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Home My WebLink AboutMiscellaneous - 70 MABLIN AVENUE 4/30/2018IN ___--___--__ --_--_----_-_- _ �"1 71' TOWN OF NORTH ANDOVERPERMIT FOR PLUMBING 46 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING CitylTown:. _ 0 Date: ! /: " �� Permit# AW�Ji g 0_. A►�1 Ave - TypeLocatii i fV Owners Name: Type of Occupancy: Commercial; Educationaf Industrial Institutional Residential P New.; Alteration: Renovation: Replacement: Plans Submitted: Yes No ctvr� INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes X -No 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 Owner Agent. Signature of Owner or Owner's Aaent -o- _•+- --- r+w===�=++a w -m nnu msuauauons perrormeo unaer the permit issues for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. - .Type of License: By t.`� Gas Fitter Tide , Signature f License ber/Gas Fitter ? " Master _In_,rnsuman... + % i City/Town J"' License Number LP APPROVED OFFICE USE ONLY LP InstaileFR V '"liJ . ( ' !- Z W i ; r Ni I �i ii + • i � i z i m 2 01 W S OU 01 X Q% LLI, i LL z H- 1- I 0 z > w � ..i i O Mi >- W a i W ~a i i i CL Q) iW- 0 wl 2' O, R w w c 0� x� I I. l O > rn -0 W to CC OI ~ O ui O a x u, Z O t3 v z c� Ia-- t» 1 W d �U' Q Z Ma z W O 0 0. z u. to 0 � x z > W wtz N- _ 4 D U. t09 S e ..1 fl H > > > �`r O I SUB::BSMT. I ;—i— BA$EMENT 1 FLOOR , 2 FLOOR I 3 FLOOR . 4 FLOOR' i S FLOOR I 6 FLOOR ; VH FLOOR f 6TR FLOOR Installing Company Name: _ - - Check one only Certificate # -t Address �( Qty1Town:,' - State: Corporation Business Tei: .- -- •- QUD Fax F .-.. MA `"' a - °Partnership ' Name of Licensed Plumber/GIs Fitter u — FirmlCompany INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes X -No 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 Owner Agent. Signature of Owner or Owner's Aaent -o- _•+- --- r+w===�=++a w -m nnu msuauauons perrormeo unaer the permit issues for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. - .Type of License: By t.`� Gas Fitter Tide , Signature f License ber/Gas Fitter ? " Master _In_,rnsuman... + % i City/Town J"' License Number LP APPROVED OFFICE USE ONLY LP InstaileFR V '"liJ . ( ' !- GENERAL AGGREGATE LIMIT (Other than . Products -Completed -Operations) S 11000,000 PRODUCTS -COMPLETED OPERATIONS AGGREGATE LIMIT S 110001000 PERSONAL AND ADVERTISING INJURY LIMIT $ 500,000 EACH OCCURRENCE LIMIT S 500,000 DAMAGE TO PREMISES RENTED TO YOU LIMIT (Any One Premises) S 100,000 MEDICAL EXPENSE LIMIT (Any One Person) S 51000 ,ty The Com inoil) ce(lltll of alclssaclrrrsetts i.. Department of Illdlistl•itll AccideWs tq Officer of Ill vestl,atlolis 600 T-V(tshington So,ect Boston, .11-=I 02111 Illt�tl�.ill trss.;oIVdia Workers! Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Iliformatlon Please Print Legible Ni1111e (Business Or`aniza;ion.lndividual): DI 3Y Address:� Cit\ state -Zip: r4e, of y� llotle 7 ®— a _ 00I> Are you an employer? Clleck the appropriate box: 1 • ❑ I alll 8 employer with 4. I am a general contractor and I Type of project (required): employees (full and or part time).` 2. I ani a sole have hired the sllb COIiCI'<Ct01's 6' -\e\\Collstl'lICt1011 listed the proprietor or partner- on attached sheet.'. RenlodelinR ship and have no employees These sub -contractors have Demolition working for rile Ill any capacity. employees and have woi'kel's' [No wor'ker's' Comp. insurance C011lp. 111S111'al1Ce.+ 9. ❑ Building addition required.] 3. ❑ 1 ain a lionleowner doing We are a corporation and its 10. El Electrical repairs or additions have all work Myself [No workers' comp• officers exercised their 11.0 Plumbing repairs or additions right of exemption per �,IGL insurance required.] _ c. 152, § 1(4), and we have no 12•❑ Roof repairs employees. [No workers' 13.0 Other comil. insurance required.] 'Any applicant that checks box #1 nutst also till out the section below showine their workers' con,.pensation polio' information. 1-10111eowners who submit this affidavit indicating they are doing all workand tiler, ;tire outside contractor n;ust submit a new affidavit indicating s,tcl;. Contractors that chick this box must attached an additional sheet sitowin� tile name of the sub-contraclor and. state whether or not those entities have employees. Ifthe sub-conu'actors have employees, they "'list provide their workers' comp. policy numbzr. I run an employer that is Providing workers' compensation insurance for 11l1' employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #: Job Site Expiration Date: City; S tate/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 S 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 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of tke DIA for insurance coverage verification. I rho hereby c llittler the pains and penalties of perjury, that the information provided abol,e is true and correct. Official use only. Do not write in this area, to be completed by city or tonal official. City or Town: Permit/License 9 Issuing Author rte' (circle one): 'i. 1 Rnae ...6of lleattllBuilding DepartI7tciir I. l.•+l\/,!'.0!`'n L iet'I t r._ � 4. Electrical Inspector• J.. lilunibi,ig inspector �1 6. Other ' Contact Person: Phone 4: k. 375 Merrimack St. Robert Camacho Lowell, MA 01852 Commissioner Office: 978-970-4028 Fax: 978-446-7103 DATE: TO: Inspectional Services FROM: City Treasurer RE: Confirmation all taxes are current As requested, please be advised of the tax status of the above listed property: Property Owner: Property Address: OTHER: OFFICE USE ONLY Taxes are current on the property Customer has made a payment plan and is current on payments Customer is in TAX TITLE and has NOT made any payment plan with the Treasurer Water and Sewer are current on this property Parking Tickets/Excise Tax on this customer are current Arnica Mutual Insurance Company Arnica Life Insurance Company Arnica General Agency, Inc. AUTO HOME LIFE Town of North Andover Building Inspector Town Hall ' North Andover MA 01845 BOSTON REGIONAL OFFICE 45 William Street, Suite 200 Wellesley Hills, Massachusetts 02481-4050 Toll Free: 1-888-7o-AMICA (1-888-702-6422) Claims Fax: (781) 431-7899 Production Fax: (781) 431-1665 June 2, 2005 File Number: F01200503419D Date of Loss: May 1, 2005 Owner/Insured: John L. Schulman Street: 70 Mablin Ave Town: North Andover Type of Loss: Water Gentlemen: Please be advised that we insure the above named individual(s). A claim has been made for Damage to Real Property and as the insurer, we are presently in the process of adjusting the loss. We are mandated to comply with Massachusetts General Laws, Chapter 139 and as such, if there are any present liens on the above property, please notify us within 10 days of receipt of this letter. If we do not hear from you, we will be under no obligation to pay you any portion of this claim. *JHO Very truly yours, Harold Val Claims Department Amica Mutual Insurance Company hval@amica.com Web Site: www.amica.com Offices Countrywide: 1-800-24-AMICA (1-800-242-6422)