HomeMy WebLinkAboutMiscellaneous - 80 EDGELAWN AVENUE 4/30/2018I
Date./. /.%.7� � 01.
TOWN OF NOR'TWANDOVER
PERMIT FOR PLUMBING
This certifies that ..... /`� ............................... .
has permission to perform ...1 7 ........................
plumbing in the buildings of ..( .!./? ��'; ...... n..
at ............... North Andover, Mass.
Lic. No.�!.� �Fe�`.......
PLUMBING INSPECTOR
Check # & 7.16
8296
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Date
Building Location "!�—oi d S^r' /��-C�c i r ,q ,pg ,�� ter./ Permit
Amoun 9.0
Owner rri Art 17, Pe A/ q-/
New Renovation rl Replacement Er Plans Submitted Yes ❑ No n
FIXTURES
(Print type)
Installing Company Name
Check one: Certificate
Corp.
Partner.
[]—Firm/Co. L L
Name of Licensed Plumber: _ </05 I;i -e
Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box:
Liability insurance policy Other type of indemnity El 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 El
I hereby certify that all of the details and infor.
best of my knowledge and that all plumbing w
compliance with all pertinent provisions of the
By:
Title
City/Town
APPROVED (omcEusEony
I have s bmitted (or entered) in above applicatio true and accurate to the
and install 'ons o Permit Issued r application will be in
4 Ge
ssa�hus s State P ib��� de apt the General Laws.
Type of Plumbing License
e r
icense Master Journeyman ❑
The Commonwealth of Massachusetts } ;
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, A"-02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address:
City/State/Zip:
Phone #:
Are you an employer? Check the appropriate bog:
1. ❑ I am a employer with 4. ❑ I am a general contractor and I
employees (full and/or part-time).* have hired the sub -contractors
2.[.--] I am a sole proprietor or partner- listed on the attached sheet. I
ship and have no employees These sub -contractors have
working for me in any capacity.
[No workers' comp, insurance
required]
3. ❑ I am a homeowner doing all work
myself. [No workers' comp.
insurance required.] t
* A.. —U -�'-- -
workers' comp. insurance.
5. ❑ We are a corporation and its
officers have exercised their
right of exemption per MGL
c. 152, § 1(4), and we have no
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9.. ❑ Building addition
10.❑ Electrical repairs or additions
11.0 Plumbing repairs or additions
12.0 Roof repairs
13.❑ Other
--J -rr -�• - �u�� �— �+ ... W,L `u "If oui me seCnon 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 subcontractors and their workers' comp. policy information.
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 Self4ris. 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 insurance coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct
Signature: Date:
Phone #:
Official use only. Do not write in this area, to be completed by city or town official
City or Town:
Issuing Authority (circle one):
Permit/License #
1. Board of Health 2. Building Department 3. City/Towu Clerk 4. Electrical Inspector 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 apartrnents 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 Iicensing 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 insurance 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 permit/license number which will be used as a reference 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 Commonwealth of Massachusetts
Department of Industrial Accidents.
Office of Investigations
600 Washington. Street
Boston, MA. 0.21.11
Tel. # 617-7274900 ext 406 or 1-877-I-ASSAFE
Fax # 617-727-7749
Revised 5-26-05
wu,w.mass.gov/dia
Date ..
AORToq
TOWN QF NORTH ANDOVER
• PERMIT FOR GAS INSTALLATION
This certifies that .... :Q e'o!��- `{.... � �-`.� . .� ................
'has permission for gas installation ... ..................
in the buildings of ...f! rxl ..........
at ..6pv... /"I .0 ......... North Andover, Mass,
Fee ... Lic. No.. � � ` :.. .^ ...... .
GAS INSPECTOR
Check #'
d
702E
MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS FITTING
(Type or print) Date
NORTH ANDOVER, MASSACHUSETTS
Building Locations F2--
.1/
"/) /i°>✓� .-1 c� Owner's Name
New ❑ Renovation ❑ Replacement
Permit # ?d
Amount $
Ev
Plans Submitted ❑
(Print or type) Check one: Certificate Installing Company
Name ❑ Corp.
Address e5 'S ❑ Partner.
/2 ' , i-
usmess Telephone 12927--:5-0,t [D-Firm/Co. j
Name of Licensed Plumber or Gas Fitterl�
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes ❑ No ❑
If you have checked ,yes, please indicate the type coverage by checking the appropriate box.
