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Home My WebLink AboutMiscellaneous - 97 BERKELEY ROAD 4/30/2018t N pO A � _ st'qN. 9800 Fredericksburg Road San Antonio, TX 78288 USAW 04664.1W3WK.JSS1043067317.01.01.812 CITY OF NORTH ANDOVER 120 MAIN STREET NORTH ANDOVER,MA 01845-2420 Reference: MASSACHUSETTS GENERAL LAWS, CHAPTER 139, SECTION 3B Attention Building Commissioner, I am writing regarding the claim referenced below. Policyholder: Steven J Gaul Reference #: 002646744-12 Date of loss: January 15, 2015 Location of loss: North Andover, Massachusetts Address: 97 Berkeley RD, 01845 May 1, 2015 A claim has been made involving loss, damage or destruction of the property referenced above, 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 my attention and include the reference #. You may submit correspondence or questions to me. My contact information is: Address: P.O. BOX 33490 SAN ANTONIO, TEXAS 78265 Fax: 1-800-531-8669 Phone: 1-800-531-8722 Sincerely, Kerri M Grannum Property -CVA Unit 3 USAA Casualty Insurance Company PO Box 33490 San Antonio, TX 78265 Phone: 1-800-531-8722 Fax: 1-800-531-8669 CMG/KEG 002646744 - DM -04664 - 12 - 9999 - 01 54577-0914 Page 1 of 1 9800 Fredericksburg Road w� San Antonio, TX 78288 usAW 04664.1W3WK.JSS1043067309.01.01.804 CITY OF ANDOVER 120 MAIN STREET NORTH ANDOVER,MA 01845-2420 Reference: MASSACHUSETTS GENERAL LAWS, CHAPTER 139, SECTION 3B Attention Building Commissioner, I am writing regarding the claim referenced below. Policyholder: Steven J Gaul Reference #: 002646744-11 Date of loss: March 31, 2015 Location of loss: North Andover, Massachusetts Address: 97 Berkeley RD, 01845 May 1, 2015 A claim has been made involving loss, damage or destruction of the property referenced above, 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 my attention and include the reference #. You may submit correspondence or questions to me. My contact information is: Address: P.O. BOX 33490 SAN ANTONIO, TEXAS 78265 Fax: 1-800-531-8669 Phone: 1-800-531-8722 Sincerely, Kerri M Grannum Property -CVA Unit 3 USAA Casualty Insurance Company PO Box 33490 San Antonio, TX 78265 Phone: 1-800-531-8722 Fax: 1-800-531-8669 CMG/KEG 002646744 - DM -04664 - 11 - 9999 - 01 54577-0914 Page 1 of 1 Date .�." � � •" . �? TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that . 7t.(5 ...�jv!''' �?/!? has permission to perform ................ plumbing in the buildings of .� t.171 �� at 1� -... �t-Kl ....�p(.�.......... , North Andover, Mass. Fee. � V.. Li c. No..... /3 J. 12. ..................... .' . PLUMBING INSPECTOR Check # r�G 8225 MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS FITTING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Locations Owner's Name New ❑ Renovation 1-1 Replacement Date ]'= '9/ > 0 0 J Permit # Amount $ 0 moi• o i— • V -4' / T zF Plans Submitted (Print or type) TO-�+ Check one: Certificate Installing Company . n Cora. Name of Licensed Plumber or Gas Fitter Partner. Firm/Co. INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes 1:1 No 13 If you have checked }_es, please ' dicate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity Bond Owner's Insurance Waiver: I am aw e 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 0 iicrcoy ccnuy tnat an or me aetaiis ana mrormation 1 nave submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and insta •�er Permit Is ii ion will be in compliance with all pertinent provisions of the Mas usetts tat e�Ga dslt 42o eneral Laws. (Title City/Town JAPPROVED (OFFICE USE ONLY) Signature of Licensed Plumber Off• Gas Fitter Plumber Gas Fitter License Number .Master Journeyman j d z H o z x z d a x x z w w z ° a A z > H W Q x H z H w O cw7 z d W Q z Cti .F", w �+ vs > z w O z C O x x o x a 3 0 O °x > aG F o SUB-BASEM ENT BASEM ENT