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Home My WebLink AboutMiscellaneous - 68 BEVERLY STREET 4/30/2018 68 BEVERLY STREET i 210/009.0-0031-0000.0 I Insurance Adjustment Service, Inc. 936 Koose,,e]t Trail t:nit 5 Windham, ''taine 04062 207-892-0522 Fnx 107-8Q�-0S')6 UNDER MASSACHUSETTS GENERAL LAWS CHAPTER 139, SECTION 3B Date: February 20,2011 TO: Board of Health/Building Inspector RE: Insured: Osama Noureddine Property Address: 68 Beverly St REC ' N Andover MA 0194.5 2 2011 Tate of T,osc- 2/9/2011 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT Policy Number: BCQYSP Type of Loss: File or Claim Number: 68048 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, Ch. 139, Sec. 38 is appropriate,please direct it to the attention of the writer and include a reference to the captioned insured, locations, policy number, date of loss and claim or file number. Thank you for your cooperation. Very Truly yours, Matt Martin Adjuster FXt_ 109 Date.he/—OA. . ..... ... NpRTq of �' TOWN OF NORTH ANDOVER X , PERM FOR GAS INSTALLATION SA US This certifies that . .5 �!dp.r'U. San S has permission for gas installations in the buildings of . . . . . Aw. C.z?PAa . . . . . . . . . . . . . . . . . . . . at 4R. T. . . . . . . . . . , North A4dover, Mass. Fee. ',.'. . Lic. No..V-34- ! . . GAS INSPECTOR 4vrC�' Check# 7838 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING City/Town: AJOAT� A,/6oi 1_z, MA. Date: �� $^ // Permit# Building Location: /0� `1 5 Owners Name:/V eUic EN)lk*c Type of Occupancy: Commercial❑ Educational❑ Industrial ❑ Institutional❑ Residential New: ❑ Alteration:❑ Renovation: ❑ Replacement:� Plans Submitted: Yes❑ No❑ FIXTURES W co vi W Z Q N � U = Cd WO w tY 0 co g F- co uj m O J v N F 0 = w W O z Z 0 W W 0 1— p N > w co 0 Z to 0 Q a H o O w X > V W Z O J W Z N = W O lq W Z W Z F- H 0 Z —i 0 LL O WW Q W W m > O Z O > z � x V o D u_ C7 L7 = _ 0 a. H > > > O SUB BSMT. BASEMENT 1 FLOOR 2 FLOOR 3 FLOOR t 4 FLOOR 6 FLOOR 6 FLOOR 7 FLOOR 8 FLOOR Installing Company Name: I Check One Only Certificate# 14 Address; C 4w A(p,4 1U City/Towe2 n:�� aC.,t State: Corporation a) Business Tel:gG.0 El Partnership Fax: Name of Licensed Plumber/Gas Fitter: -L�`2El Firm/Company-ed ,�. v��bvriP� INSURANCE COVERAGE: I have a current liabilityinsurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Yes LJ ryo❑ If you have checked Yes,please indicate the type of coverage by checking the appropriate box below. A 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 Massachusetts General Laws,and that my signature on this permit application waives this requirement. Check One Only Signature of Owner or Owner's Agent Owner ❑ Agent ❑ By checking this box❑;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 compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. By Type of License: Plumber Title ❑Gas Fitter Signature�Wice�nsedIberlGas Fitter ®-Ilfiaster City/Town ❑Journeyman License Number: APPROVED OFFICE USE ONLY El LP Installer The Commonwealth ofMassachusetts Department of Industrial Accidents Office oflnvestigations 600 Washington Street Boston,MA. 02111 yY www.mass gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information please Print Leawibly Name(Business/Organization/fndividual):A • S( f 06kIA-[} -,e S _!Q_ - Address: Z / A 17 City/State/Zip:_ �1 l t�- k'-et*9 ® r Z( Phone#: ' ale 4!� Are you an employer?Check the appropriate box: 1.❑ I am a employer with ,ZP/ 4. Type of project(required): ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6 El New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheget. t 7. ❑Remodeling ship and have no employees These sub-contractors have working for me in any capacity. workers'comp,insurance, g' ❑Demolition [No workers comp.insurance 5. 9. ❑Building addition P ❑ We are a corporation and its 3.❑ required.] .officers have exercised their 10.❑Electrical repairs or additions I am a homeowner doing all work right of exemption per MGL 11.