HomeMy WebLinkAboutMiscellaneous - 53 CEDAR LANE 4/30/2018 / 53 CEDAR LANE
f 2101106.A-0145-0000.0 \`
Phone: 978-632-2660 Fax. 978-632-2662
JAMES A. TRUDEAU
Adjustment Service Inc.
P.O.Box 7
Gardner,MA 01440
claims(&tru deauad i.co m
Notice of Casualty Loss of Building
Under Massachusetts General Laws, Chapter 139, Section 3B
February 10,2015
wilding Inspector
120 Main Street
North Andover,MA 01845
Board of Health
120 Main Street
North Andover,MA 01.845
Fire Department
Dept. of Records
124 Main Street
North Andover, MA 01845
Insured: Tracy&Thomas Beasley
Loss Location: 53 Cedar Lane,North Andover,MA 01845
Insurance Company: Preferred Mutual Insurance Co.
Policy No.: PHOO100846052
Date of Loss: February 7,2015
File Number: 15-12662
Claim Number: 15102912
Type of Loss: Ice Dam
Claim has been made involving loss, damage, or destruction of the above captioned property, which may either
exceed $1,000.00 or cause"Mass. Gen. Laws,Chapter 143, Section 6"to be applicable. If any notice under"Mass.
Gen. Laws, Chapter 139, Section 3B" is appropriate, please direct it to the writer and include a reference to the
captioned insured, location,policy number,date of loss,and file or claim number.
On this date, I cause copies of this notice to be sent to the person(s) named above at the address indicated by first
class mail.
Sincerely,
Joshua M.Trudeau
Claims Adjuster
/:q- �-
Date.. . .I. .. .... . . . ... ..
f ,SORT/,
o= TOWN OF NORTH ANDOVER
p
PERMIT FOR GAS INSTALLATION
SACMUSEt
Y
This certifies that : . . . . . . . . .
has permission for gas installation . . . . . . . . . . . . . . . . . . . . .
in the buildings of • ./.��-��'?^�jr/ . .. . . . . . . . . . . . . . . . . .
at .- .. . ... ` . . North Andover, Mass.
Fee"x5 .. Lic. Nd'?. . . . � �-�- z -. . . . . . . . . . .
GAS It ISPE R
Check<0/ -4'd a//f
6951
b
MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS FITTING
(Type or print) Date Z . /3 • Q
NORTH ANDOVER,MASSACHUSETTSBuilding Locations Cerla t- (' k``E Permit# 9Q
Amount$ c
C Owner's Name
New Renovation Replacement Plans Submitted
x
o V
o f F x z z o F w
z o a w
V F z F d x . x w W F w F x x
z w > w ° z o z o x
x o x w 3 a td7 U a > a a H 10
SUB-BA SEM ENT
BASEM ENT -
1ST. FLOOR
2ND . FLOOR
3RD . FLOOR
4TH . FLOOR
5TH . FLOOR
6TH . FLOOR
7TH . FLOOR
8TH . -FLOOR
(Print or type) ('`(' �- Check Certificate Installing Company
Name 9.�-1-�1-1�� JIr��I'� Corp.
Address :@ 7-lifel- OY®y l&C Partner.
usmess ep one Q 7 Fj^ eo 7 7 Finn/Co.
Name of Licensed Plumber or Gas Fitter b rY 1 �j 61e
1e
INSURANCE COVERAGE Check one•
I have a current liability Insurance poli y or it's substantial equivalent. Yes No 1-3
If you have checked}_es,please in 'cate the type coverage by checking the appropriate box.
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 1:1 Agent 0
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 of my knowledge and that all plumbing work and installations performed jLpader Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts Statt Gas Cod Chapter 142 of the General Laws.