IST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH. FLOOR 5TH. FLOOR 6TH. FLOOR 7TH. FLOOR 18-T H. FLOOR (Print or type) TO-�+ Check one: Certificate Installing Company . n Cora. Name of Licensed Plumber or Gas Fitter Partner. Firm/Co. INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes 1:1 No 13 If you have checked }_es, please ' dicate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity Bond Owner's Insurance Waiver: I am aw e 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 0 iicrcoy ccnuy tnat an or me aetaiis ana mrormation 1 nave submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and insta •�er Permit Is ii ion will be in compliance with all pertinent provisions of the Mas usetts tat e�Ga dslt 42o eneral Laws. (Title City/Town JAPPROVED (OFFICE USE ONLY) Signature of Licensed Plumber Off• Gas Fitter Plumber Gas Fitter License Number .Master Journeyman j ....c• .jzwea.r`%j o,%` �II�QCfIllSS�` DePerrt oflRriustriarl �4ccidents ii l` i, dice Of lresti; efions r .s� 644 f2rhi TMH Street ti Boston c7 ,M402111 Workers' Camngation Pe iasitranee ALf5—d$vit: Eiafiders/Contractors/Eletctricia 'k "icamt Information Qs/Pi®bars Please jorint Name (Rusinmeorganization/Endividual); L 'bf Address: 01, City/•Statelzip. Phone #: Are you an employer? Cheek.the appropriate •boz: I: I, am a einpEoyor with 4. Type of proiect (req employees ❑ 18:n a g<emeral coitfr:actoi and I P o3'� (M and/or an 'Bole � have hire the sub-cone 6 j]'New coradrUC6 . � or d IM t he atlaahed sheet i 7. ip and have no employees _ Tit 0 Remodeling working forme at sem-contractors have (1Ja woiicers' co W' CaP�'• workers' comp. insurance 8' Q Domolifiom m pomp. iissuaaisce .. 5. �] We are a. corpora#ion and its 9' SwIding addition �� kers have excrcised their 3 • ❑ I am a homeowner doing all work ri • 10'[] $i�ical r•epa h or additions myself yo'wgda , of exem an Per insanatce • G I � 2, § 1(¢�, d' We haven 1 bmg �Pa n or additions rtgn>re�]'t employe.-s: (No workers' 12.1] Roafrepairs *Amy aPpaicenrti�at COniP• irisurancerequired.] 1ether TSneaks be�t�l mart aero flit Mthe rection wow ebowie KOC woo sribmit this af5dadit WiC ting they an B tiieirwmkac� 60r,#= �foraisfio ;Caaaractors that eh sa wori Poany tiva, la outside eontraeters eek this box mart and hi t crs: Mist Lbntt an E ro adcF.�tiaasl ar wii;g. r�tiee oftit= sub c affidavit indics q mic Y� g►mviautg:roor&,';._ woria`x ,-' isfcnnetion. infnrnrrrfirrrL 'v'�� nsararireforrerp.�hr,� Be`Irew.�••;�,e Fo' mrdenbr . Insurance Comparry Name: ' Polite # or Se --ins. Lic. Job Site Address.. 1 i s:Pirsiiort Date: ------------ Attach a copy of the workers' .n / riy�t> IZrp: mpeasation Poi �rafioo p�„oe (sbowiag the policy somber and e d Faiha a to seems coverage as requited under Secdon 2SA of MCiL c. 152 mm lead to the ' Rpit�fioa oEate) . fine up % V1,50Q DO and/or one-year imprisonment; as Weil nnpositiou3 of ct�ririal � Of up to S250.00 a as civil penalfies in the fbrm of a S7 on of cram p P.M6ea of a Investigations mat tine vioiatOr. Be advised thea a copy of this statement P—DF-R taut a fine gations of the DIA for insurance coverage verificaticnI. be forwarded to the OfiSM of t do herelry cell underlhe and °/ tsfrm the irtformaliott pmvt�Qfiove is Si erre and aorr� Phan t7 `ieiQt rise o* do not write in this ser¢, In bt eortrpterdw afty or IOWA off[ City or Town; hmuinnb Authority (circle ooe): Permitlumnse v L Board of Firatt6 Z Suilrling Department 3. CitylTosvn •(perk 4. Electrical las 6 Other Pector S. plumbia, lttapecfor Contact person. Phone#{; :I iniormanon a inct instructions, Massathusafts General Laws.chaptcr 152 requires all emp, I OY= to PMVidt W.06=t'coaTpensation far ffi I cir =pIDymm Pument to this statute, an enpioyce is defined as P=Mn in the service of another under any contract afhh-i,- cxprtss