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21010660000.0
IDEDIC .AMERICAN CLAIMS SERVICE 0MULTI-LINE ADJUSTERS
BUILDING COMMISSIONER OR BOARD OF HEALTH OR
INSPECTOR OF BUILDINGS BOARD OF SELECTMAN
1600 Osgood Street
North Andover, MA 01845
RE: INSURED: Grace Remmes
PROPERTY ADDRESS: 52 Highland View Ave, North Andover
POLICY NUMBER: 1066873
LOSS OF: 8/5/13; Water Damage
FILE/CLAIM NUMBER 30529 PD
Claim has been made involving loss, damage or destruction of the
above-captioned property, which may either exceed $1, 000 . 00 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' the
attention of the writer and include a reference to the captioned
insured, location, policy number, date of loss and claim file
number.
Tim McLaughlin
Claims Representative
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.
Unless we hear from you within the next 10 days, we will not be
obligated to pay any portion of this claim to you.
Date 8/5/13
7 KIMBALL LANE, BUILDING C, LYNNFIELD, MASSACHUSETTS 01940
TELEPHONE (781) 245-9516 • FAX: (781) 245-1077
Date . 7. . . . .Z
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that . . . . . . . . . .. . . S
has permission to perform . . . . . . . . . . . . . . . . . . . . . . . .
wiring in the building of . . . . . . M!1'1 S. . . . . . . . . . . . . .
at . . . . Z . �iy..Garr, �l / /� orth Andover, ass.
Fee Lic. No. I`�~. . . . . . . . . . . . . . . .
ELECTRICAL INSPEC OR�
Check#
10976
i
F
��e► -�. Commonwealth ®f Massachusetts Official Use Only
Department of Fire Services Permit No. 6a ! 76
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] leaveblank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00
(PLEASE PRINT INLNK OR TYPEI4LL INFORMATION) Date:
City or Town of. NORTH ANDOVER To the Ins for ofWires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location(Street&Number) 5dd11 G- .14 L,QAA kti,) A 1/8'
Owner or TenantOr j� �- A11ZA) '—j tfA-IAj S Telephone No.q-2&&5,3• �6oC
Owner's Address A / t:
Is this permit in conjunction with a building permit? Yes ❑ No LW (Check Appropriate Box)
Purpose of Building j FSM I CY Utility Authorization No.
- Existing Service Amps / Volts Overhead ❑ Undgrd❑ No.of Meters
New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:`� L � QS r,6-M ,Q 1e
limon k)
Completion of the followin table may be_waived by the Inspector of Wires.
No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total
Transformers KVA
No.of Luminaire Outlets No.of Hot Tubs Generators KVA
Above In- o.o mergency Lighting
No.of Luminaires Swimming Pool rnd. ❑ rnd. Battery Units
No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones
No.of Switches No.of Gas Burners No.of Detection and
Initiating Devices
No.of Ranges No.of Air Cond. Tons TotNo.of Alerting Devices
No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained
P Totals: ....................... Detection/Alerting Devices
No.of Dishwashers S ace/Area Heating KW Local❑ Municipal ❑ Other
P g Connection
No.of Dryers Heating Appliances KW Sectio.uritof Devices or Equivalent
No.of Water No.of No.of Data Wiring:
Heaters KW Signs Ballasts No.of Devices or Equivalent
No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring.
No.of Devices or Equivalent
OTHER:
Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work:
(When required by municipal policy.)
Work to Start;o > Inspections to be requested in accordance with MEC Rule 10,and upon completion.
INSURANCE VER GE: Unless waived by the owner,no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The
undersigned certifies that such joverage is in force,and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE 10 BOND ❑ OTHER ❑ (Specify:)
I certify,under the pains andpVnalties of perjury,that the information on this application is true and complete.
