HomeMy WebLinkAboutMiscellaneous - 61 MILLPOND 4/30/2018 61 MILLFONU--.
210/095.A-0061-0000.0
Date.... ..11�.. .............
OF NORTIy,� .
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PERMIT FOR GAS INSTALLATION
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has permission for gas installation ....df-Y�n
inthe buildingl s of...r..............................................................................................................
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Andover, Mass.
Fee3 v...... Lic. No. 3.?. .
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GAS
Check# v
1028
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/ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY North Andover MA DATE 06/17/15 PERMIT#
JOBSITE ADDRESS 61 Mill Pond,North Andover,MA 01845 OWNER'S NAME Boris Ostrovsky
GOWNER ADDRESS 41 Broadlawn Drive,Chestnut Hill.MA.02467 TEL 978-314-3123 FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL
PRINT
CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO
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 1
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM/SPACE HEATER
ROOF TOP UNIT
Tf ST
(UNIT HEATER
U VENTED ROOM HEATER
WATER HEATER
OTHER
INSURANCE COVERAGE
I have a current liabili insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO
I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
RLJe LIABILITY INSURANCE POLICY
M,40.-31�(�� OTHER TYPE INDEMNITY BOND I
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 kno edge
and that all plumbing work and installations perforated under the permit issued for this application will be in co liance withI Pertinen rovision
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 00. r
PLUMBER-GASFITTER NAME Ernest G.Hamilton 3rd LICENSE# 23749 SIGNATURE-
MP
IGN TUREMP MGF JP + JGF LPGI CORPORATION # PARTNERSHIP # LLC #
COMPANY NAME: ADDRESS 551 Princeton Blvd
CITY Lowell STATE MA ZIP 01851 TEL 508458-5825
FAX CELL 508-423-0283 EMAIL EAGLEERNIEI@AOL.COM ,y
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ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLYC'INA.L INSPECTION NOTES
Yes NO
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT#
PLAN REVIEW NOTES
71
MASSACHUSETTS PROPERTY INSURANCE UNDERWRITING ASSOCIATION
Two Center Plaza
Boston, Massachusetts 02108-1904
(617) 723-3800, Ma Only (800) 392-6108, Fax (617) 557-5675
04/24/01
Form of Notice of Casualty Loss to Building
Under Mass. Gen. Laws, Ch. 139, Sec.313
NORTH ANDOVER HEALTH DEPT.
NORTH ANDOVER TOWN HALL
NORTH ANDOVER MA 01845
Re: Insured: ELENA& BORIS OSTROVSKY
Property Address: -61 -M-ILL.-POND,.NORTH ANDOVER, MA 01845
Policy Number: 0614551
Type Loss: Water Damage
Date of Loss: 04/20/01
Claim Number: 186144
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 3 B 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
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APR 3 0 201101
CMA00021