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HomeMy WebLinkAboutMiscellaneous - 54 ELM STREET 4/30/2018 54 ELM STREET " 210/042._ x.0015-0000.0 a � J ROBERT J. SWAJIAN & ASSOCIATES, INC. INSURANCE ADJUSTERS ASSOC110144 1820 TURNPIKE STREET-STE. 207 WE A L J ft= NS N. ANDOVER MA 01845 TELEPHONE(978) 655-4994 FAX (978) 655-3571 Info(a)RJSAssodates.biz "; FOR"JvI CSF NOTICE OF CASALT-Y LOSS` � _. .a. . ' TO BUILDING A UNDER,MASS IGEN LAWS, CH; 139„ SEC. 3B TO: Building Commissioner o'rb's i' f :3: f" ; Board of Health or Inspector of Buildings City Hall North Andover, Ma 01845 Same `Insured: Michael Keohan . Loss Location: 54 Elm Street Date of Loss:, - 10/26/16 Policy Number 1387390 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 or file number. ADJUSTERS TITLE: 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. Rob E Swajia Adjuster d�1 November 21, 2016 MASSACHUSETTS PROPERTY INSURANCE UNDERWRITING ASSOCIATION Two Center Plaza Boston,Massachusetts 02108-1904 (617)723-3800 Ma Only(800)392-6108,FAX 18001851-8424 111512016 Form of Notice of Casualty Loss to Building Under Mass.Gen.Laws,Ch.139,Sec.36 i . NORTH ANDOVER BUILDING COMMOSSIONER NORTH ANDOVER TOWN HALL NORTH ANDOVER MA 01845 i I w Re: Insured: MICHAEL KEOHAN Property Address: 54 ELM STREET,NORTH ANDOVER,MA 01845 Policy Number: 1387390 Type Loss: Water Damage:All Other Water Damage r Date of Loss: 1012612016 Claim Number: 410136 Claim has been made involving loss,damage or destruction of the above captioned property,which may either exceed$1000.00 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 or file number. MPIUA Claims Division CMA00021 .,� ,, � . i V G s f i I I 1� We X11,n ai ` AAl �___ Via.4�� , .� _�!�►1.� ,�,,_ � . �, .�� .�� � F� • '� f- �•. ! . „ J i / ' 1 r', ' � /i/ . � ' � � --1 ��. f --- -r I� _ / _ i 1 hIl �' _ _I__ M { I�1 t � 1 �. �� �, _ .� , , . ,- _ , � 1 �' _ �,� • ��� r _ �. . 4 f'� _ -_- .. ,�" -it � ' - ;� - `�,. fFt. '' r'� >.� ,� ` _ -- ,. ��_,. .,,�� ®� �� �. .:, �� �� � � �� ,��. „� J w S I r�.i 1� f i ; 7, ,' �1,. �S.3 �,_'4��� -'a; ��'a� �I i - � �� � — ' ', :�� 1 ��� � �� m ���- P 1_ -� ,� / �� ..�, �t, MASSACHUSETTS PROPERTY INSURANCE UNDERWRITING ASSOCIATION Two Center Plaza Boston,Massachusetts 02108.1904 (617)723.3800 Ma Only(800)392-6108,FAX(800)851.8424 10/25/2016 Form of Notice of Casualty Loss to Building Under Mass.Gen.Laws,Ch.139,Sec.36 NORTH ANDOVER BUILDING COMMOSSIONER NORTH ANDOVER TOWN HALL NORTH ANDOVER MA 01845 Re: Insured: MICHAEL KEOHAN Property Address: 54 ELM STREET,NORTH ANDOVER, MA 01845 Policy Number: 1387390 Type Loss: Water Damage: Plumbing Systems Date of Loss: 10/07/2016 Claim Number: 409858 Claim has been made involving loss,damage or destruction of the above captioned property,which may either exceed$1000.00 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 or file number. MPIUA Claims Division CMA00021 ....................... OF NOiiTM�� TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION CHUS� r This certifies ..............,.�... .r.!! :.0)/.................................................. v has permission for gas installation ....1r,;.*.:...,i.: ....:....................................... in-the buildings of............................................... � r i at .�...:......-..............:...................................................... ... North Andover, Mass. ..... Lic. No.t.,.L{........ .. ...r' ?! . GA9INSPECT6R Check#---L - >' ' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK f CITY MA DATE PERMIT# JOBSITEADDRESS� i�lC" Imo{' l.