Loading...
HomeMy WebLinkAboutMiscellaneous - Exception (202)C_ I__ January 29, 2016 THEW OPtIFOdOI 13EDHAHNGROUP@ v FORM OF NOTICE OF CASUALTY LOSS TO BUILDING UNDER MASS. GEN. LAWS, CH. 139, SEC. 3B Building Commissioner, or Inspector of Buildings c/o City or Town Hall 1600 Osgood Street North Andover, MA 01845 Board of Health or Board of Selectmen c/o City or Town Hall 1600 Osgood Street North Andover, MA 01845 Fire Department or Arson Squad c/o City or Town Hall 1600 Osgood Street North Andover, MA 01845 RE: Our File No.: P1605885 Insured: 315 GREENE STREET CONDOMINIUM Address: 315 GREENE STREET, NORTH ANDOVER, MA Policy No.: R1434437A Loss Date: 03/06/2015 Loss Type: Building or Other Structure Damage A 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, Ch. 143, Sec. 6 to be applicable. If any notice under Mass. Gen. Laws, Ch. 139, Sec. 3B is appropriate, please direct it to my attention and include a reference to the captioned insured, location, policy number, loss date and claim or file number. If no reply is received from your office within ten days, we will assume you have no liens of any type against this property, and the claim will be paid in our customary manner. Sincerely, Lorraine A. Peirce Sr. Property Claims Examiner 1-800-688-1825 x1139 NORFOLK & DEDHAM MUTUAL FIRE INSURANCECO.we 222 Ames Street, P.O. Box 9109, Dedham, MA 02027-9109 DORCHESTER MUTUAL INSURANCE CO.Telephone: (800) 688-1825 FITCHBURG MUTUAL INSURANCE CO. Fax: (781) 329-1818 MASSACHUSETTS PROPERTY INSURANCE UNDERWRITING ASSOCIATION Two Center Plaza Boston, Massachusetts 02108-1904 (617) 723-3800, Ma Only (800) 392-6108, Fax (617) 557-5675 Form of Notice of Casualty Loss to Building Under Mass. Gen. Laws, Ch. 139, Sec.3B NORTH ANDOVER BUILDING COMMOSSIONE NORTH ANDOVER TOWN HALL NORTH ANDOVER MA 01845 Re: Insured: Property Address: Policy Number: Type Loss: Date of Loss: Claim Number: JAMIE A. DIXON 315 GREEN ST., NORTH ANDOVER, MA 01845 0761553 Water Damage 01/31/05 214988 02/14/05 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 CMA00021 W This certifies that—./— Date TOWN OF NORTH ANDOVER PERMIT FOR WIRING has permission to perform .....z ... 1'2\ e- le Iz wiring in the building of ......... . ^ .................................................................................. at ............................. .... ................................. . North Andover, Mass. ............... . .............. Fee ........... Lic. No. . .... ............. . ........ L CAL INSPECTOR Check# 12345 Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Usp Only Permit No.gp�(, 1(;J 4. Occupancy and Fee Checked [Rev. 1/071 (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (NEC), 127 CMR 12.00 (PLEASE PRINT ININK OR TYPE ALL INFORM4TIOA9 Date: City or Town of: NORTH ANDOVER To the Inspectol of lYires: By this application the undersigned gives notice of his or her int ent'on to perform the electrical work described below. Location Street & Number I Owner or Tenant Owner's Address Telephone No. `lj '% Is this permit in conjunction with a building permit? Yes ❑ No r. (Check Appropriate Box) Purpose of Building ��� (��' Utility Authorization No. - Existing Service4�00 Amps 1 ac / a olts Overhead FZ Undgrd ❑ No. of Meters New Service � Amps 1a�) /2A CjVolts Overhead R Undgrd ❑ No. of Meters Completion of the following table maybe waived by the Ins ector of Wires. No. of Recessed Luminaires No. of Cell: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ElIn- 1:1o. rnd. rnd. o Emergency ig ting BatterV Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Totals:'��'��"' Number Tons KW ..."".... No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KW No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or E uivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value oflec Ica Work: (When required by municipal policy.) _ Work to Start: ` Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: 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 is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE 1. BOND ❑ OTHER ❑ (Specify:) I certify, under thepains and pe 1 'es o u t at tli information on