or, impfied, oral or writtz-m" An employer is defined as "am individus; partnership, L-Mcidikian, carparsfian or other Ito entity, or any two ormore aftin= famping engaged intjoint enterprise, and hicludir-kS.the legal rzprc=Tt6= ofadeceased employer, Ortho receiver artmstc-e-of an individual, partnership, essocia:tic>in are other legal entity, employing employe= 'Howea the owner• of a dwelling house having not more thea tu-- zPaLir-trneft and who resides fimrch or theoccupant of the ' dwelling house of another who mploys pwsmu W dna me-lmtetmce, con&ac6an or repair w6rk an such dwtilirghatise or ori the gmUids or building appurtenant thereto shall net b=zi= of m=b muployment be &--med to be an COOYM." MOL chapter 152, PC(6) also* states that "every state ow X- weat licensing arency'sha Wfthow the issa>aome Ii renewal of a license or permit to operate a busman or 11m construct buildinp in the cummonweaft for any , appfi6nt who has not produced mmieptable evidencemir comPERD cc with &e hisurancecoveriqe repaired" Add�ionzlly, MOL chapter I52, §23C(7) states "Neither tJbt'c:ommanweahh nor . any of its -polificgl subdivisi= W enter irm'miy contractfbr the perform nn= of public wmir- I mmi-jicceptabIr, evidence of compiiince with the insumce. MqLM U11=11IS .of ft chapter have been presaited tD.fim cc:xT*Wtm9 Ruff=*." .,kppr=u(S Please fill out the workers' POMPMER16maffidavit COMPL--toly, by checking the boxes that apply W your situation and, if necessary, fwme(sl ad&`MsKeS):2Md phone ntunber(s) along with their camificatc(s) of insurance— Limitndtiability Companies; (LLC) ar Limilea Liability Pwtnerships; (LLP)-Wfffi no -employees otherfium the members -or partzq%, am not razluiredu Geary workan' ars an inumm = Van LLC or -LLP does have =Play=, R PDRCY is TeqUiMi Be advised that this of iCLMVjt may be submitted to the Dcpwtaicat of Industrial -Accidents far confirmation of insurance coverage. Also *fes Sum to sign NW data; the fiffrdaviL The armclavit should be retrained to the. city or town that the zp ' pfication fh0he peimit cr ji=W is being mquest-4 notthe Dzpaiunaj Of Industrial AccidantL Should you have any questionc re tim law or if you are required to obtain a work=, 0014pamtion poliety, please -call the Dopartmimt at the -mxrmb=.'jistod b6low, Self-insured wrupanim should W= their City or -Town Offinials Please be sum firer the em -davit is compleft and printed 6g;ib)y. The Dqmtn�thes provic6daspace atthe bottDm of the affidavit for you to n -P out in the m=9 the Offic: of Inv=6 98fiam has W contact you regarding fizz applimnt Please be 9= tar fill in the permWlic:n= nUMb= which WHI be used as a ref renes number. In addition, an zOpjj=d that must Submit Multiple; POrnlitIlitimnsC RPPHCRtiOM ih any givc.n ycir, need onlysubmit am affidavit indicating-MMIent policy (if n=:cssary) and under "Job Site Adds -CW" tim applicant Should m7ift '�&11 coca dons in or town)." A wpy ofibe affidavit that has been.of ficially starn-pod or Marked b y be city or town may be provided to the appficait as proof theta valid affidaik.is: an file for fdarm. Permits or liccnsm A =w affidavit must be flied oat=h yew. Where a home owner or citizen ib obtain HcCmt: "or permit not related to any buiinew or commercial vmh= Cm- a. dog li6mm or pat -mit to burn 1CM-cs atz.) said pers&n is NoT.M*md to- complete this M,-n&viL Tim Offi= of Invesfi ons would lilm to thank you in ad-ww= for y 'd should .90 our cDoperatim an, you have any questions, please do not. hesitatz W give us a call. Tim Dcpartm=t's addrms, telephone and fax nwnber The Corarn:mwmaith of Mai sichum= Lac Eartta-ni Of 1xidnStrial Aarziderft Office-orfEmefifiPtions - 600 Washington Stmt Basion, MA 02111 TeL W 617-7274900 i= 406 or 1-977-MASSAFE Rz- eraser 5-26-05 Fax '?4r 61 7-7"27-7744Www-Mass grovidia