� iOWNER'SNAME i✓ GOWNER ADDRESS _rn ,r2� i TE TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL PST RESIDENTIAL CLEARLY NEW:[] RENOVATION:E] REPLACEMENT:[3 PLANS SUBMITTED: YES 0 NOE] APPLIANCES 7 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 1 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/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVONTED ROOM HEATER WATER HEATER OTHE _ I - INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES JE-11 NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Ell OTHER TYPE INDEMNITY E] BOND F OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massa husetts Ge eral La ,,and that my si ature on is permit application waives this requirement. ,zr V2 CHECK ONE ONLY: OWNER I AGENT SIGNATURE OF OWNOR 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 ompliance with all Pertinent oylsipn of the / Massachusetts State Plumbing Code and Chapter 142 of the General Laws. / 10 PLUMBER-GASFITTER NAME - LZ i ,� LICENSE# � SIGNATURE MP VMGF Ej JP D JGF Q LPGI© CORPORATION 0# PARTNERSHIP[J#=LLC E]# COMPANY NAME: 2 ADDRESS _ CITY _ _ _) STATE ZIP TEL _ FAX CELL EMAIL 9 The Commonwealth of Massachusetts f Department oflndustrialAccidents 1 Congress Street,Suite 100 Boston,MA 02114=2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Le ibl Name(Business/Organization/Individual): Address:-43 A' -Al ,S � ie City/State/Zip:VReLeo&e 6 2 -7 � Phone#: 791— 7,3 O q31 Are you an employer?Check the appropriate box: Type of project(required): 1.Vam a employerwith employees(full and/or part-time).* 7. [:]New construction 2. a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity.[No workers'comp.insurance required.] 9. F1 Demolition 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 properly. I will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.[Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs 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. 14.❑Other 152,§1(4),and we have no.employees.[No workers'comp.insurance required.] *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-corilractors 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: 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 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 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 DTA for insurance coverage verification. Ido hereby certi under the pains andpenalties o perjury t1 at he information provided a ove is t e and correct. Signature: 0 r Date: Phone#: f 9 c,2�_L q-3 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#: 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance-with the provisions of M.G.L.c.143,§3L,the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166,§32,an electrical permit shall be issued to the person,firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L.c.143,§3L. Permits shall-be limited as to the time of.ongoing construction activity,and may be.deemed.by the Inspector_of_Wires abandoned-and.invalid.if he—__. ._ or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this puipose by establishing an automatic four-year extension to certain permits and licenses concerning the use of development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence"during the qualifying period beginning on August 15,2008 and extending-through August 15,2012. e 8—Permit/Date Closed: Note:Reapply for new per> 0 Permit Extension Act—Permit/Date Closed: Date—elf...II—I.le?.......l..... + NORTH °ft °:•�"° TOWN OF NORTH ANDOVER PERMIT FOR WIRING SSACMU�� } •This certifies that ... ��✓..`. � ...v!...'.I :. .. ................................... .i J: I� v has permission to perform ...1 S!»l. , f... ....................................................... wiring in J the building of... .1.!1.. ' ...... 1.� ............................................ C Si at...S)(.......�� .............................................Pl;�Ti . .North Andover,Mass. Fees ..�....r..... Lic.No..........`. .�... .... .. ... .. . ... ... ICAL INSPECT Check # i r % I. L: .. Commonwealth of Massachusetts =Checked Department of Fire Services Per BOARD OF FIRE PREVENTION REGULATIONS Occ[Rev. APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC) 527 CMR 12.00 (PLEASEPRINTINIAW OR TYPE ALL INFORMATION) Date: & vl 9 1 Oq City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) 5 q a-14 G'�P_Mj Owner or Tenant M C44i4 tL (,-I�jv Telephone No.