICE USE ONLY) 10348 Date./463 !, TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that.......-4-..........��'� '`— ........................:.................. has permission to perform ......... .:........... plumbing in the buildings of..:.... `� �.>'+.:................... at ........�'1. ......'Adg± ............ ................................... North Andover, Mass. Fee..P.".... Lic. No. 1�', �?�.°.:. .....1............................................................ PLUMBING INSPECTOR Check # x t�` 01 )\\A 1) MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK j CITYM A-" CA)90- �� MA DATE --] PERMIT JOBSITE ADDRESS .e $ 5 W oaa Lyil.9C- OWNER'S NAMEFit IJ le- Cb Li Jig tA OWNER ADDRESS *414P- �� TEL ,��—� ]FAX ' TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ EDUCATIONAL RESIDENTIAL r✓ PRINT CLEARLY NEW: Ej RENOVATION:[; REPLACEMENT: PLANS SUBMITTED: YES NOR FIXTURES 1 FLOOR— BSM 1 2 3 4 5 6 7 8 9 to 11 12 13 14 BATHTUB - - - CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEW DEDICATED GASIOIUSAND SYSTEM - DEDICATED GREASE SYSTEM - DEDICATED GRAY WATER SYSTEM - --' - DEDICATED WATER RECYCLE SYSTEM - DISHWASHER DRINKING FOUNTAIN - - - - -- FOOD DISPOSER FLOOR t AREA DRAIN INTERCEPTOR (INTERIOR) - r; KITCHEN SINK - LAVATORY ROOF DRAIN - SHOWER STALL SERVICE I MOP SINK -- TOILET URINAL WASHING MACHINE CONNECTION - _ _ _ _ _ . - _ WATER, HEATER ALL TYPES I I : - WATER PIPING OTHER I_._ I INSURANCE COVERAGE: I have a current liability 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 1._.1 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 [3 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 tl;jacau0iance w th all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. ;�—Y�c—. PLUMBER'S NAME r FAAdWK C.oLJVEtA - L I C E N S E # 1�i� SIGNATURE MP[�% JP[J CORPORATION�✓2STe PARTNERSHIP ---I r--- COMPANY NAME ff F&,' -FJ V— 120 U V15 -'IA I Lit'_. ADDRESS F N 5`f"kI h4 CE T'o t4 57- CITY �t.Cl1E�t-lsFo2�j �STATEC�ZIPL—Df8rn3 TEL (]78-25(—l8®0 FAX Lj;8-251-IBot CELL EMAIL ff ��2 �N 1�' CC 6�1 r�M 7d/R t r;' .Cort _ t____�_-___ . r t�` 01 )\\A 1) on z N ❑d r I Date, . ...... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ............ Pt) tLvt-j >,— ....................................................................... has permission for gas installation ...... ......................... in the buildings of .................. . .. .............................................................. ... at 4-145 . ......./A ),.h.cL ..... 4.,......e.�..........,e, ..... . North Andover, Mass. Fee .q?A= ...... Lic. No. lAi 1 a ........ &4�� .............. .......... ....... GASINSPECTOR Check# 6 .1 9063 MASSACHUSETTS -UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY V ,&abC VaJL MA DATE l- q - t 4 PERMIT # D JOBSITE ADDRESS '4-4 S Woo I -A, S OWNER'S NAME I FO.A.14UL 90►J1Ji_1A GOWNERADDRESS 5�41AF_ TEf _]FAXQ TYPE OR OCCUPANCYTYPE COMMERCIAL® EDUCATIONAL[] RESIDENTIAL[P2 PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT: Cj'� PLANS SUBMITTED: YES® NO[P' APPLIANCES 1 FLOORS- BSM 1 2 3 4 5 6 7 B 9 10 11 12 13 14 BOILER BOOSTER i - — �—._. ---- LOW CONVERSION BURNER Is` COOK STOVE ° G 1 T— _ _ DIRECT VENT HEATER DRYER FIREPLACE ['-v FRYOLATOR FURNACE GENERATOR GRILLE