th'application is true and complete. FIRM NAME:. f LIC. NO.:���i Licensee: Signatur LIC. NO.: " (If applicable,enter " xempt"in,,the license number line.) us. Tel. No. • �!a Address: I --) , r2V 1 It. Tel. No.: *Per M.G.L c: 147, s. 57-61, security work requires 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 PERMIT FEE: $ Signature Telephone No. i— ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance -with the provisions of M.G.L. c. 143, § 3L, the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shall.be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012. ❑ Rule 8 — Permit/Date Closed: *** Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: f.• Trench Inspection Pass Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: p g Date: ROUGH INSPECTION: ~ Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPECTION: Pass IN Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: ate: DEB WEINHOLD ...TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com F-' 1 The Commonwealth ofMassachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA. 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Pidnt Le 'bl Name (Business/Organization/Individual): Address: f J i rc_�Aj� City/State/Zip: �V _ _ _ Phone #: Are you an employer? Check the appropriate box: 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. Wain a sole proprietor or partner- listed on the attached sheet. Zip and'have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ 1 am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 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 10ZElectrical repairs or additions 11. ❑ Plumbing repairs or additions 12. ❑ Roof repairs 13.❑ Other ,Akny applicant that checks box#1 must also fill out the section below showing their workers' compensation policy information. i -Homeowners who submit this affidavit indicating they a're doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors 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 is providing workers' compensation insurance for my employees. Below is the policy anal job site information. r___ I Insurance Company N Policy # or Self -ins. Li Job Site Address: 3 t -5 l� �r�2,�T V n� Pity/State/Zip: i�,,J e kff� Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder 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 tap to $250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of h2vstigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties ofperjury that the information provided above is true and correct. Signature: Date: Official use only. Do not write in this area, to be completed by city or town official. City or Town: PermitUcense # 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 ofpublic 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 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 maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should1 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. I ` 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 burn 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 Massahv..setts Department of Industrial Accidents Office of Investigations 600 Washington Street - Boston? M.A. 02111 Tel. # 617-7274900 ext 406 or 1-877:MASSAFB Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/data ,i �� ,,.%' Y Date .�-/.� tX. 1-1 ....................... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that /--i . ................................................. has perr*m* ssion for gas installation 4��144L .... ....... in the buildings of ................................... at ...... 71,57.62-f �-. A.) ............................... Fee �60... Lic. No. Check # pS-D 9305 ............... North! Andover, Mass. .............................. GAS INSPECTOR 10549 Date ..-54.!.1../..'f , TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING vB�iHVgFi - - Yom. - This certifies that77; ;...... ......................... ...............................:............................ has permission to perform . �t....... c t t^ -%, ............................. P P plumbing in the buildings.......................................................................................... at . 