�iu nbing repairs or additions ` myself. [No workers'comp. C. 152,§1(4),and we have no insurance re uired. 1 12.❑Roofrepairs q ] • employees.[No workers comp,insurance required.] 13.❑Other !Any applicant that checks box#1 must also fdl out the section below showing their workers'compensation policy information. 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. lam an employer that is providing workers'compensation insurance for my e information. mployees. Below is thePolicy and job site Insurance Company Name: ,`qr Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: i'tJ>=i2 C• '- jJ d ty/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 maybe forwarded to the Office of Wvestigations of the DTA-for insurance coverage verification. fP J ry do hereby certify under the pains and penalties o er'u that the information provided above is true and correct. 'i nature: / Date: o none#: 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 Inspec#or 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 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 apartinents 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 insuranc6 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 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 permithicense number which will be used as a referencd 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 Col-uy:uon-weaIth. of S/%assaehuse-tis Department of Industrial Accidents Office of InVestigatitons 600 Washington Street Boston;.MA 02111 Tel.# 617-727-4900 ext 4406 or-1-877-MA.SSAFE fax#61,7,727-7749 Revised 5-26-OS - Ok#O§DEALT OF MASSACHUS , � . , . . Al, _w >: < \ ƒ Z R) IIJASM w 1£N-ED AS A MASTER PW. 2». ISSUEST&Lcm$ET - 12� LEkE A &ROtIDORO \\\ , > ; \ #A«PA R# . » \ -- . MA' \_ \4£ %§}Cf . . \/� \ a.326 05/0lzl2 /�2 5 A / . . . ., , . a: a> . . .�. . � { » f 5 � Date. . . . ... .. . .. . . .. . . . . . R ,ap RTr, TOWN OF NORTH ANDOVER r PERMIT FOR GAS INSTALLATION SA HUS r a This certifies that ' . ` has permission for gas installation . . . . . . . . . . . . . . . in the buildingsofif �� . .. . . . . . . . . . . . .il. . . . . . . . . . at . .,/ o?,t , . �.,� . . . . .. North Andover, Mass. Feel?f 0 Lic. No.��1 . GASINSPECTOR Check# 7 47U2 i MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO CASFI`CTING y� _ (Print or hype) 470) - Date Mass. — 3 20 Permit t#_ Building Location f' 4ner's Name— l I a h "Zf Type of occupancy_ New p Renovation Q R ac trent [�� Pians Submitted: Yes(] No p N W N Y = a Vf C 0 Q N = r ' W W N Q O Vj Z O W ~ < Q 9 O w r e; A to O W < y z s- p Q y o W ar W w W W1 Z < _ Q o > v. v .1 w yr < yt " (• W O W ` Q .+ t 0. 012 4=2 W O p h 's O d w 7 3 o d ca x SUB—BSMT, BASEMENT IST FLOOR 2ND FLOOR 3R0 FLOOR 4TH FLOOR sTH FLOOR ETN FLOOR ?TK FLOOR STH FLOOR Installing Company Name Check s 4 �^ Check one: Certificate Address_ — M Ileo-922"m— LA h�, � � O Corporation 0 V I ❑ Partnership - Business Telephone 1 7$— `�7 �" o / 2—EiR'n/Co. - -- Name of Licensed Plumber or Gas FitterINSURANCE COVERAGE: COVERAGE: I Aave A current i�ib. ility insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142, Yes CV No O if y Ou have checked yes. please Indicate the type coverage by checking the appropriate box A liability insurance policy Other type of indemnity O Bond O OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. Genera) laws, and that my signature on this permit application waives this requiren),antt Check one: Owner❑ Agent ❑ Signature of Owner or Owner's 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 the permit issued.for this application will be in compliance with 40 pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. by T of Plmber�' Signature o. l�se�Niffib�er rr o ash fltte fitter Tine ter License Numberj Z 2— 9 GtyA?PFit7 ED _ Journeyman tL _l�:e lVL BELOW FOR OFFICE USE ONLY FINAL INSPECTION SKETCHES PROGRESS INSPECTION FEE NO. APPLICATION FOR PERMIT TO DO OASFITTINO NAME A TYPE OF BUILDING LOCATION OF 21MILDIN, G PLUMBER OR OASFITTER „_ - L1C.NO. PERMIT GRANTED GATE_... .....»20 ` OAS INSPECTOR