r--- - — (— INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT�— OVEN POOL HEATER ROOM I SPACE HEATER��- ROOF TOP UNIT i I TEST I— _ UNIT HEATER UNVENTED ROOM HEATER WATER HEATER INSURANCE COVERAGE I have a current liabili insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES Ej'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 ® 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 ail plumbing work and installations performed under the permit issued for this application will be iZT;nce wr -all P tine t -provision of the. . Massachusetts State Plumbing Code and Chapter 142 of the General taws. PLUMBER-GASFITTER NAME > JVEIA LICENSE # Ib2201 SIGNATURE MP F MGF Q JP Q JGF ❑ LPGI n CORPORATION F%# I i2 7e7CJ PARTNERSHIP#[� LLC Q#�� COMPANY NAME: FLAW GouVEtA 10e.. ADDRESS j 45 0-19126. Oki 57 - CITY I m. C uGLµs Fo a—� STATE MA ZIP 01863 TEL Eq • 2 51- 1800 FAX qU-251"16°I CELL EMAIL F1�A�16c e F4'(�LUM$1dJC, . Col►_4 ❑{ co N Ez a T -1 m = m r c� D O ro. z r cn y m z xt m to trJ -p D M M cn m z G m H I � ❑{ co N Ez a 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 i Please Print Legibly Name (131 Address: City/Stat Are ypu an employer? Check the appropriate box: f . YI am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors '.. ❑ I am a sole proprietor or partner- listed on the attached sheet. f ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] r ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t These sub -contractors 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.❑ Electrical repairs or additions 11. Plumbing repairs or additions 12.❑ Roof repairs 1;.❑ Other nL,y appuca IL uiai cnecKs Dox 41 must also 1111 out the section below showing their workers' compensation policy information. Homeotimers 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 their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. r, Insurance Company Name: Policy # or Self -ins. Lic. #: L 2 C(,jC Z12!? I—f6 Expiration Date: Job Site Address: _ Cc/VC�GY Co City/State/Zip: 1 Attach a copy of theworkers' O '1 compensation policy declaration page (showing the policy number and expiration date). ',F 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 un er the pains and penalties of perjury that the information provided above is true and correct Si ature: I Date: / ! / 1 Official use only. Do not write in this area, to he completed by city or town officiaL 1 City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Buildi' g Department 6. Other Contact Person: 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector Phone #: ��-'VIASSAekU -pLu�BERS AND REGIS s u A PLUMBINGTERS - RED qS r Es` THEABOVE UCENSE To:. FR"ANK GOUVEIq c%.. _..FRANK . 1 6 WARREN VEIA VE pLB CONT RACTOR MAfl I &24_. 2787 fl 0.9 fly/Oil14 /� _ _—� s I `.:. e a ALTH OFMAss UgEr-, SACiS -_; g F'L�IA►IBERS ANSI GASFITiERS LICENSED AS A MASTER p .UMBrIt ISSUES THE ABOVE LICENSE TO: FRANK CpUV€IA 6: -WARREN AVE g. CHELMSFORD MA 01824-3Qp.s :10220 05/0 -F- 1/14 1832641\ COMMONWEALTHflF MAssACHUsEF: S , ®..Q o m a, a PLUMBERS AND GASFiTTERS UCENSEED AS A JouRNEYMAN PLUMS.E , ISSUES THE ABOVE UCENSE TO: a FRANK GOl1 VE IA i 6'WARREN AVE cs CHELMSFORD MA 01824-300 19659,, a5/l11/14 183253 n\i Date. A)! TOWN OF NORTH ANDOVER K PERMIT FOR GAS INSTALLATION • jw This certifies that. NAI �49.e-i 111� ilas permission for gas installation.. .....e_�.............. ... n I in the buildings of.. ............................ at .... 44,��..�-4 ...-.r'3...L d6i��p . ... North Andover, Mass. Fee A10.7... Lic. No. .WZ).. GASINSPECTOR Check # k-15-pX 8533 V, 1� MASSACHUSETTS UNIFORM APPUCATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY ' . I�!-1��15 A-� MA DATE PERMIT # *7-1 JOBSITE ADDRESSOWNER'S NAME L...FAX4iZ abaVF-tA GOWNERADDRESS44 5 woos (,,t.^TEL yFAX TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL D EDUCATIONAL RESIDENTIAL I? CLEARLY NEW: % RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES[] NO APPLIANCES 1 FLOORS— BSM 1 2 3 45 6 7 B 9 10 11 12 13 74 BOILER 1^ „_ - - - _ BOOSTER � - CONVERSION BURNER - - t - -• -° COOK STOVE �y 17 1 - ,� DIRECT VENT HEATER Vii-" `"`--�. t -• ,! _ DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER d __--•-` �1r �' ! LABORAr I MAKEUP AIR UNIT OVEN P xsa.'.y..:' SiS� 3C '•YN - _:.=-2• "� _u w_. �.�:I�. _;_� POOL HEATER .�: . , _ � LL - �. _ ROOM/ SPACE HEATER{ TEST TOP UNIT U me ..� UNIT HEATER - �--.. _ _� - .-�-'--•-�<��' -_-- UNVENTED ROOM HEATER _ �_"• _- `�. j : _ —. WATER HEATER � - --�=�---- •-°� 1--•.v--- -__ �-��--�- OTHER_--•t _ - - --._ - E d, °fib•"S. I JL INSURANCE COVERAGE I have a current Habilgy insurance policy or its substantial equivalent which meets the requirements of MGL. Ch.142 YES EP'NO L- I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW 1 LIABILITY INSURANCE POLICY ✓ OTHER TYPE INDEMNITY 0 BOND ! OWNER'S INSURANCE WAIVER: I am aware UW the licensee does not have the insurance coverage required by bmpter.142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. — CHECK ONE ONLY: OWNER AGENT L SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or enters (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 t iance Writs all Pertinent. provision of the. - Massachusetts State. Plumbing Code and Chapter 142 of the General Laws. �� PLUMBER-GASATTER NAME L FQAM K 113CL V01A �'����� -�✓ r �>f �/- ��c' C�- LICENSE r lb2� SIGNATURE _ MP �`�MGF JP El JGF i LPGI Ej CORPORATION ✓IQ C PARTNERSHIP []r j�a-' LLC COMPANY NAME- F utG 6'o4iVElA i t�lC. ADDRESS r( qe X12/A(CETnM CITY L !� • C 1.(Eiµs Fo STATE Fm—AZIP Ci/:843 L_P 78 • 2 5 t - FAX Ea--- s1 - —le of CELLF—_ -EMAIL, F&A,MIX- a F4CPLVK;9i"a . Coil► -t V, 1� oo z Wp r w O n LU *- 3 w LU w L LU y 2 O I -- a U J CL a _ +A LU w r r, DATE: LOCATION: OWNERS NAME: GENERATOR Icw I C� NQ INSTALLATION OR GROUND DISTURBANCE BEFORE APPROVALS* CONTRACTOR: � I` -a N-)vvo�� PHONE NUMBER: ELECTRICAL GAS RESIDENTIA COMMERCIAL TEMPORARY q%4 LOCATION OF GENERATOR: 21*ZONING DISTRICT: 13 C. -e -,c-0 vz�71 Nu 1UC.'� 40 *CONSERVATION APPROVAL 7� wt-�-w Town of North Andover Page 1 of 1 Base Map zoning 2012 Aerials Watershed zone Utilities Size 0E]Fj Help Scale i" = j45 g i\,az2"120 I 1:S 9' gam �104 � �R4': ti22:Q-0Q89� , m� I tD22:081Qi3s Get Pictometry Imag �J! Go v3.2.0 AppGeo Save Map as Image Select Parcels. Q (show all) Owner Prop_ID Address ';Lot! GOUVEIA, FRANK 022.0-0084 0000 0 445 WOOD LANE; 121! i D 1 selected To Mailing Labels To Spreadsheet QProperty Building Permits Planning Sept P ii Print Ownerl GOUVEIA, FRANK Owner2 GOUVEIA, INNA Address 445 WOOD LANE PropertyID 022.0-0084-0000.0 Lot