-701 25111!8 Owner's Address + Vi7 V h/ ;• w1�'jj2.Lj� V�1q ©217 Is this permit in conjunction with a building permit? Yes Purpose of Building 0 t3Ak NO (Check Appropriate Boa) Utility Authorization No. Eidsting Service '44 Amps /6 /C Z.O Volts Overhead 2 Und rd g ❑ No.of Meters7r,: — New Service Amps / Volts Overhead ❑ Undgrd ❑ No,of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: F to t Com letion of the ollowin table may be waived by the Ins ector of Wires. No,of Recessed Luminaires No,of Ceil:Sus No.of- No. f Total p.(Paddle)Fans fKVA ' No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of LuminairesSwimming Pool Above ❑ In o, o mergency Ig g d• rnd. Ba Units - No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of 7- nes No.of Switches No,of Gas Burners No.of Detection and No.of Ranges No.of Air Cond. Total Initiating Devices Tons No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons_ KW No,of Self-Contained Totals: DetectionJAlertina Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal Connection ❑ Other No.of Dryers Heating Appliances KW Security Systems:* No.of Water Noof No.of Devices or E valent Heaters KW . Si s Ballasts Data Wiring; No.Hydromassage Bathtubs No.of Motors No.of Devices or E uing:ent Total HP Telecommunications Wiring: OTHER: No.of Devices or Equivalent r Attach additional detail tf desired,or as required by theInspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: 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 cove a is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE [� BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalde�f perjury,that the information on this application is true and complete. FIRM NAME: dj LIC.NO.: ;; 08 A Z Licensee: j A m.o I t Signat (If applicable enter" e�npt"in the lice numb r 1' e.) LIC.NO.: C—.f y Address: I , /7� Q Bus.Tel.No.: '7w- 7«••O _rY *Per M.G.L c. 147,s. 57-61,security work req ' s D „ „ Alt:Tel.No,i'TF�- i 3a'-L'3 epartment of Public Safety S License: Lic.No. WAIVER. I am aware bili insurance covers .normally re d b I e ow, ere y way wner/Agent owner's agent. Signature e PERMIT FEE: $ C ,r . The Commonwealth of Massachusetts k ! Department of Industrial Accidents • Office of Investigations i' 600 NTashin,ion Street Boston, MA 02111 t�J www.mass.gov/dia . Workers' Compensation I itrance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legably Name (Business/Organization/Individual): Address: City/State/Zip: Phone#: . Are you an employer?Check the appropriate box: 1.❑ I am a employer with 4. ❑ I am a general contractor and I Type of project(required): employees(full and/or part-time).* have hired the sub-contractors G. ❑New construction 2.❑ I am a:sole proprietor or partner_ listed on the attached sheet I 7. ❑ Remodeling ship and have no employees These suits-contractors have 8. ❑Demolition working for me.in any capacity, workers' comp.insurance. [No workers'comp.insurance 5. ❑ We are a corporation and its 9. Building addition required_] officers have exercised their 10.0 Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11-7 Plumbing repairs or additions myself.[No•workers'comp. c. 1.52, §1(4),and we have no 12,7 Roof repairs insurance required.]t employees. [No workers' • 13.7 Other comp• insurance required.] 'Any applicant that checks bort#l must also fill out the section below showing their worketa'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractorsmusuc st submit a new affidavit indicatingh. suc ;Connectors that check this box mustattached an additional shectshowing the name of the sub-contractors and their workepers'cp,policy in�mg . I am an employer that is providing:workers'compensation insurance for my employees: Below is the policy andjob site information ` Insurance Company Name: Policy#or Self-ins. Lie.