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HomeMy WebLinkAboutMiscellaneous - Exception (134)MetLife Auto & Home® Homeowner Operations Field Claim Office Mail Processing Center P.O. Box 2201 Charlotte, NC 28241 (800)854-6011 March 4, 2014 North Andover Building Inspection 1600 Osgood St., Ste. 2035 North Andover, MA 01845 Our Customer: William Kenney Our Claim Number: JDE12464 96 Date of Loss: February 20, 2014 Dear Building Inspector: Pursuant to M.G.L. 139 § 313, please be advised that a property loss at the address referenced below has been estimated to have damage to the dwelling or other structures that will exceed one thousand dollars. Please let us know within ten (10) days if there is a pending or existing lien against the property as provided by M.G.L. 139 § 313, or if there is an intent to initiate proceedings to perfect such a lien. Loss Location: 61 Farrwood Ave., North Andover, MA 01845 Sincerely, Chiquita Moser (st) Metropolitan Property and Casualty Insurance Company Claim Adjuster (800) 854-6011 Ext. 7023 Fax: (866) 406-7388 Email: cmoser@metlife.com MetLife Auto & Home is a brand of Metropolitan Property and Casualty Insurance Company and its Affiliates, Warwick, RI MPL BLANK Printed in U.S.A 0698 Date..................... TOWN OF, NORTH ANDOVER i.. PERMIT FOR'-GAS-114STALLATION This certifies that_.�C ! .� ' '� :..... !'`. !�4............. . has permission for gas installation .-`""'.`'' �................ . in the build! gs of . ��L`�-%...��............. at . G !.. .... .. `. ........ , North Andover, Mass. Fee' ..... Lic. No:z�0:..?--`-'-� "'^ .. . GAS ASPECTOR Check # 6974 MASSACHUSETTS UNIFORirt APPLICATION FUR PERMIT TO DO GAS FITTING r_ b City[Town:\--\. NynC S;i3OQ-C _,MA. Date: 1zoQ% Permit# Building Location a►\C` VJ Owners Name: r t 1 AS4yY'=�h Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential [J New: ❑ Alteration: ❑ Renovation: ® Replacement: ® Plans Submitted: Yes ❑ No I] SUB BSMT. BASEMENT 1 FLOOR RO 2 FLO RO 3 0 4 FLO RO 5FLOOR 6 F—m- LOOR _ Check One Only Installing Company Name L r` { c� ['& Corporation Address%� VAN-T%t�+ltg ''"t City1Town�'Ec% ► State: _ v ❑ Partnership Business Tel: Lw ra3'N +� Faax: ❑ Firm/Company Name of Licensed Plumber/Gas Fitter: rRc R.: INSURANCE COVERAGE: I have a current liabilityinsurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes No ❑ If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy X 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 thisCheck One Only Owner ❑ Agent ❑ Si nature of Owner or Owner's AXlent By checking this box ❑; I hereby certify that all of the details and information 1 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 W of the General Laws. Type of License: By ® Plumber ❑ Gas Fitter Signature of LI nsed Plumber/Gas Fitter Title 31 Master Cityrrown ❑Journeyman License Number: �� APPROVED OFFICE USE ONLY ❑ LP Installer FIXTURES LLI W vi = Z D f- 2 (n 0 Lu coU � O U ~ (n p w W ZO Z w w ZZ g -)W m OIr- Lw.. Q D o. w h- a p w Q� w X w > N Ir-> V U W N R J (7 O _CO Z J 0 0 u_ W W ~ ZLUWW W p W W z D W W �- Z w =Q (n H � Q P Q m W O O fL Z 0 W FN- N P >> > z Z > _ O u. SUB BSMT. BASEMENT 1 FLOOR RO 2 FLO RO 3 0 4 FLO RO 5FLOOR 6 F—m- LOOR _ Check One Only Installing Company Name L r` { c� ['& Corporation Address%� VAN-T%t�+ltg ''"t City1Town�'Ec% ► State: _ v ❑ Partnership Business Tel: Lw ra3'N +� Faax: ❑ Firm/Company Name of Licensed Plumber/Gas Fitter: rRc R.: INSURANCE COVERAGE: I have a current liabilityinsurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes No ❑ If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy X 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 thisCheck One Only Owner ❑ Agent ❑ Si nature of Owner or Owner's AXlent By checking this box ❑; I hereby certify that all of the details and information 1 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 W of the General Laws. Type of License: By ® Plumber ❑ Gas Fitter Signature of LI nsed Plumber/Gas Fitter Title 31 Master Cityrrown ❑Journeyman License Number: �� APPROVED OFFICE USE ONLY ❑ LP Installer NORTH 0 0. SACHUS This certifies that has permission to perform ":'l�- /Date..b57 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ....................... %,-. .91t t. Q .................. plumbing in the buildings of U.Y.i. .1- ..... ................... (i./. 'r'.0V0 at..