The URL can be used to link to this page

Home My WebLink AboutMiscellaneous - 450 MAIN STREET 4/30/2018 450 MAIN STREET ® 21101057.0-0006-0000.0 �v i I I Cunningham Lindsey U.S.,Inc. �U�1�11� �� P.O.Box 703689 Dallas,TX 75370-3689 T 1ney Telephone(888)738-8714 Facsimile(214)488-6766 L� / CLCAT@CL-NA.COM ***********************AUTO'*3-DIGIT 018 775 T3 P1 95000058965 Building Commissioner or Inspector of Buildings 120 MAIN STREET N Andover,MA 01845 _I Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS Ch. 139, Sec 3B Claim Number: 2244078 Policy Number: 2244078 12 co Company Name: MERRIMACK MUTUAL FIRE INS 0) Cause of Loss: ICE DAM LO Date of Loss: 3/5/2015 0 Insured: Kenneth Racicot Property Location: 450 Main St Claim has been made involving loss, damage, or destruction of the above captioned property, which may either exceed $1,000 or cause Massachusetts General Laws, Chapter 143, Section 6, to be applicable. If any notice under Massachusetts General Law, Chapter 139, Section 313 is appropriate, please direct it to the attention of the writer. Kindly include a reference to the captioned insured, location, date of loss and claim number. Section 313. No insurer shall a an claims 1 covering pay y ( ) g the loss, damage, or destructions to a building or other structure, amounting to the one thousand dollars or more, or (2) covering any loss,damage or destruction of any amount, which causes the condition of a building or other structure to render section six of chapter one hundred and forty-three applicable, without having at least ten days previously given written notice to the building commissioner or inspector of buildings appointed pursuant to the state building code, to the fire department or arson squad of the city or town and to the board of health or j board of selectmen of the city or town in which the same is located. If at any time prior to the payment the said city or town notifies the insurer by certified mail of its intent to initiate proceedings designed to perfect a lien pursuant to section three A, or to section nine of chapter one hundred and forty-three, or section one hundred and twenty-seven B of chapter one hundred and eleven, the said payment shall not be made while the said proceedings are pending; provided, however, that said proceedings are initiated within thirty days of receipt of such notification. Any lien perfected pursuant to section three A, or to section nine of chapter one hundred and forty-three or section one hundred and twenty-seven B of chapter one hundred and eleven, shall town against an casualty insurance policy or policies extend to and may be enforced by the city or to g y y p Y covering any loss, damage, or destruction pursuant to which the proceedings to perfect the lien were initiated. No insurer shall be liable to any insured owner, mortgagee, assignee, city or town, or other interested party for amounts disbursed to a city or town under the provisions of this.section, or for amounts not disbursed to a city or town under the provisions of this section. On this date, I caused copies of this Notice to be sent to the persons named above at the addresses indicated above by First Class Mail. i Cunningham Lindsey Catastrophe Department cicat@cl-na.com 800-867-3885 Date.1-...11:414..... 10307 F"opT o TOWN OF NORTH ANDOVER ..o ,•'tic z PERMIT FOR PLUMBING 8`4gCNUs� This certifies that....6.&—.....� t l..!4 ................................................................. has permission to perform..4 cr. `.--f............................................................. plumbing in the buildings of... (,,.... ........... .. ............................................................. at....... ........... �, North Andover, Mass. t. Fee 3 v Lic. No./? (,w.... - . .................... a PLUM ING INSPECTOR Check# �� I� I MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY. J MA DATE ' PERMIT# JOBSITE ADDRESS �/ � ,,} , OWNER'S NAME POWNER ADDRESS , - TYPE OR OCCUPANCY TYPE COMMERCIAL PRINT CLEARLY NEW: RENOVATION:F REI ^ 3 NOF FIXTURES Z FLOOR- BSM 1 r��-x a 13 14 BATHTUB 1 -! f � CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEMj7 DEDICATED GAS/OIL/SAND SYSTEM J I _ DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAINI FOOD DISPOSER g IFLOOR/AREA DRAIN ._.____JINTERCEPTOR(INTERIOR) ____^i __ I IKITCHEN SINK __I _ _ ILAVATORY � ROOF DRAIN SHOWER STALL SERVICE I MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES _I WATER PIPING I OTHER _ - -- Vim Ir 1 have a current liability insurance policy or its substantial IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY 0 BOND D 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 _i AGENT SIGNATURE OF OWNER OR AGENT 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 com ' nce with all inent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME T,�,, /n //�aii, _ P LICENSE# SIGNATURE MP JP CORPORATION R# j PARTNERSHIP�# i LLC COMPANY NAME J=' // ,J f� ADDRESS f 1/`/ S-_ j I V\ IVA CITYnNt��:�_�_....._...._..