3...J`..... ... ...... ...........................WPL61VIB�fIG ., N , rth Andover, Mass. Fee�g-.5'.... Lic. No. s .......... .... INSPECTOR. Check #� ( MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK W�j CITY O _ MA DATE�,S PERMIT # d � JOBSITE ADDRESS OWNER'S NAME GOWNER ADDRESS TE — FAX TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ® RESIDENTIAL°P CLEARLY NEW:'3 . RENOVATION: El REPLACEMENT: ® PLANS SUBMITTED: YES FQ NO Q APPLIANCES Z FLOORS- BSM' 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE �.. T r �-� -- - DIRECT VENT HEATER__ -_-_- DRYER FIREPLACE FRYOLATOR FURNACE % —� I—J _— — �- _ — GENERATOR _ GRILLE INFRARED HEATER_ -[^—f LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOFTOP UNIT TEST_ [_- J I. _ I I _ I � — �. -- =-- _ UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL. Ch. 142 YES NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY N OTHER TYPE INDEMNITY Ej BOND E] 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 0 AGENT SIGNATURE OF OWNER OR AGENT 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 Pe ent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �. PLUMBER-GASFITTER NAME I allA.-O LICENSE # SIGNATURE MP q MGF 0 JP ® JGF nLPGI CORPORATION [J# � PARTNERSHIP 0# LLC E]# COMPANY NAME: _ _ ADDRESS 0-n CITY STATE E8ZIP _TEL O FAX CELL�EMAIL _ v W 0 O U W a � � �' z ❑ O N W >- F_ W O w O W z a w W P! w O � LU C0 0 a a a U J H (L IL � w = w Gn W H oz z 0 H U a u The Commonwealth of Massachusetts - Department of Industrigl Accidents Office of Investigations kvi 600 Washington Street Boston, MA. 02111 www.massgov/dia Workers' Compensation Insurance davit: Builders/Contractors/Electricians/Plumbers ' Name (Business/Organization/Individual):, City/State/Zip: 0 10.SS3 (i Phone #: 603 Are you an employer? Check the appropriate box: 1. q, I am a employer with Z 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. ship and'have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3111 am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, §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 11.15a Plumbing repairs or additions 12.❑ Roofrepairs 13.❑ Other *Any applicant that checks box#1 must also fill 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. tContractors 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 is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. Policy # or Self -ins. Lic. #:/' Expiration Date: Job Site Address: 16— v�l° �° n 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 requiredunder 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 DTA for insurance coverage verification. I do hereby certify under the pains and zalties of perjury that the information provided above is true and correct. Signature: Date: — 2-0t/_ 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 Pers Phone Informati®n and Instruction - S 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 employes." 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 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 j 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 burn 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 Caaimonwealth of Ma ssacl?vsefts Department of Industrial Accidents Office of Investigations 600 Washington. Street Boston, SLA, 02111 Tel, # 617-727-4900 ext 406 or 1--877�,MASSABB Revised 5-26-05 Fax # 617"727-7749 www-mass.gov/dia MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY COC _ ] MA DATE 0 `ZO PERMIT# JOBSITE ADDRESS OWNER'S NAME 1 POWNER ADDRESS TEL �— FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ® RESIDENTIAL 49 PRINT CLEARLY NEW: ] RENOVATION: El REPLACEMENT: Q PLANS SUBMITTED: YES NO I FIXTURES 'l FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM 1 — _ I _j —A J —AL—A--J (___-___1 ___, I —1 f DEDICATED GREASE SYSTEM ___j =J DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN l -_-__1 t j _.� I INTERCEPTOR (INTERIOR) KITCHEN SINK I ___._.I --__- LAVATORY ROOF DRAIN SHOWER STALL f j I f __-- ( I _ _ 1 I .._._ _. --...1 _-_ SERVICE / MOP SINK TOILET URINAL I _.._._.I ___. I __ 1 __--_ (-____J ..___._f ____.-- _—AE ---__j --___1_.