� ... 4 . ............... I North Andover, Mass. Fee....... * ' ' '-V ......... _372. Lic. No.. PLUMBING Check ff r F MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Date (o"ZZ'ia 7 Building Location �f ��I�(� �d Owners Name ' D4 t ("'�V JPermit #�%y13 Amount ) i C Type of Occupancy �P3 t c%,_,_( New� Renovation 1:1 E3"**' Plans Submitted Yes 1-3No ❑ (Print or type) Check one: Certificate Installing Company ame a ( ❑ Corp. Address • d • ri Partner. Business Telephone — Firm/Co. Name of Licensed Plum .f Insurance Coverage: Indicate the t pe of instrance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity ❑ Bond ❑ Insurance Waiver: I, th ndersigned, have been made aware that the licensee of this application does not have any one of the above three insurance it I hereby certify that all of the details and in; best of my knowledge and that all plumbing compliance with all pertinent provisions of t By: own ZOVED (OFFICE USE ONLY Owner) [3/1 /Age ion I have su Re a ert in ve a lication are true and accurate to the and installa 'ons d unde e it I ued for this application will be in ssach tate m ing o an pter 142 of the General Laws. nature o �cen um Type of Plum ing Lice se 013/ E]ense um er Master Journeyman r • it � -. WF .1 17111 --W-.-------------------- i': `D1l D►I --.----.----------------- MW 1 11' wm�mm�m�M--WMMW-MW-M (Print or type) Check one: Certificate Installing Company ame a ( ❑ Corp. Address • d • ri Partner. Business Telephone — Firm/Co. Name of Licensed Plum .f Insurance Coverage: Indicate the t pe of instrance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity ❑ Bond ❑ Insurance Waiver: I, th ndersigned, have been made aware that the licensee of this application does not have any one of the above three insurance it I hereby certify that all of the details and in; best of my knowledge and that all plumbing compliance with all pertinent provisions of t By: own ZOVED (OFFICE USE ONLY Owner) [3/1 /Age ion I have su Re a ert in ve a lication are true and accurate to the and installa 'ons d unde e it I ued for this application will be in ssach tate m ing o an pter 142 of the General Laws. nature o �cen um Type of Plum ing Lice se 013/ E]ense um er Master Journeyman The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 fflashing ton Street Boston, MA 02111 c ' www_n a<cs,gov/dia . Workers' Compensation Insetrance Affidavit Builders/Contractors/Electricians/plumbers MhCBnt infnrrr.af;.... Name (Business/Otgaoirafion/Individu ): City/State/Zip: 1F— Phone Are you an employer? Check the appropriate box: t • 1,6'I am a employer with - �Q 4. ❑ I am a general contractor and I employees (full and/or part-time).* 2. ❑ I am.a.sole proprietor or have hired the sub -contractors listed partner. ship and have no employees on the attached sheet. $ These sub -contractors have working for me in any capacity. [No workers' comp, insurance workers' comp, insurance. 5. ❑ We are a corporation and its required.] 3. ❑ 1 am a homeowner doing officershave exercised their all work right of exemption per MOL myself. [No•workers' comp, c. 152, § 1(4), and we have no insurance required.] t .employees. [No workers' comp. izisurance required_] Type of Prem (required): 6. ❑ New contraction 7. ❑ Remodeling 8. [] Demolition 9. Building addition 10.❑ Electrical repairs or additions 1117 Plumbing repairs or additions 12.❑ Roof repairs 13-17 Other t'Any applicant that checks ba# I must also 5II out the section below showing their workers' Isom satiOn Homeowners who submit this affidavit indicating they ars doing all work and then hire outside contractors pmustssubmit aaeew affidavit indicating each. ;Cat►tractnrs that check this box must a trtacleed an additional sheet shawir i+ke name of the sub-catMactors and their worriersmm— porn. irfomiation. I ant an employer that is providirtg:warkers' compensation insurance for my employees; Below is the policy sect job site information. insurance Company Name: Policy # or Self -ins. Lie. #: 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 Of, jcial use nn1y. Do not write in this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): L Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: I , Information and Instructions Massachusetts General Laws chapter 152 requires all employer; 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, assadiation, corporation