---�STATE ,._N �� ZIP �3�3 �Y/� TEL _-_5/ FAX i CELL Q3s"f o-sI AIL ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ f� FEE: $ PERMIT# PLAN REVIEW NOTES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY _ ( MA DATE PERMIT#. JOBSITE ADDRESS ,, r�� -�� OWNER'S NAME POWNER ADDRESS „1 S 7- - TEL g7 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL 0 RESIDENTIAL®� PRINT CLEARLY NEW: DI. RENOVATION: REPLACEMENT:Imo" PLANS SUBMITTED: YES 0 NOD FIXTURES Z FLOOR- BSM 1 2 3 4 5 1 6 7 8 9 10 11 12 13 14 BATHTUB .. I _____I --1 CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM ( [ _TM I _�.I L_j _ _ ( ___-_ DEDICATED GAS/OIL/SAND SYSTEM i f _.! l __! DEDICATED GREASE SYSTEM I ._.._1 DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER __..I ___._._6, DRINKING FOUNTAIN .__..__..I -..___.E ____.__f FOOD DISPOSER ._.__._i .._ _-� _..-_1 I FLOOR/AREA DRAIN _.._.__J ._,____.,I ._____I __.-_-__1 INTERCEPTOR(INTERIOR) .__.._ 1 1 KITCHEN SINK ___! LAVATORY ROOF DRAIN __ I _._._.D _____I _-_—! 1 1 _ _1 ._..._.j I SHOWER STALL ( .__._� 1 _._._f -__— [ . w1 i I __._.._J ._.__I SERVICE/MOP SINK _ I _I I ! I ._ I ( f J .__.._ ...___._f J .. _Di _._-_I 1 .TOILET URINAL _I _ __-- ! I _...._ € WASHING MACHINE CONNECTION f - ( f ._ . _ _t r WATER HEATER ALL TYPES WATER PIPING i OTHER E f INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES INNO _I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY 01 BOND M 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 01 AGENT (0 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 com ' nce with all inent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME /�= / J—LICENSE# SIGNATURE IMP 0 JP CORPORATIONFID D# LLC M, COMPANY NAME :� . ��/: ,J f- ADDRESS n jV"�"TIIANP i CITY STATE ZIP TEL FAX _^ C CELLPAIL -- ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No 1-11 1 THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: PERMIT# PLAN REVIEW NOTES y i The Commonwealth of Massachusetts Department ofIndustrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly NaMe(Business/Organization/Individual): Z!�;:Q Address: City/State/Zip: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. El am a general contractor and I ` ❑ * have hired the sub-contractors 6. New construction epiployees(full and/or part-time). 2. I am a sole proprietor or partner- listed on the attached sheet.1 7• ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. E]Building addition [No workers' comp.insurance 5. El We are a corporation and its required.] officers have exercised their 10.El Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]i employees. [No workers' comp.insurance required.] 13.[JOther *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. I Homeowners who submit this affidavit indicating they aie 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. 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 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 certo under the pair ndpenaldes of perjury that the information provided above is true and correct. Si /� Signature: Date: /�d/ Phone#: Official use only. Do not write in this area,to he 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#: 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 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 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 be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or loeal 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 who 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 Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)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 a 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 that 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 bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations actions 600 Washington Street Boston}M.A,02111 Tel,#617-727-4900 ext 406 or.1-877rMASSABB Revised 5-26-05 Fax#617-727-7749 vvww.Mass,govfdia a, r' PLUMBERS AND SFITTERS �',ULICENSED AS A.�J-OURNEY. AN PLUMBER 1SSUE8 SE TO: THbmAS S FARHADIAN 1 415 -MAIN ST HAMPSTEAD "","4--'NH '03541=2D73 r 0'., j I05/01/14 163615 19420 i I r 4158 Date.................................. 'toR of Oq TOWN OF NORTH ANDOVER 0 0 PERMIT FOR WIRING . ..... ....... SSA CHU This certifies that ......... .................................. has permission to p, -11 .................................... ... ........ . . .... ' ?- t� wiring in the building of . ... .................................................... at.�XJ�...... ............................. .North Andover,Mass. Fee...... Lic.No.�.�/.....-Z-/o ... . ............. � .... .. .. . ........................ 7 �iLECTRICAL INSPEMR Check