#: Expiration Date: Job Site Address: City/State2ip: 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 thisstatement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. ,l I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Siam= e., Date- Phone#: Official use only. Do not write in dJris 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 Inspector7P �or 6.Other Contact Person: Phone* MASSACHUSETTS PROPERTY INSURANCE UNDERWRITING ASSOCIATION Two Center Plaza Boston,Massachusetts 02108-1904 (617)723-3800 Ma Onlv(800)392-6108,FAX(800)851-8424 716/2016 Form of Notice of Casualty Loss to Building Under Mass.Gen. Laws,Ch.139,Sec.36 NORTH ANDOVER BUILDING COMMOSSIONER NORTH ANDOVER TOWN HALL NORTH ANDOVER MA 01845 Re: Insured: MICHAEL KEOHAN Property Address: 54 ELM STREET,NORTH ANDOVER, MA 01845 Policy Number: 1387390 Type Loss: Water Damage: Plumbing Systems Date of Loss: 0612812016 Claim Number: 407459 Claim has been made involving loss,damage or destruction of the above captioned property,which may either exceed$1000.00 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 or file number. MPIUA Claims Division CMA00021 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance-with the provisions of M.G.L.c.143,§3L,the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166,§32,an electrical permit shall be issued to the person,firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L.c.143,§3L• Permits shall-be limited as to the time ofongoing construction activity,and may be-deemed.by.thednspector_ofWires abandoned.and.invalidlflre—_. ._ or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. El The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this puipose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence"during the qualifying per' beginning on August 15,2008 and extending-through August 15,2012. 15m ule 8—Permit/Date Closed: —Z•.? Note:Reapply for new permit 0 Permit Extension Act—Permit/Date Closed: i 0 2- 6 Date.....17=... TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING 'S'SACHUS This certifies that ............ ..........L4i4:m' .e�................................. has permission to perform ... /:' Z�...... wiring in the building of..............k 0 f7'-op"v .... ........................................................... at.....`1 .L/...6�......�F ........... North Andover,Mass. Lic.No..! .... . .......... ]&LE��ZCA*L INSPECTOR Check # Commonwealth of Massachusetts Official Use only –— Permit No. O-L 7j Department of Fire Services - Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. ]/07] leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code((ME527 CMR 12.00 (PLEASE PRINT ININK OR TYPE ALL INFORMATION) Date: 5,.-F ? I1{ City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives noti e of his or her intention to perform the electrical work described below. Location(Street&Number) ��`A,, Q Owner or Tenant / t kevkA-10 Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No [�r (Check Appropriate Box) Purpose of Building S t 6tL.Y 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 roposed Electrical Work:cel t- t r e K t f. Completion of the ollowing table may be waived by the Inspector o 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 No.of Luminaires Swimming Pool Above In- o.o Emergency Lighting rnd. ❑ rnd. E] Batter 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. Total No.of Alerting Devices Tons g No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: ........................ '.""'................ Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters 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: Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: 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 coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify,under the ins nd penalties of per'ur ,that the information on tis pplication is true and complete. FIRM NAM y� IC<l 1.a K LIC.NO.: 0199950- A Licensee: 11e1 �r yt t Signatu LIC.NO.: (If applicable,enter " xempt"in he license number ne.) Bus.Tel. No.: Address: -0. �oIt //f /1/a, /�, �dOtst/ /4-4 C9[ �Slf Alt.Tel. *Per M.G.L c. 14 ,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 Owner/Agent PERMIT FEE: $ Signature Telephone No. ~ The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Y www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Z l Address: I�� d • o l l s City/State/Zip: /y D. A&40IFt,- Ax4 Phone #: Are you 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 2.09 1 am a sole proprietor or partner- listed on the attached sheet. $ ? E] Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.®Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.]t employees. [No workers' 13.❑ Other comp.insurance required.] • *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 their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is tite 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for in7ilhce coverage verification. I do hereby ce nder t nd nalti o erjury that the information provided above is true and correct. Signature/, YDate: l. Phone#: `7 r! — 1 T Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Date. ~2�l..l.Z' .... . HORTM o= �` °t% TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION SACMUSES This certifies that . . . L / c9 . .d:��s. . . . . . . . . . . . . . . . . " has permission for gas installation in the buildings of . . . . . .zkohgn. . . . . . . . . . . . . . . . . . . . . . . . . . at . . .,.S"��. /. . .-. . . . . . . . . . . . . .. North over, Mass Fee., .,.4?�! Lic. No..,?, .�/S� GAS INSPECTOR Check# Ab.27 7 Bi 53 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) NOUN A11lI ) VEIC , Mass. Date_ 0 [ Z Permit # Building Location 54 ELM s-t, Owner's Name HICHAEL KEOHAM IV(krP AI�D�lE�2;, 14k Type of Occupancy 2 FAMiI�/ New ❑ Renovation ❑ Replacement ❑ Plans Submitted: Yes❑ No ❑ N c� N W N z a to n N N U y cc N Q Q N = F- N S !A W -� W F- U m N � x w ~ a ¢ x O T- 0 w Q m 0 ►- W W o E a � ar ►- m rt m (j w N W Q a o. a > w W W N J z Q S M rz a W F'" W F' _ (A a O f- Z J N Z W W O > W F- U J W z a W Q C F✓ 5- N m 2 0 z a 0 S Q W > W O Z. Q d Q O cti S u. 7 3 c d J U a > Q a F- O SUB—BSMT. BASEMENT 2 7STFLOOR 2ND FLOOR O 3R13 FLOOR _ 4TH FLOOR STHFLOOR 6THFLOOR 7TH FLOOR STH FLOOR Installing Company Name COLUMBIA (SAS GF MASSACHUSETTS Check one: Certificate # Address 55 MARSTON STREET D3 Corporation 1862 LAWRENCE, MA 01841 - 2312- ❑ Partnership Business Telephone 9 7$-691- 640 6 ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter Francis X. Corkery INSURANCE COVERAGE: I have a current liability FNo ur❑ ce policy or its substantial equNralent which meets the requirements of MGL Ch. 142. Yes If you have checked rimes, please Indicate the type coverage by checking the appropriate box. A liability insurance policy D< 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 ❑ 1 hereby certify that all of the details and information I have submitted(or entered)in abo pplication are true and accurte to the best of my knowledge and that all plumbing work and installations performed under the permit 5C= liance with all Pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Ge — T e of License: Plumber Signature of Licensed Plumber or Gas Title Gasfitter Master License Number 3745 City/Town Journeyman — n APPROVED O FIC SE ONLY I" 1 aw/If MASSACHUSETTS PROPERTY INSURANCE UNDERWRITING ASSOCIATION Two Center Plaza Boston,Massachusetts 02108-1904 (617)723-3800 Ma Only(800)392.6108,FAX(800)851-8424 1/10/2007 Form of Notice of Casualty Loss to Building Under Mass.Gen.Laws,Ch.139,Sec.3B ,.i r-1 V;: NORTH ANDOVER HEALTH DEPT. NORTH ANDOVER TOWN HALL JAN Z 6 2007 NORTH ANDOVER MA 01845 TOWN AOFN ORT4 ANL)OVER DEPA:zT;,;i1 T Re: Insured: MICHAEL KEOHAN Property Address: 54 ELM STREET,NORTH ANDOVER,MA 01845 Policy Number: 0949067 Type Loss: Personal Article Floater Date of Loss: 01/04/2007 Claim Number: 236866 Claim has been made involving loss,damage or destruction of the above captioned propert,which may either exceed$1000.00 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 or file number. MPIUA Claims Division CMA00021 MASSACHUSETTS PROPERTY INSURANCE UNDERWRITING ASSOCIATION Two Center Plaza Boston,Massachusetts 02108-1904 (617)723-3800 Ma Only(800)392-6108,FAX(800)851-8424 1/6/2007 Form of Notice of Casualty Loss to Building Under Mass.Gen.Laws,Ch.139,Sec.36 IRE��,VaD NORTH ANDOVER HEALTH DEPT. JAN 1 NORTH ANDOVER TOWN HALL 6 ZOO) NORTH ANDOVER MA 01845 TOWN OF tgORTH ANppVE HEALTH DEPARTMENT R Re: Insured: MICHAEL KEOHAN Property Address: 54 ELM STREET, NORTH ANDOVER.MA 01845 Policy Number: 0949067 Type Loss: Theft Date of Loss: 01/04/2007 Claim Number: 236808 Claim has been made