or other legal entity, or any two ormore of the'foregoing engaged in a joint enterprise, and includir ag 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 ownerof 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, MOL 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 umtil 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 compimtely, by checking the boxes that apply to your situation and, if necessary, supply .sub-contactor(s) name(s), addresses) 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 requiredto 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, pleasecall the Department at the number. elated below, Self-ina�rrri Enmr _I;# ahn��iri P.nto rf�tirir self insurance'Iieense 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/licw= 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 02111 TeL # 617-7274900 ext 406 or 1-8.77-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www-mws.gov/dia Date....:-- . �ca :.v?..... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that G.......... ....................................................... has permission to perform ` .....: - - '�1L.............................................. wiring in the building of , ..(............................................... ............... at %O ��'�'�`�`? ...................IELEcPrRiIiCAL ... . North Andover, Mass. F ` � �....... Lic. NZ. a y" �9............ PE R Check#f_—_ r, t Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS V I I Official Use Only Permit No. LAI,?, Occupancy and Fee Checked C,% + " :ev. 1/07] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (ME ), 527 CMR 12.00 (PLEASE PRINTflV M OR TYPE ALL INFORMATION) Date: (� City or Town of. NORTH ANDOVER To the Ins ect of ire s: By this application the undersigned gives notice of his or her intention to perform the a ectrical work described below. Location (Street & Number) T Owner or Tenant r-L-AQ1(Fa j"�f U Telephone No.7100.1fe2 YO Owner's Address Is this permit in conjunction with a building permit? Purpose of Building . t:TM6 p Yes No ❑ (Check Appropriate Box) Utility Authorization No. Existing Service -A-2 Amps �U/ d Volts Overhead ©---- Undgrd New Service Amps / Volts Overhead ❑ _ Undgrd ❑ Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: No. of Meters_ No. of Meters No. of Recessed Luminaires — uJ ar1cJUuUw1r1 No. of Ceil.-Susp. (Paddle) Fans iaore may oe waived oy the Inspector of Wires. No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of LuminairesSwimmin 2—g Pool Above in - 11rnd. ❑ o. o mergency ig g 2rnd. Batte Units ' No. of Receptacle Outlets.4 No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and l:nitiatin Devices No. of Ranges No. of Air Cond. TotTons No. of Alerting Devices No. of Waste Disposers Heat Pump Number ` _. _...._.........._.__...._ Tons. KW No. of Self -Contained Totals: . - Detection/Alertin Devices No. of Dishwashers Space/Area HeatingKW Local ❑ Municipal El other Connection No. of Dryers Heating Appliances KW Security Systems: No. of WaterNo.of No. of Devices or Equivalent No Heaters KW . Data Wiring: of Si s Ballasts . No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total Hp Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: ,S , r,%D (When required by municipal policy.) Work to Start: is Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE VE G . Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee. provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE OND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM N�: LIC. NO__ Licensee: „t -j /ttc< k4c Signature i LIC. NO.: (If applicable, enter "exempt " in the license number line.) �— Bus. Tel. No.:frP F7 3 /Sri Address: S d Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work req ares Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $`✓ The Commonwealth of Massachusetts Department of Industrial Accidents c` Office of Investigations 600 Washington Street Boston, MA 02111 { 1 www_ nxass.gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/organization/individual); Address:_ C U S�ffp�iL -- City/State/Zip:f Phone #:. Are you an employer? Check the appropriate box: 1. ❑ I tim a employer with 4. ❑ 1 am a general contractor and I em (full and/or part-time),* have hired the sub -contractors 2• m.a.sole proprietor or partner- listed on the attached sheet x ship and have no employees These suit. -contractors have working for me .in any capacity, workers' comp. insurance. [No workers' comp, insurance 5. ❑ We are a corporation and its required.] 