Liability insurance policy {.Lsf 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 ❑
11C1 COY ooi Lily Will au of me aeraiis ana mrormauon i nave submitted (or entered) in above appy 'on are true and accurate to the
best of my knowledge and that all plumbing work and installa'ons pedormed under Permit for this application will be in
compliance with all pertinent provisions of the Massachul6tts Stgte Gasstode 4pptefr42 of the General Laws.
itle
own
(APPROVED (OFFICE USE ONLY)
Signature of Licensed Plumber Or Gas Fitter
Plumber o-,
❑ Gas Fitter License Number"
Master
❑ Journeyman
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SUB-BASEM ENT
BASEM ENT
1ST. FLOOR
2ND. FLOOR
3RD. FLOOR
4TH. FLOOR
5TH. FLOOR
_:::±6T
-H. FLOOR
7TH. FLOOR
STH. FLOOR
(Print or type) Check one: Certificate Installing Company
Name ❑ Corp.
Address e5 'S ❑ Partner.
/2 ' , i-
usmess Telephone 12927--:5-0,t [D-Firm/Co. j
Name of Licensed Plumber or Gas Fitterl�
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes ❑ No ❑
If you have checked ,yes, please indicate the type coverage by checking the appropriate box.
Liability insurance policy {.Lsf 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 ❑
11C1 COY ooi Lily Will au of me aeraiis ana mrormauon i nave submitted (or entered) in above appy 'on are true and accurate to the
best of my knowledge and that all plumbing work and installa'ons pedormed under Permit for this application will be in
compliance with all pertinent provisions of the Massachul6tts Stgte Gasstode 4pptefr42 of the General Laws.
itle
own
(APPROVED (OFFICE USE ONLY)
Signature of Licensed Plumber Or Gas Fitter
Plumber o-,
❑ Gas Fitter License Number"
Master
❑ Journeyman
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office oflnvestigations
600 Washington Street
Boston, MA 02111
www.mass govldia
Workers' Compensation in Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address:
City/State/Zip:
Phone #:
Are you an employer? Check the appropriate bog:
1. ❑ I am a employer with 4. 111 am a general contractor and I
employees (full and/or part-time).* have hired the sub -contractors
2. ❑ I am a sole proprietor or partner- listed on the attached sheet,
ship and have no employees
working for me in any capacity.
[No workers' comp. insurance
required.]
❑ I am a homeowner doing all work
myself. [No workers' comp.
insurance required.] t .
* A--. `-I-' a_
These sub -contractors have
workers' comp. insurance.
5. ❑ We are a corporation and its
officers have exercised their
right of exemption per MGL
c. 152, §.l (4), and we have no
.employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.❑ Roof repairs
13.❑ Other
J rr� -• W« �••��� n; ..:::;: ;;;sa 1,11 OW me sectson below showing the 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 isproviding workers' compensation insurance for my employees Below is thepolic
information. y and job site
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 insurance coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and—
correct
Signature: Date
Phone #:
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 #:
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 apartments 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 insurance 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 uLntil 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 -contractors) 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 t
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 permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permittlicense 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 Commonwealth of Massachusetts
Department of Industrial Accidents
Mce of Investigations
600 Washington, Street
Boston, MA 0:2111.
Tel. # 617-7274300 ext 406 or 1-877-MASSAFE
Revised 5-26-05 Fax # 617-72.7-7749
vA,u w.mas.s. z.ovfdia
ETT 3667
Date. — /- !.` ....
M
TOWN OF NORTH ANDOVER
I
PERMIT FOR PLUMBING
This certifies that ... Al ............ . .
A
a
has permission to perform .. D. (...........................
plumbing in the buildings of . LA -44r f ................... .
v ~
at .. . <<� .� �. <<? w .. L C. ..... , North Andover, Mass.
Fee . ,�.Q, r . �Lic. No.. '�"?. X3.3 .
PLUMBING INSPECTOR
m
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WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
11
(Print or Type)
/1I� iJ (/'�✓Y , Mass. Date 19f
Building Location„ --v ^^ Owner's Name
Permit # i -or
Z -L2 Z/-1 la Type of Occupancy -2 5 � 17 E ti;
New ❑- Renovation ❑ Replacement 2”" Plans Submitted: Yes ❑ No ❑
FIXTURES
Installing Company Name AlOt�Ee? A - SPair»,4TAP-Q Check one: Certificate
Address ? CO /q c H maPj ❑ Corporation
it E l N o Yo Ay 1'� ❑ Partnership
Business Telephone Iff, Z -i97 1 2-Arm/Co.