❑ Si ab of Licensed Plumber Or; i
By: lG
Title
City/Town Gas Fitter icense um ber
❑ Master
APPROVED(OFMCE USE ONLY) ❑ Journeyman
• •ti �� ru riweatc`fi Of M4Wachase#s
D�pa�rnent Qf Industrial Accidpntc
�� i��� �tce aflrmestidafiorr.�
600 Rrmizhwmn Street
BOSZO
, .1kIA02111
wrvw&zasx,0vv/dk ,
workers' Campeut atioa Ltskrance.AfidaviL $ut'Ner9/Cunt m&Ors/Eiec raas/Pi
k 'cant In&M tian ambers
Please Print Leeibf.
Nan2i(Busier s/brgaoization/individual);
Address:
CityLSt>�/T�tg: -
Phone
Are you ea employer?Cheep.the sppropri:ate•box:
I:(] I Sim i enepleyer with 4. �] I ase a Type of Project
geme:ral contractor and I (r'egaim(l):
2•❑ =Ploy=(fulland/arp _tines.* have 6. -New corioroction .
7 am.a sole • ] d the sub-cortlzaOrs ❑.
proprietor or pmrtner- listed on the attached sheet Itemodeiai
ship and have no cmpioyem . Thome g
working forme sub-contractors have
��• workars, comp.insurance. 8' (]D-511101ition
[No woriters'comp,nummsce.. S. [] Wz art a corporation and its 9. 0 Buildi
requntd.) ng addition
�ae:m have exercised their 1Q.[]El=ftical
3•❑ I am a homeowner doing all worst repairs or additions
.myself'[No-workers'comp, of exemption,par MDL 11.�]Plumb'
Z, §1(4j,.and we have no ng TePa or additions
insurance. t Roof .
gnrred.) .•amPZayews.[No worker' 12. f;*n
`A"3 WMP. irtsurancerequirecL] 13.[].pth�
aPPi t that ciiecics bob#I mast etso fM out tbz seance below
Homww*who edbmit this sWavit tndicebreg they ars �j ehDwrag timrrworkart'oompac soil mfonnefio�•.
Coatraamrs that check.this b..moat �Qf"g 11p t-and than has omaide oonuactars rruist submit anew
' cn add.�fioasl ahearshowiirg theRumofthc cvb.contracta� afndnvit MDt0 *yU�,
ce;.aa ea pioyer thjr h'.PT*dM :worF.ers''corn.Persia than
iitfarmvdiort �+rsrw-arrae�orirry.entpiny�; 8,��.Lr•f�,E
Insurance Com
Pam'Name: '
Policy#or Self-ins.Lie.#:
ozi Imo:
Job Site Address:
Attach a copy of the workers' corn CttylStaitfL�'
peDsafiDo Policy dxFar-adioo showintr
Faiitati to secte coverage as required under 9:.cdon 25A of P { e the Policy Dumber and e
l+►�1C�L c. I S2 can lead to the imposition xpir�fioa
Erne up to 50.0 QDO and/or one-year 1mPns`Onmerrt;as well civil on of 01ifninai
Of up to$250.00 a pesea}fies of a
�3 $€sinst the vioiator. Be advised Penalties in the form of a 57L7P WORK ORD£?{ a fine
investigations of the DIA for inatuance c:ov a Copy of this statement may be forwarded to the Office of
. wage verification. . .
I do hereby certify under the pairar and
perialfec ofPerl+Qy thm the atfornratioa provided above is tragi and aonrcz
5i
Date:
Phone#:
axial use only. do not wtZe in Chic cs�¢,m bt ca►tr�ot�.�byJ'
or town.Off=W
City or Town;
Issuing Permit/LicaDse#
d Aatleorify(circle one):
L Board of Heattb Z %filing t),eWbwent 3.City/TowD•Clerk 4. Electrical Inspector
6.Other
S. Plumbing I
inspector
Contact Person:
Phone#:
inrormatlon a. nC! instructions
Massachusetts General Laws.chap ter 152 requires all em
p loyers to provicic worked' eomperrsafaan for thou employe...s.