—_- WASHING MACHINE CONNECTION ,___-j —._.._._! WATER HEATER ALL TYPES I WATER PIPING I f _-._.. __I I _._.- __I ---J € OTHER _ I " I (-...--! --_I —f ----! —I.._..--- -----J f I= _.....--_F_._.�I INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES Ey NO M1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY' OTHER TYPE OF INDEMNITY Q BOND D 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 Q AGENT _I SIGNATURE OF OWNER OR AGENT 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 complian a with all Pe ' t provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAMELICENSE # --SIGNATU MP t JP Q CORPORATION ...I #� PARTNERSHIP Q#� �1LLC COMPANY NAME F ADDRESS CITY �� ---- ...--- --� STATE ZIP ZIP ��-�(� TEL FAX j CELL L. -----_--- EMAIL — - -- --- — -- -- - - --- _ _ --- _...--- ---- _ --- o z w Ix �r The Commonwealth of Massachusetts - Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass gov/dia Workers' Compensation Insurance davit: Builders/Contractors/Electricians/Plumbers UP f 1_./ J Address: �� // i�( City/State/Zip: ©P /�/ N �38�( Phone It: Are you an employer? Check the appropriate box: 1. I am a employer with _ 2 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. t ship and'have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] i 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 *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. I Homeowners who submit this affidavit indicating they aie doing all work and then.hire outside contractors must submit a new affidavit indicating such. tContractors 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 is providing workers' compensation insurance for my employees. information. Insurance Company Name:, Below is thepolicy and job site Policy # or Self -ins. Lie. #: Expiration Date:, Job Site Address:lld516� i° n 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 requiredunder 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. Ido hereby certo u epains andpen lties of ferjury that the information provided above is true and correct Siunatirre. (/ /C � 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 Pers Phone J\ 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 lic'ensing 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 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 burn 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 CoUlMonwe .1thofMassarhvsetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston} MA 02111 Tel # 617-727-4900 ext 406 ox 1.-877,MASSAFE Revised 5-26-05 Fax # 617-727;7749 www�ass.go�fdia .MORTGAGE INSPECTION PLAN NORTHERN ASSOCIATES, INC. 342 N. MAIN SMEE'T ANDOVER MA 01810 TEL: (978) 474-4410 FAX. (978) 474-5067 MORTGAGOR: ROBERT & JAMIE DIXON iLOCATION : 315 GREENE STREET j CITY,STATE: NORTH ANDOVER MA DATE: APRIL 6,1999 F1 4a -01kuN tZeNt� PPe�evNtic� c? C� DEED REF: 2698 / 337 PLAN REF: ASSESSORS JOB#: 99/02799 SCALE : 1" = 40' /�A S In -9 LQ-cj 01 T--k-v, , k -i- c� G CERTIFIED TO: INTERATE NATIONAL MORTGAGE CORP. NOTE: This mortgage inspection was prepared specifically for mortgage purposes only and is not to be relied upon as a lend or property ZN OF line survey, used for recording, preparing deed descriptions, oc construction. No corners were set. Building location and offsets are CAR MEN G approximately located on the ground and .% A are shown specifically for zoning determination 1 TEST only and ere not to be used to establish property lines. The matters shown hereon are based on No. 18467 client -turns sited information and may be subject Sl to turther out -sales, takings, easements end rights �'^ FQ p�� of way, and other matters of record and prescriptive F'pS/Q f TE. or other rights. Northern Associates, Inc. assumes no NAL LANA re sponslbility herein to the land owner or occupant, accepts no responsibility for damages resulting from said reliance by anyone other than the said mortgagee and its assigns G/ In connection with Its proposed mortgage financing to said mortgago . SET This mortyage lnspectlnn was prepared In accordance with the Technical Standards ink NOrtyage Loan Inspections as adopted by the 1lassachusetts hoard of Reglatratlon of 1'rofessonnal Euy lneers and Land Surveyors 250 CNN 605. 