Name of Licensed Plumber '&r Fe r h� SAn�rvla4 tr4�r"'
INSURANCE COVERAGE:
I have a currentjAbilfty insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes No ❑
If you have checkedrtes, 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:
Owner ❑ Agent ❑
I hereby certify that all of the details and information 1 have submitted (or entered) in above application are true and accurate to the best of my
knowledge and that all plumbing work and installations pajormed under the permit issufor this application will be in compliance with all
•
pertinent provisions of the Massachusetts State Plum g jeode and apter of the eral laws.
By vl. L
Title
re of Ucensed Plumber -
/T
Type of License: Master % Journeyman E]Cityown -
APPROVED O I NL License Number 3
Y
•
•
Installing Company Name AlOt�Ee? A - SPair»,4TAP-Q Check one: Certificate
Address ? CO /q c H maPj ❑ Corporation
it E l N o Yo Ay 1'� ❑ Partnership
Business Telephone Iff, Z -i97 1 2-Arm/Co.
Name of Licensed Plumber '&r Fe r h� SAn�rvla4 tr4�r"'
INSURANCE COVERAGE:
I have a currentjAbilfty insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes No ❑
If you have checkedrtes, 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:
Owner ❑ Agent ❑
I hereby certify that all of the details and information 1 have submitted (or entered) in above application are true and accurate to the best of my
knowledge and that all plumbing work and installations pajormed under the permit issufor this application will be in compliance with all
•
pertinent provisions of the Massachusetts State Plum g jeode and apter of the eral laws.
By vl. L
Title
re of Ucensed Plumber -
/T
Type of License: Master % Journeyman E]Cityown -
APPROVED O I NL License Number 3
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Date. p(%GT .
I" . ,, - TOWN OF NORTH ANDOVER
3? .�.e -�•.-'• OL
i r
PERMIT FOR PLUMBING
,SSACHUS�
This certifies that % J . .... .. .
has permission to perform !,:/!�� , .........
1�p J� G't1
plumbing.. in the buildings of
at(t� .:. . ..!/.1....: f .16.� ......... North Andover, Mass.
Fee���� .. Lic. No.. G� ............................. .
Check # J /-� — 2
PLUMBING INSPECTOR
�l
5878
MASSACHUSETTS UNIFORM APPLICATION
(Print or Type
Mass. Date
Building
New ❑ Renovation ❑
FOR PERMIT TO DO PLUMBING
Permit #—'0/_1
Owner's Nam , , L;d I'd "'da
Type of Occupancy, 2i-51 17 E IJ TI �-) (_.—
fes" Plans Submitted: Yes ❑ No ❑
FIXTURES
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2ND FLOOR
3RD FLOOR
4TH FLOOR
5TH FLOOR
6TH FLOOR
7TH FLOOR
STH FLOOR
Installing. Company Namet'� i�El�7 _A �rY,rY►A?��(� Check one: Certificate
Address :;o C0,4cNman) y -AJ ❑ Corporation
C j b/L% ❑ Partnership
Business Telephone (o
Aame of Licensed Plumber
ONSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes No ❑ '
If you have checked Les, please indicate the type coverage by checking the appropriate box.
A liability insurance policy Q' 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:
Owner ❑ Agent ❑
or
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 ormed under the permit issu for this application will be in compliance with all
pertinent provisions of the Massachusetts State Plum •ng a and Ctiapter A of the oral Laws.
Byv(.1�
re o m Licensed Pluer
Title
4 Type of License: Master % Journeyman ❑
City/Town
APPROVED (OFFICE USE ONLY) License Number
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MASSACHUSETTS PROPERTY INSURANCE UNDERWRITING ASSOCIATION
Two Center Plaza
Boston, Massachusetts 02108-1904
(617) 723-3800, Ma Only (800) 392-6108, Fax (617) 557-5675
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
... � ... is .. .. ... i.. ... 4 ,.
CMA00021
03/1_4/01
Form of Notice of Casualty Loss to Building
so��
Under Mass. Gen. Laws, Ch. 139, Sec.313
�FMf1 --� --
AR 2 O
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NORTH ANDOVER HEALTH DEPT.
NORTH ANDOVER TOWN
HALL
NORTH ANDOVER MA 01845
Re: Insured:
VINCENT LA CORTE
Property Address:
80 EDGELAWN AVENUE, UNIT 6, NORTH ANDOVER, MA 01845
Policy Number:
0376668
Type Loss:
Other Section I losses
Date of Loss:
03/03/01
Claim Number:
184688
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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CMA00021