3. ❑ I am a homeowner doing all work officers have exercised their right of exemption per MGL myself [No -workers' comp. c. 1.52, § 1(4), and we have no insurance required.] t 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 I I - Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other r�,... a... u�. "IDUKs oox IF i must also nit out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are daring 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 li information. I ant an employer that is.providing,:workers' compensation insurance for my employees: Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lie. #: 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 5250.00 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 andpenalties of perjury that the information provided shove is true and correct. Officiat use only. Do not write in this area, to be completed by city or town officio! 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 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 -contractors) name(s), address(es) and phone number(s) along with their certificates) 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 Dep"ent 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 NvilI 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 02111 Tel. # 617-727-4900 ext 406 or 1-8.77-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia MetLife Auto & Home® Homeowner Operations Field Claim Office Mail Processing Center P.O. Box 2201 Charlotte, NC 28241 (800)854-6011 March 4, 2014 North Andover Health Department 1600 Osgood St. Ste. 2064 North Andover, MA 01845 Our Customer: William Kenney Our Claim Number: JDE12464 96 Date of Loss: February 20, 2014 Dear Health Department: MAR i U 2014 Pursuant to M.G.L. 139 § 313, please be advised that a property loss at the address referenced below has been estimated to have damage to the dwelling or other structures that will exceed one thousand dollars. Please let us know within ten (10) days if there is a pending or existing lien against the property as provided by M.G.L. 139 § 3B, or if there is an intent to initiate proceedings to perfect such a lien. Loss Location: 61 Farrwood Ave., Unit 9, North Andover, MA 01845 Sincerely, Chiquita Moser (st) Metropolitan Property and Casualty Insurance Company Claim Adjuster (800) 854-6011 Ext. 7023 Fax: (866) 406-7388 Email: cmoser@metlife.com MetLife Auto & Home is a brand of Metropolitan Property and Casualty Insurance Company and its Affiliates, Warwick, RI MPL BLANK Printed in U.S.A 0698 Datet7 - /�. !D3 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING Th**! certifies that ...... . .......................... ,�e hast .ermission to perform . r��; .. ....................... plumbing intb,e buildings of ./. -. ........................... -I� at. 4 ..... ............ ....... North Andover, Mass. Fee,—,.5 ..... Lic. No .......... ...... 181N . . . ........ P UM,!�ING S CTOR Check # 6111 5519 MASSACHUSETTS, (Print or Type) A G New ❑ UNIAORM APPLICATION FOR PERMIT TO DO GASFITTING Mass. DataL & Za,&„ Pe G(.iJ�CY y . C� Owner's /,• kewl?,�l A Type of Occupancy Ii7� = N T1 4 L Renovation ❑ Replacement Q111"`Plans Submitted: Yes❑ No [3 ■ :. a ...�� u G Name, of Licensed Plumber or Gas Fitter c Check one: ❑ Corporation ❑ Partnership 2-11rM/Co. INSURANCE COVERAGE: I have a current a bury insurance policy or its substantial equMala t which meets the requirements of MGL Ch. 142. Yes No ❑ It you have checked yg, please indicate the type coverage by checking the appropriate box A liability insurance policy 0-' 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. a Check one: _ Owner❑ Agent ❑ Signattr Owner or Owner's Agent I hereby certify that ell of the details and information I have submitted (or entered) in above application are We and =mate to the best of my knowledge and that all plumbing work and Mstailations performed under the pormW—Wued for this application wAbe in compliance with d pertinent provisions of the Massachusetts State Cas Code and Chapter 142 of Laws. ey 7 of License: pw ure or Gas Fitter license Number City/Tcowr, ,bumeyman I" m m > pl m Z m v o Z+ to d m o a I" m m