involving loss,damage or destruction of the above captioned propert,which may either exceed$1000.00 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 or file number. MPIUA Claims Division CMA00021 MASSACHUSETTS PROPERTY INSURANCE UNDERWRITING ASSOCIATION Two Center Plaza Boston,Massachusetts 02108-1904 (617)723-3800 Ma Only(800)392-6108,FAX(800)851-8424 1/6/2007 Form of Notice of Casualty Loss to Building Under Mass.Gen.Laws,Ch.139,Sec.36 RE CE1%�,PED NORTH ANDOVER HEALTH DEPT. JAN NORTH ANDOVER TOWN HALL 6 2007 NORTH ANDOVER MA 01845 TOWN 0,-NO,RT 1-(EAITH DE; H�NDOI/(R Re: Insured: MICHAEL KEOHAN Property Address: 54 ELM STREET,NORTH ANDOVER,MA 01845 Policy Number: 0949067 Type Loss: Theft Date of Loss: 01/04/2007 Claim Number: 236808 Claim has been made involving loss,damage or destruction of the above captioned propert,which may either exceed$1000.00 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 or file number. MPIUA Claims Division CMA00021 Date. . . NORTM TOWN OF NORTH ANDOVER , p PERMIT FOR PLUMBING SSACMUS� This certifies that . : . . . . . . . . ? . . . . . . . . . . . . . . . . . has permission to perform . r . . . . . . . . . ... . . . plumbing in the buildings of I`. ... . . .. . at . . . . . .r. :. . !t. . . . . . . . . .f,. . . . . . . . ., North Andover, Mass. Fee. . . .`. .Lic. PLUMBING INSPECTOR ' Check # ' %b MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or prin NORTH AN OVER,MASSACHUSETTS Date 3—,?.? - Building L�cation S L/1'1 57- Owners Name A42CH,4,5L ti E©H4i/1/ Permit# Amount T e of Occu anc -F9 ,�.L 4/I/ S New Renovation Replacement Plans Submitted Yes No FIXTURES u ce Cr SLIMM H�ig1V1NT M H JOCIt 3�I2 HIDCR �dl HIDCR 4IH Fl" SII3 HLD(R 6MH fm 7M MIR SIH HI�(it (Print or type) � / Check one: Certificate Installing Company Name El Corp. Address 77 19 Vl= F_ YFa-U-77-T RA =jq,70 Partner. Business Telephone Z/ a q / O /) Q, Finn/Co. p _ Name of Licensed Plumber: -1 A V L I. 6o0T) H V E Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy ❑ Other type of indemnity Bond ❑ 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 �igaature 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 of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massac setts tae Pl ing Co d Chapter 142 of the General Laws. By Signature of LiVnscum Type of Plumbing License Title C� City/Town icense Numver Master Journeyman APPROVED(OFFICE USE ONLY L_I A Date. f HORTM O TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING 41 ,SSACHUS� r ti This certifies that . . �. . . . . . . . :. . . . . . . . . . . . . . . . has permission to perform .t.`�. -`��"�- � �.': plumbing ifpe buildi s of . . . . . . . . . . . . . . . . . . . . . at.v.�•. f . . . . . . . . . . . .. North Andover, Mass. Fee—*.? `. . . .Lic. No. f: "--�r--c'`:-. .. �1�: �+ .. . . . . . MBING INSPECT�A 04/06/99 11:29 30.00 PAID (� WHITE: Applicant CANARY: Building Dept. PINK:Treasurer MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS ( Date Building Location J T( �� _ Owners Name ��"�� Permit# U S, `Alp�t Amount Type of Occupancy New Renovation 0 Replacement IT Plans Submitted Yes 0 No FIXTURES z w a cr a � w z adz H O z O W d W a d w z a s a a o a 'n f� d w w x w > o x ° z z o o s SL]3.BIAE BASD Evr Isr.F,_rm t rQRDM _3M FLOCR 4MROM sm RIM 6M RJOCIR RaR (Print or type) �I, Check one: Certificate Installing Company Name �9�� �" /'�� �� 6 ��7� Corp. Address f jj kj � Partner. 7C/JJSLi IJ kl, Business Telephone 5; ; r 7 Firm/Co. Name of Licensed Plumber: U (— Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: ❑ Liability insurance policy Other type of indemnity ❑ Bond 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 Signature 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 of my knowledge and that all plumbing work and installs' ns performed under Pe it Issued for this application will be in compliance with all pertinent provisions of the Massachus ate Plug�Cter 142 of the General Laws. By: Signature o rcense um er ,/(� T e of Pllu mg License Title 77 ( 1 City/Town License Number— Master Journeyman ❑ APPROVED(OFFICE USE ONLY