1 further state that In my prnlesslonal npinlon that the structures shown conlorm with Lire local zonlny horizm:tel dimensional setback requirements at the time of construction mn. ar////a exempt urrdgc prowls! o,ps of N.C.L. CII. 40-A Sec. 7. tI.Property/llouse is not In a Flood Hazard.2-Property/llouse is in a Flood Hazard Area. p 3.lnformation Is insufficient to determine Flood Hazard. Flood Hazard determined fro lat §,t Fede q� Flood 1nSuranp�II e Map Panel � ��J d_3G =Datezone—U eel Location ' rJ S tr2c� r -,No. r 13 Date - z " 1 / &ORTPI TOWN OF NORTH ANDOVER O? •' • OL Certificate of Occupancy $ * ; ; Building/Frame Permit Fee $ Foundation Permit Fee $ us�� Other Permit Fee /wL $� J& CMionnection nnection Fee $ #p.,� 1991 Fee $ Ila/ TOTAL $ ';Z' ober CO/20 Fcgor Building Inspector Div. Public Works Location No. Date N0R7p TOWN OF NORTH ANDOVER „ Certificate of Occupancy $ 41 Building/Frame Permit Fee $ Foundation Permit Fee $ S�cMus Othr r nit Fee t - $ Sewer CoPec 'o? Fee $ Water Co � ectiolln"" FOX e $ ��T L 2,99 c i ndOy 1 et C% Building Inspector Div. Public Works PER-Af '"NO. a.le i 1�. I APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. V PAGE 1 MAP K40. LOT NO. 2 RECORD OF OWNERSHIP IDATE (BOOK '.PAGE ZONE SUB DIV. LOT NO. LOCATION PURPOSE OF BUILDING OWNER'S NAME NO. OF STORIES SIZE OWNER'S ADDRESS BASEMENT OR SLAB ARCHITECT'S NAME SIZE OF FLOOR TIMBERS IST 2ND 3RD BUILDER'S NAME /''�/ SPAN DISTANCE TO NEAREST BUILDING , DIMENSIONS OF SILLS DISTANCE FROM STREET POSTS DISTANCE FROM LOT LINES — SIDES REAR " " GIRDERS AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW SIZE OF FOOTING X IS BUILDING ADDITION MATERIAL OF CHIMNEY IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION. IF ANY IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS, S w 1 '`yam t rN CQ. Tco L_ SEE BOTH SIDES �L'��CLJ��yi�� 1ou,-., (j tv-tt'rj lb PAGE 1 FILL OUT SECTIONS 1 - 3 PAGE 2 FILL OUT SECTIONS 1 - 12 ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR DATE FjjeED _�/'� / op ,Y//S GNATURE OF OWNER OR AUTHORIZED AGENT F E E PERMIT GRANTED 19 3 PROPERTY INFORMATION LAND COST EST. BLDG. COST EST. BLDG. COST PER SQ. FT. EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. 4 APPROVED BY BOARD OF HEALTH PLANNING BOARD BOARD OF SELECTMEN t BUILDING INSPECTOR 'NV1d 10•ld S30V ld3H SIHl.'43SOdWIHi .ins '013 'S39V21 -VE)'S3H02i0,d H1II1M 'S9N1a-f18 40 SNOISN3W10. L:M? 3 aNV S3N11 101 _ W021d 30NV1§la aNV.LO1dOSNOISN3W1a .LOVX3 MOHS1S11W N01103S SIHl - = ZL AONVdf1000 L 04033N ONiaiine °ON.ON'11V3H. Pic 42 _ I PUZ 1.W.9 �1b1�313 110 .SVO. swool d0 'ON L Sd3lV3Hc11Nn O.1.H '1NVIOVa ONINOI110NOD 81V aOdVA a0 8.1.M lOH WV31S -Nand 81V lOH 03D80d 3JVNand SS313did _ _ _ Sd31dW DOOM S10� B 'SW9 13315 'SlO:) T *SW9 a39WIl lsfor DOOM ONIIV3H L L I ONIWVad 9 OOVO 3111 80011 3111 — S38n1X1d N630OW ONIJOOS 1108 —_ b3MOHS 11V1S 13AVa0 T 8V1 `ON19Wnld ON- 31V1S _ FINIS N3HDlIX S30NIHS DOOM MDiVAV1 S310NIHS 1lVHdSV 13SOID a31VM 03HS livid 13a9WVO ('Xld ZI WN 131101 OaVSNVW 'Xld EI H1V9rr—dlH 319VO ON19Wflld OL loos LNONgood 3aOla03dns r ONIaIM 3WVad NO 3NO1S ABNOSVW NO 3NO1S X19 a30NIO a0 'JNOO —I aOOld ? 'Sa1S 7I11V 3WVad NO )IDIHIa AMOSVW NO )ID9 —� _ E � l 9 3WVad NO onis Aallosvw No omnis 31,11 'HdSV ONIOIS 'la3AO NVIWO'D ON101S SOIS39SV O.N\OaVH ONIOIS 11VHdSV HldV3 S310NIHS DOOM 313aJN0� lJ SO V09dVNIGIS Sa001d 6 I S11VM v KDII)l Na3_OOW ' S3DVMll Id �.- V3aV .1.W:9 'Nld W008 OV3H 1.WON - . ` .,, llnj V3ay 1N3W3SV9 t £ — — Z — I _ E, NI3Nn a31SVld Sa31d Q.MQaVH 3NO1S 80 >0189 3NId , 'X.19 313aDN00 - 313dDNOD HSINId aOluml' +8 NOI1VONt10d Z NOIlOfI N1SN00 S1N3Wlab'dV _- S3�Idd0 -_ AIIWVd I11nW 53180!5 AIIWVd 31ONIS cn ® Z. o r ® m Z Z 100 m n goCOO m ov2a L Z m 3v � z � —Z u>� m 0z O cm ADZ m mD� D �y CD C m (D ' C .lm o a CID e» oyonj cD `� c o m Z 0a -- 7 CO) D O (O a �a ril �o z �= v o ° MM 1'79 w c a° m °i (D C -w w m cn CD= M 3 cD Vi 6- C C w O 7 ((D w m w Q m(D r Cn CD w Q O Q O � Q 0 CA S N TNZC ((DD :D n X—W w (o NN� _ v N Z(:S v � (D o N00w 21 CD ��G m --J O ZD3 t { �O — C �f A .. w CL �m CD w O� � CD w� CD w oC A N W O O co O (D (D mco _��'m3 ar3owmoN_63(- COD a I. C') m°o~OorCs1 T m m 3No3(D>�1zi7='wCD cn� `�o.y003.Cac ¢°r 0- C2 Baa P'moo�3r(°O�3ocnoDa°"��R7w�oOrM m�Cr c 00rrm �o• N w�. o o 3m3 _ Cama �wMa., wcoc w 'Om C a�dc°i•fl N 3 a�V�c o c or- �0OL v �mm OO.