Pursuant to this statute,an employer is defined as"..:evccy person in the scrvice of another under any contract dhirt:, ,^
express or implied,oral or writ=" ' I'
An wiq&yer is defined as"an individual partnership,associatian,mrpor$iim or other legal entity,or arty two or more
of the'faregcaing engaged in a joint aribmprise,and includi"g the legal represcntativcs of a de c=zd employer,trrIbc
rrzxsiver ortrnstes•of an individual,partnership,associatio inor other legal=tity,employing cmpioye:s.'liowewthe
owner-of a dwelling house having not more than flux apa i-tm=ts and who resides therein, or the,occupa=nt.of flu
dwelling house of another who.employs persons to do mai:rt==ce,construction ar::pair wriric an such dwel ttg house
or on the grounds or building apputtr-r=thereto shall naT b==of such muployment bt deemed to be sn employar."
MGL chapter 15Z§25C(6)also states fhst"every state as-local iic6nsing agency shat!withhold the ismanmor
renewal of a license or permit to operate a baseness or to comsa-nct bnAirmp in'the commonwealth for any
appseant who has not produced Mable"erttt at csmprmnee wfth the.iasarancx coverage required.",
Additironatiy,MOL chapter 152,§25C(7)states"Neither ti c commanwea lth nor any of ita-polifical m6divisiam shall
ento into arty contract for the petiormmeee of public wore until•acceptablt mdenx of=npliancx with the insiaatrtx
requirements.of this dsapter have been prod to.thc ccllintr8�g aut,arity."
Applicants
Please fill out t6 workers',compensation.affidavit c ample--tely,by checking the boxes that apply to.your situation and,if
necessaary, supply suirconfractor(s)name() phone numbex(s)along with their ce rif cate(s)of
insurance:. Limned Liability Companies(LLC)or Limitma Lability.Partnerships(LLP)with naeanployees othert6m the
members or,pmtrt;m,are notrogrmrd,tD caay workers'cx�oTnpmmation irstaancx. Ifan LLC orUP does have
empipyees,a policy is required. Be advised that this afidb-a-&may be submitted to the Deparimearrt of Industrial
Accideris for conf rmatian of insuashat coverage. Aim �e wire to sign and date the affidavit The affidavit should
bre retranesd m the city or town that tIm appCcatiom for.tbe p it or ficenst is being requested,nat'the Deparhnent of
Industrial Accidents. Should you have any questionsregacs-dmg the law or if you art required to obtain a workers`
ooMpe.nsataon policy,please:-ea11 the Department it the-nurnber.listed below. Self-insured cx}rnpanies should orriethcir
self insurancc iicenst trureiier an the'llMropi'iatt►iris. 4• i s
City or Town O icinis
Piease be sure brattint affidavit is complete and printed irgibly. The DRartmeit hes provided a space at the botmm
of ft affidavit for you to fill out in.the-event flit.Office of inves#pfiom has t D==you regarding The applicant
Please be sure to fi 1 in the parmit/Iicmm number which vteZi bt used as a referent:number. In addifion, an appiiceat
that must submit multiple permit/Jicansc appiicatibns in any given year,need only submit one affidavit indiceting•marent
policy`information ff nocemq)and under"Job Site Address"the applicant should writ"all locations in (city or
town)."A Dopy attire affidavit thmd has bc_zn.officisily slasnped or marked by flee city or knvn may be provided to the
applicant as proof thata valid afridnvit is on Me for ntrdm permits or li=wm. A new affidavit must be flied out each
year. What a homt owner or citizen.. obtaining a licenser or permitnot related to any business or commercial vmhse
(i.e. a Bog iicenst or permit to bum leaves este.)saidniN . qudesOto•complete this affidaviL
The:Office of InvextiQions would lice to thank you in advance for your cooperatirm and should you have arty questions,
pieeso dw not.hesitate to give us a tail
The Department's address,teL.phone and fax number:.
The Commonwealth of Massac�tzsetts
Deparhnent of lxidustiiai Accidrmts
Office-Of Laavesfigntions
600 Washington St=t
Basion, hAA 0.2111
Tee#617-727-4900 i=406 or 1-9.77-MASSAF'E
ft_-vistd 5-26-{15
Fax-461 7-727-7744
WWW.MaSS.g-OV{dIa X