FIRM NAME: =L� /�/ C'i�/ LIC.NO.:
Licensee:
,e� ,�jV�j / Signature LIC.NO.:
ffapplicgle,enter e em t' in the license number line.) Bus.Tel.No.:2� o�?
Address: _7 � ✓ `' Alt.Tel.No.:
*Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent.
Owner/Agent PERMIT FEE. $
iSignature Telephone No.
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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 Legibly/
Name (Business/Organization/Individual). . ....
Address: Z�'2 � (&4y
City/State/Zip: 4 �hone#: , 7,57
Ar an employer?Check the appropriate box: Type of project(required):
1. I am a employer with_� 4. ❑ I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
�S El am a sole proprietor or partner- listed on the attached sheet.$ Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers' comp.insurance. 9. M Building addition
[No workers' comp.insurance 5. ElWe are a corporation and its
required.] officers have exercised their 10. & lectrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 1 l.❑Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑Roof repairs
insurance required.]f employees.[No workers' 1311 Other
comp.insurance required.]
*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 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.
Insurance Company Name:
Policy#or Self-ins.Li c.#: - ' (3S1-7 Expiration Date:
Job Site Address:_5 ,f QAe�> /// Gt�.,lll✓ '" City/State/Zip;41z// jQ!f�e-1+ j' S
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.
T do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Sip-nature: Date:
Phone#:
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#•
r
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 of hire,
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 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 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." r
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
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 Z
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 burn 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
600 Washington Street
Boston,MA 02111
Tel.#617-727-4900 ext 406 or 1-877-MASSAFE
Revised 5-26-05 Fax#617-727-7749
www,mass,gov/dia
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTIH(3
(Print or Type) -
f NORTH ANDOVERs. Date A-3
, Mas ~ (./
W
building Location � Permit # 2- a�
/ Owners Name ,,
New Renovation Replacement Plans Submitted
FIXTUPFS
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SUR—$STJT.
BASEMENT
1ST FLOOR
2140 FLOOR
3R0 FLOOR
4TH FLOOR
STH FLOOR
6TH FLOOR
TTK FLOOR
8TH FLOOR
(Print or Type) Check one: Certificate
Installing Compan Name / Q Corp.
Address Partner.
'• , w Firm/Co.
Business Telephone:
Name of Licensed Plumber or Gas Fitter/ / is et4 ..,
Insurance Coverage: Indicate the type of insurance coverage by checking the
appropriate box:
Liability insurance policy JL� Other type of indemnity 0 Bond Ej
Insurance Waiver: I , the undersigned, have been made aware that the licensee of
this application does not have any one of the above three insurance coverages.
Signature of owner/agent of property Owner Agent
1 hereby certify that all of the details and information I have submitted(err entered)in above applicatio a and accurate to the best*(my
knowledge and that all plumbing work and Installations performed under"Permit issced fox this sppLica. a wiU-be Compliance with all pertinent
provisions of the Massachusetts State Gas Code snd Chapter 142 of the General Laws.
By TYPE LICENSE:
Plumb r
Title Gasfitter Signatur of Licensed
City/Town: .aster Plumber or Gasfitter
Journeyman 143 /
APPROVED (OFFICE USE ONLY) License Number
.....,,�,?1 J'7rt ''�+ _' +uir'r- .?iat„d1+` .F.lt^Ls•9y- yP.e...+.`'N'Wi2.aa'a r'...�-r•,y�y�w:.�a ���"''.`f='-
71
Date.... ......... ...........
e . 2374
Of•,O RT e.,ti - TOWN OF.NORTH ANDOVER
PERMIT FOR GAS INSTALLATION ;
�9SSACHUS�tA� 4 _
This certifies that . . . . . . .P
has permission fo"itAfllatii.on .�It
in the buildin s ocu
at S.� . . y(�. , North Andover; Mass.
Fee:, . ic. No.. � �.
GAS INSPECTOR
WHITE:Applicant CANARY: Building.Dept. PINK:treasurerGOLD:-File