�oa-M.0 00� vw� c w33 °��.°� oc0 ooCN� Oowm�a30 ,7oC oho < ��.c' �rnao� -a��<�a T�–nOi�nncmc �In � cn.N3 mac' a0 ap°o c.�mw°o "O"I mmn= mac m@o o :3 (D mo mo m v a "w m w O �F < mcn � C w �� a m� m w I�xNQ yww'a°Z �`n`n `n 7a off' �� `�wa 0 a °' <n o W A (D w ;? n °� � w N m a 0 a `OC w (n a o l< --0 o `n - NL x m w aD a� °co' o o w w o o: ��w –mAGco c 400w-0 ~mc �� - ET 0. c: ja 2, z) < < X- 7(0 00= m m'a ° m CD c �'c o� � 3 o �.c �� 0 X 0 C 7' a° Cl (a a 0 ° a a o w '0 CD (0 j7T CD (w�D C .0 7 Z 7 C:Z� (D .N+ �.cnm mw0w� �wm�•�o w°p °�c cw�o 3° m ocfl c = x < o ��o � v m w o m o u .'mo : °' a <° m 7 ° m 95 =W m = o x IF t t=ip z., �� t � 'Y'k.. � h y y C7 y o �c "s o, m rL cp C-3 rL M Z:6 cn y ,f,. x a CL a � o ..a ,,'.�, �����>.•�, ,. �_ �'�>, "�+k"ra�:-,� `�' err —ilk„ � .e =h Y NF:+u`ae .�, w S'Y� Y'x d�•$f '�' CD N c CD mppt�ic�y� y p� 0. / w rbihxi: �}"'' '•� �''. •Fr„�"W ,xxfi.., ��'bb, 0 0 o m ''•t ,” �'", ' E.m 7 NN1�1� Z7 �n oQ � c � x oC7 a4 co C-3 � � -mi � � m •.• � x o - m� m= C7 F'+mcol , CCn m � x x x x x x Ce N 05; o ti CP m c -1B cp T T T T OD cp T cz a c tia y = m m 7 7 7 7 7 7 C A m o y = a c m m = Z - �• n tz 0 N d a O O ° G Q O 7 i E; -9 �wo�cn?ate r' C c (-n ? v in W-0 0000(NJ10�=' �-a w w w w w v� INTI – – N yCL D Qa o o CD w W W N N X z n 7 C7 W O A A W v O 0 O 3 < m a (D a w _ DMLn NNN 0 w o, n 0 N a a 3 Q O O TG ♦0 n ° Q� X X X X X C w A A A A A a :; C: a aomw0000 r w N 3' 3' 3' 3' 3' c Tcn 3 d t. c y -, m �, a rnrvo-4Cn w 90 0 0 0 ° CO N3" O 7P2 O O O Co cn vm� CD rx �– co (0 (o (0 (o d x d a o o Q w w w w w a - ---- � O � CD C. CD CD iii Cn CD O Q Q L7 y Cl) lz `Q a m CD° C 1 O CD O o�O (D �. O_ Q Q j O O CL o� ti O Zi CD �v C20� co X. Ay �.•a, 9 s , ,V � ry Q \ \4 a - 74 s x t [ J _ ' p •Yf p. 3 w t z. a!V � x. 1 •"�[ i. »a��` .�q��yr r ; s s� S `' t 4s.��.(n },.e„�. � � e r,�y * e� � �� n, c` ^'y' h. �*r ._ _. �/� �a^S ° '� �(7�,\ �vr,ys �, a,��,-. �.�. .., � ��`►� +.-� �:; �e'�4�ay, ixv .' '�..�yy�yy ,!�hx#�tyy �.,7� it4 �k��'d !`�.+�;.„... '�g��� K���y ,���- y,'4.k ,ea ..z .a� i } �.. , 7 3z �� '7 }. ° �-'° ,• 'v��-. s i . ir. � ra'k 'i�s� Tit �- « '� .�r �t'w� sa '��;fi ?' �^. p- � D �t � � ”. •'�1i+�'., f.-.. - ' r�. ,�-t_.^�,��„ rF•� '✓ii���.*� j-�_J -+�S �� f i� �.y� .yam �.��?. �- r�� � k .�'�_.�°° `r4 �t p�� v} c -,_Ya f; js3 5 - �` /�f fs �"*�,.�'�,t,'��,Y�"J^ �"��:,';<, '?,p :k£ -y ''� �' +,.�.�°,r ��"���+�ie'�t�'��T'i ���-r':• �*'��4 p•F,.y t-� ''k'�,.� ^h `kt �``a5*., g" x �:� F�� tt �"� �.:.'')Ws� f'��,��� �°� Y•re., .. z-." " ., _'; . .k � �' `�'�,. , '} .,w:? r:# ._� '�"r";..s"..„;s�� �i.�'� .`4v:,.< r� r; � f' e.`', ':w �rsY. h... FnR THEL!hi l?F ;(11: IPJ:TAL1_ CT;:- BE ETATEI) PU0L FOR THE SLIM OF 1;- J..�...�- 23/f ),p ,i: r PRICE r u u nr r n „ !HI'-F:'E I� FOR ,:(OF.M�L SWIM:.: -F-DOL L:STn;-LL�I,TO"s lel „ FniRL'f LEVEL BACKYARD. :,C -ESS TO THE CnNSTRL?CTION SITE AND THE LOCATION OF THE POOL 5HALL BE THE BUYER'S RESPONSIBILITY. THE BUYER AGREES TO 0PTA.Itd AND rS50ME THE COST OF RECONSTRUCTING EXISTING FENCE. SECTIONS AND SUPPLYING TEMPORARY FENCE, IF NEEDED, FOR' THE POOL, WE WILL REMOVE AND FILE THE SOD IN THE IMMEDIATE POOL AREA AND REPLACE IT WITH STONEDUST FOR THE POOL BASE. THE BUYER=i5REES -O OSTA'11d AAND ASS;IME THE I, OF C'd`r' REQUIRED PERMITS; COST OF BLASTING, JACKHAMMER WORK, ADDITION .L F^"IF'►lE'Q? AND L;G'nR CH�.RGES I LEOiE OF' n3JE:;?S TOO LARGE FOR OdIR EQUIPMENT ARE. ENCOUNTERED; STUMPING AND REMOVAL OF TREES: r','IiITTntd�,l GR -'! ,-EL r''�. RTn, R F Eiw:' iRLfi F TNR', PROPER 'MS I 1.1 THE C y GRADING G ':'E ., i R u CR> IA LATIO OF nc POOL n5 ADVISED b THE JOB FOREMAN; Gr.Ail_,1G .M., Jt 1, THS POII: y^I 1 f LE -Tr, l` f"y II rl �;T l?4? ^.G J C I TLI T L' f ^ f I 1 ;r, `AL Rid L' rjaui d,,IP.G LU.. L .., WATER TCF HE OOL TJ OPERATIN E1EL AT THE TIME OF C�-*d TRL•fT'f SWi'NING PlOOL CENTER ;ILL NOT E LIABLE OR RESPONSIBLE FOR