Size 12196.8S Fiscal Year 2013 Land Use 101 Code � • c. t�� + not7onn�,,,•,,,, e \.MftyRmk V4 r �"N&Cmnffi nn does not make anYwatts mteqxrsged m lmyced, rot ass:are anY legd bNNty orn'WOsb6ty to the acnutacY• oonoe'eneas. ce usefutneg @ the Geographk inmtmatton %-tern (=, Dasa or any ong data pm*&A herein. the data does W Wke the pme of a PMasam:W su%" am hmno kga4 beamg do the twe snap; sse. bcatinn, or o e W a geXratk tmtire, property ine. orpmfical reprmefa m Mertim3ck \2Sky f�brtnay CarxMsdon regues[s Me! any use of M kawmrl n be aeW vented 4 a reference to Ps source and the Memma:k. Va r Phm*v Commissnn aneveat mm a makes no wana.•xiesor r2Py..k0290m m to the amraW of W;d tMomaum Any use of this attrnnatmn Is at the feC�so*n das http://mimap.mvpc.org/NorthAndovermimapNiewer.aspx 12/31/2012 Town of North Andover Page 1 of 1 Select arc . els tt _... L� ................. .. (show all) —— ........ Owner I Prop_ID Address 1 Lot! GOUVEIA, FRANK 1022.0-0084-0000.01445 WOOD LANE 121! 1 selected To Mailing Labels To Spreadsheet Print Ownerl GOUVEIA, FRANK Owner2 GOUVEIA, INNA Address 445 WOOD LANE PropertyID 022.0-0084-0000.0 Lot Size 12196.8S Fiscal Year 2013 Land Use 101 Code 11 fl McMwn kV,ieypl A*V cmntrtalon aces nm mateattywartamy,ew etna swdm Oww.nwessuany � lalsMy orregxxisuyfcethe axuracy.ron ys,. crt sak&wes d@w r aWspNc kttamV=' SYstan iof% Rita crany ovwdae pmt rwem.Ihedataacesndtaketheppaed8pmtesSbWssw_y andhasno "gat baarktg en Me bue sMp`-si. bratork ce e*tmae or a 9eb8ta M feats prapftV 6% orpofltirm mj�tevom Meek Veney P19nnsy cwt jssAm mqueft 1 MZ MV Me Of tt>+fi f rWMWM be aoob Wroed ttya refere9ae to Im=me atrt ttp hte�. Mey Pbmliw rpRml.°.q m-sca W MM a makes no wwxmesor "AIICMaS to tte=&acy d Salo iMOmtaMm Any used ON$ adotttsrt¢m t9 M dM MCoetd'sown dax http://mimap.mvpc.org/NorthAndovermimapNiewer.aspx 12/31/2012 Safely Insurance Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS. Ch. 139. Sec. 3B To: Building Commissioner or Inspector of Buildings City Hall NORTH ANDOVER, MA 01845 RE: Insured: Property Address: Policy Number: Claim Number: Date of Loss: Company: Board of Health or Board of Selectman City Hall NORTH ANDOVER, MA 01845 FRANK GOUVEIA 445 WOOD LANE, NORTH ANDOVER, MA HMA 0254891 BOS00042342 3/26/2014 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 313 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. Allan Leavitt Claim Examiner Safety Insurance Company Homeowners Claims Unit P. 0. Box 55098 Boston, MA 02205-5098 Phone: (617) 951-0600 EXT 3213 Fax: (617) 531-8891 Email: AllanLeavitt@Safetylnsurance.com . 3/28/2014 ISafety Insurance Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS, Ch. 139, Sec. 3B To: Building Commissioner or Inspector of Buildings City Hall NORTH ANDOVER, MA 01845 RE: Insured: Property Address: Policy Number: Claim Number: Date of Loss: Company: Board of Health or Board of Selectman City Hall NORTH ANDOVER, MA 01845 FRANK GOUVEIA 445 WOOD LANE, NORTH ANDOVER, MA HMA 0254891 BOS00032806 10/30/2012 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. David Meuleman Claim Examiner 10/31/2012 Safety Insurance Company Homeowners Claims Unit P. O. Box 55098 Boston, MA 02205-5098 Phone: (617) 951-0600 EXT 5194 Fax: (617) 531-2778 Email: DavidMeuleman@Safetylnsurance.com