DAMAGE DONE TO WALKWAYS, DRIVEWAYS, PATIOS, LAWNS, HRU88E^:Y, TREE:, FLOWERS, S'"INi:LE SYSTEMS, !BELL LINES, UNDERGROUND UTILITIES, OR DRAINAGE PIPES. :F THE CONTF:ACT CANNOT cc FU! F11 BY THE SWIMMING PDLL CENTER DUE TO: 1:IBUYER"S CANCELLATION DURING CONSTRUCTION; 'r)s,inn.IN`,G IMPROPER GRni2l! CONDI T., OtS FOR A PROPER I dSTALLATION; THE :'U,`z.R 3GFEES ,rO ::SSUME THE COST OF LABOR AND MATERIALS ALREADY PROVIDED BY THE SWIMMING POOL CENTER. ^LI"iiTED dARRANIV: SWiI'I,-i,7 f' POOL CENTER AGE'EES THAT ;:OR A PERIOD OF ONE (1) YEAR FR71 THE DATE THE POOL IS COMPLETED, IT WI! LI OTTHOUT CHARGE, F'RIOV'IDE THAT THE LABOR TO REMOVE AND REPLACE ANY COMPONENT FART OF THE POOL THAI I5 SUBJECT TO A',' It'lDEPEt'1DENT MANUFACTURER'S 14ARRAIdT'YI PROVIDING THAT THE FOOL HAS BEEN CERTIFIED BY THE SWIMMING POOL CENTER. ')AT THE OPTION OF THE S W 1 M M I N 6 POOL CENTER, THIS WAPRANTY IS VOIDED IF THE SWIMMING POOL IS USED BY ANYONE PRIOR T'. CE^TIFICATION BY THE SWIMMING FOOL CENTER .4 THE BUYER HAS FULFILLED ALL PAYMENT OBLIGATIONS INCLUDING E`TRA CHARGES, IF rN. ?)THIS W.ARRAhdT'r' GOES NOT IT!OL!!OE THE =:OGT OF SUPPL I'ING WATER'. TO REFILL THE SWIMMING POOL IN CONNECTION WITH THE p:npn , nr r � : RR,.. T,, '`r-,VTCE 01.11A E Or A; W.; RANT,( _ „r F .r .'f? Jt�('R" '('�C' �Il r.n r r G: 11 1Q 1 r L' '" G �': F [ G NCLU [ ^�' 'T" uEGrH;;!: ..:ILIT. HE RE ARE G +,SNI JICH FXTEND B_70'll THC E CESCF.'I3F0 ON IHc A:,_ HE , INCL_ G THE WARRAN I OF N .L ALL ABOVE-GR+L!'I' P 0 0 L PK!:'S INCLUl0E:EAt•JD FILIES,THRU-W.ALI. 'S rHMER LADDER(sI,IANUAL VACUUM CLEANER CHEMICAL STARTER t:I?,r'=`T. w:1T. PInT0F_^TE IST T -F _ FI;_F, T :Il obi: ._1 ( -... ` OUT -_ ry L r ! -_ i NCC•,. 5 B1_ jc ALL ='R I NT JF'I'I0R'):= U. !-IL,LP. -----------------... _ ^'G1)L'FR')')-------------• -- — 3-� '_QU jt iT i;; UPGRADE: SWIPI;:IP:G Ei..F; - POOL DISTRIBUTOR'S - ,.; , SOUTH UtJ!ON ST. -- LAWRENCE, MA 0184:. �.R: Sl D :,R Cnl:!: -�K /Y /..._ .... _....__..-_... PHONES �( 508) 682-6916 (508)685-0711 / �--�`-�-- /� 'S., 1 � y_�r �C ��/„�1�---- ��•. _3 J • --- /�> � �1�_D_ _.._..- --- --- V_� �-- r rid � -------_------ I � � � � , Y� _1 .. = t ; T � . _. -• -- - _ _ ^..03 �� !'�;I'. PFiL'h!E In,0N.,E F"u,Cr.TE _..�% lJ _ --------..._-- ------- iac: P 'ni= LE TL:I l!,N" I :;! CL1PI1 '0,f'T LP.IE �f!�Q�W � _ AB0'JF-6 F:r?l,P1C SllTi!tfTtlr' I?!?;.. FnR THEL!hi l?F ;(11: IPJ:TAL1_ CT;:- BE ETATEI) PU0L FOR THE SLIM OF 1;- J..�...�- 23/f ),p ,i: r PRICE r u u nr r n „ !HI'-F:'E I� FOR ,:(OF.M�L SWIM:.: -F-DOL L:STn;-LL�I,TO"s lel „ FniRL'f LEVEL BACKYARD. :,C -ESS TO THE CnNSTRL?CTION SITE AND THE LOCATION OF THE POOL 5HALL BE THE BUYER'S RESPONSIBILITY. THE BUYER AGREES TO 0PTA.Itd AND rS50ME THE COST OF RECONSTRUCTING EXISTING FENCE. SECTIONS AND SUPPLYING TEMPORARY FENCE, IF NEEDED, FOR' THE POOL, WE WILL REMOVE AND FILE THE SOD IN THE IMMEDIATE POOL AREA AND REPLACE IT WITH STONEDUST FOR THE POOL BASE. THE BUYER=i5REES -O OSTA'11d AAND ASS;IME THE I, OF C'd`r' REQUIRED PERMITS; COST OF BLASTING, JACKHAMMER WORK, ADDITION .L F^"IF'►lE'Q? AND L;G'nR CH�.RGES I LEOiE OF' n3JE:;?S TOO LARGE FOR OdIR EQUIPMENT ARE. ENCOUNTERED; STUMPING AND REMOVAL OF TREES: r','IiITTntd�,l GR -'! ,-EL r''�. RTn, R F Eiw:' iRLfi F TNR', PROPER 'MS I 1.1 THE C y GRADING G ':'E ., i R u CR> IA LATIO OF nc POOL n5 ADVISED b THE JOB FOREMAN; Gr.Ail_,1G .M., Jt 1, THS POII: y^I 1 f LE -Tr, l` f"y II rl �;T l?4? ^.G J C I TLI T L' f ^ f I 1 ;r, `AL Rid L' rjaui d,,IP.G LU.. L .., WATER TCF HE OOL TJ OPERATIN E1EL AT THE TIME OF C�-*d TRL•fT'f SWi'NING PlOOL CENTER ;ILL NOT E LIABLE OR RESPONSIBLE FOR DAMAGE DONE TO WALKWAYS, DRIVEWAYS, PATIOS, LAWNS, HRU88E^:Y, TREE:, FLOWERS, S'"INi:LE SYSTEMS, !BELL LINES, UNDERGROUND UTILITIES, OR DRAINAGE PIPES. :F THE CONTF:ACT CANNOT cc FU! F11 BY THE SWIMMING PDLL CENTER DUE TO: 1:IBUYER"S CANCELLATION DURING CONSTRUCTION; 'r)s,inn.IN`,G IMPROPER GRni2l! CONDI T., OtS FOR A PROPER I dSTALLATION; THE :'U,`z.R 3GFEES ,rO ::SSUME THE COST OF LABOR AND MATERIALS ALREADY PROVIDED BY THE SWIMMING POOL CENTER. ^LI"iiTED dARRANIV: SWiI'I,-i,7 f' POOL CENTER AGE'EES THAT ;:OR A PERIOD OF ONE (1) YEAR FR71 THE DATE THE POOL IS COMPLETED, IT WI! LI OTTHOUT CHARGE, F'RIOV'IDE THAT THE LABOR TO REMOVE AND REPLACE ANY COMPONENT FART OF THE POOL THAI I5 SUBJECT TO A',' It'lDEPEt'1DENT MANUFACTURER'S 14ARRAIdT'YI PROVIDING THAT THE FOOL HAS BEEN CERTIFIED BY THE SWIMMING POOL CENTER. ')AT THE OPTION OF THE S W 1 M M I N 6 POOL CENTER, THIS WAPRANTY IS VOIDED IF THE SWIMMING POOL IS USED BY ANYONE PRIOR T'. CE^TIFICATION BY THE SWIMMING FOOL CENTER .4 THE BUYER HAS FULFILLED ALL PAYMENT OBLIGATIONS INCLUDING E`TRA CHARGES, IF rN. ?)THIS W.ARRAhdT'r' GOES NOT IT!OL!!OE THE =:OGT OF SUPPL I'ING WATER'. TO REFILL THE SWIMMING POOL IN CONNECTION WITH THE p:npn , nr r � : RR,.. T,, '`r-,VTCE 01.11A E Or A; W.; RANT,( _ „r F .r .'f? Jt�('R" '('�C' �Il r.n r r G: 11 1Q 1 r L' '" G �': F [ G NCLU [ ^�' 'T" uEGrH;;!: ..:ILIT. HE RE ARE G +,SNI JICH FXTEND B_70'll THC E CESCF.'I3F0 ON IHc A:,_ HE , INCL_ G THE WARRAN I OF N .L ALL ABOVE-GR+L!'I' P 0 0 L PK!:'S INCLUl0E:EAt•JD FILIES,THRU-W.ALI. 'S rHMER LADDER(sI,IANUAL VACUUM CLEANER CHEMICAL STARTER t:I?,r'=`T. w:1T. PInT0F_^TE IST T -F _ FI;_F, T :Il obi: ._1 ( -... ` OUT -_ ry L r ! -_ i NCC•,. 5 B1_ jc ALL ='R I NT JF'I'I0R'):= U. !-IL,LP. -----------------... _ ^'G1)L'FR')')-------------• -- — 3-� '_QU jt iT i;; UPGRADE: TOTAL I_XIRA - . II Tr. ra ;.,-• 'IA;Ci.1-----------...------_..--------`_'7. :,:., I . ti�lA 'SALES TAX -----..... �.R: Sl D :,R Cnl:!: -�K /Y /..._ .... _....__..-_... Tn T L. PRICE: - ---------...-cam+- �--�`-�-- /� W1NTEF; F'I;(S: DEF'05IT RECEIVED:----- _-_ _��.._t20 E -C STEP: BAL. OF CONTRACT:. ( DUE UPOtd POOL. DELIVER`() P91' T tj T LINER: ( AJC (GU= !!PCr,J COMPLrTIOr'J) v i THE ) UYE: AC1:";CIIJL_E:D!;ET; THAT THEY HA''.':: RF.AI) ANI) ACC'EF'TED ii!..L COMP I T IONS OF 1 HI S C;ONTFt-(­' i AND nr. r. -� T I % 0'n' Hlit c;C"inn irr4G _ �, i .107J T�.cr-C�I: c ACT ���n%: Ju `i / ' L z O S Vrl LA OrtO z _• rD O .0 ,� = O c �u z pop Po fll� �• V I ¢' eD Q,D� ft MD 'z a �• cr ws: :n z m CA G� v 0 o ' w cI m c °-' t0 T " c t010 w 3 co CD (D mr 0 =rrTT1 ? r n CD =F cc v m n n C C 0 21 > ; o > ILI o > Z v T Z v M '' O TT10 Z Z Z T ri O T T T T ws: :n z m CA G� v 0 in Q7 T T (/1 T M T O 37 0 N C W C y C y C 7D m m - ? WCD C v m n n O m� A p a z m z n v o y v 19O Z •n m m Z Z ri � " _ M n n r, 700 OO 0 2 70 7p 70 IF m y CA v r, 94- 0 mss. �o E"� Phone: 978-342-2660 October 7, 2011 Fax: 978-342-2699 JAMES A. TRUDEAU j ; l Adjustment Service Inc. P. O. Bog 942 TOWN OF NLr Fitchburg, MA 01420 HEALTH DEPARTMENT claims(i�trudeauadi.com Notice of Casualty Loss of Building Under Massachusetts General Laws, Chapter 139, Section 3B /Building Inspector V/120 Main Street North Andover, MA 01845 Board of Health 120 Main Street North Andover, MA 01845 Fire Department Dept. of Records 124 Main Street North Andover, MA 01845 Insured: Laura Ahern Loss Location: 315 Greene Street, North Andover, MA 01845 Insurance Company: Preferred Mutual Insurance Co. Policy No.: PHOO100801404 Date of Loss: March 5, 2011 File Number: 11-10442 Claim Number: 11027476 Type of Loss: Property Damage 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, Chapter 139, Section 3B" is appropriate, please direct it to the writer and include a reference to the captioned insured, location, policy number, date of loss, and file or claim number. On this date, I cause copies of this notice to be sent to the person(s) named above at the address indicated by first class mail. Sincerely, James A. Trudeau General Adjuster — —MASSACHUSETTS PROPERTY -INSURANCE -UNDERWRITING ASSOCIATION Two Center Plaza Boston, Massachusetts 02108-1904 (617) 723-3800, Ma Only (800) 392-6108, Fax (617) 557-5675 Form of Notice of Casualty Loss to Building Under Mass. Gen. Laws. Ch. 139. Sec.313 NORTH ANDOVER HEALTH DEPT. NORTH ANDOVER TOWN HALL NORTH ANDOVER MA 01845 Re: Insured: Property Address: Policy Number: Type Loss: Date of Loss: Claim Number: RECEIVED FEB 2 2 2005 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT JAMIE A. DIXON- 315 GREEN ST., NORTH ANDOVER, MA 01845 0761553 Water Damage 01/31/05 214988 02/14/05 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 CMA00021