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Building Permit #722-15 - 13 UNION STREET 3/9/2015
l � > Of NO D q BUILDING PERMIT �? 6�"a,�. TOWN OF NORTH ANDOVER ° o APPLICATION FOR PLAN EXAMINA N Permit NO: vDate Received ^o �* Date Issued f SSACHUS IMPORTANT:Applicant must complete all items on this page LOCATION 13,1(6�Union Street, N.Andover, MA Print PROPERTY OWNER Justin Nealy PrintCA a7 MAP NO: PARCEL: ZONING DISTRICT: Hi toric D strict s no 210/014.0-0027-0000.0 Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition %Two or more family ❑ Industrial Alteration No. of units: Z ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District %Water/Sewer Identification Please Type or Print Clearly) OWNER: Name: Justin Nealy Phone: 978-686-6717 Address: 13-15 Union St, N.Andover, MA CONTRACTOR Name. Phone: 603-864-8239 Crossroads Contracting Address: 15 Londonderry Rd#6, Londonderry, NH 03053 ; Supervisor's Construction License: Exp. Date: CS-104779 6/4/16 Home Improvement License: Exp. Date 160986 9/17/16 • ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ 18,360 FEE: $ `22e 220"0 Check No.: /9-S-3/ Receipt No.: 9 F5-7/ NOTE: Persons contracting with unregistered contractors do not have access to the guaran and Signature of Agent/Owner Signature of contractor d � i tNORTH O1�T BUILDING PERMIT TOWN OF NORTH ANDOVER" APPLICATION FOR PLAN EXAMINATION ', , �- °09 Date Received A°"ATE°�Qp Permit No#: gSSACHU`+t Date Issued: IMPORTANT: Applicant must complete all items`on this page LOCATION Print � � t PROPERTY OWNER Y 100 Year Structure yes fho es no ZONING DISTRICT: Historic District a yes no Pnnt MAP PARCEL: `Machine Shop Villag y TYPE OF IMPROVEMENT PROPOSED USE Non- Residential Residential ❑ New Building ❑ One family [I Industrial ❑Addition ❑Two or more family ❑ Commercial ❑Alteration No. of units: ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Other ❑ Demolition _ - -- Watershed District ❑ Septic ❑Well ❑ Floodplain D Wetlands ❑Water/Sewer _ DESCRIPTION OF WORK TO BE PERFORMED: Identification- Please Type or Print Clearly Phone: OWNER: Name: Address: Contractor Name: Phone: Address: Supervisor's Construction License: Exp. Date: _ .. Home Improvement License: Exp. Date:. Phone: ARCHITECT/ENGINEER . 't Reg. No. Address: i FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S_I=_ ig FEE: $ Total Project Cost: $ Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do.not have.access to the guaranty f un ` Signature of contractor:. Signature of Agent/Owner -- Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ rYPE OF SEWERAGE DISPOSAL PvbIic Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Pennanent Dumpster on Site ❑ i THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM i PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature I COMMENTS HEALTH Reviewed on Signature COMMENTS t • Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes ° Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date 9 _ � COMMENTS u Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL. Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA — (For department use) I I 1 I 1 i ❑ Notified for pickup Call Email 1 3 Date Time Contact Name j Doc.Building Permit Revised 2014 Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits o Building Permit Application Li Workers Comp Affidavit o Photo Copy Of H.I.C. And/Or C.S.L. Licenses o Copy of Contract o Floor Plan Or Proposed Interior Work o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks o Building Permit Application o Certified Surveyed Plot Plan o Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses o Copy Of Contract o Floor/Cross Section/Elevation Plan Of Proposed Work-With Sprinkler Plan And Hydraulic Calculations (If Applicable) o Mass check Energy Compliance Report (If Applicable) o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) o Building Permit Application Li Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses Li Workers Comp Affidavit o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o Copy of Contract o Mass check Energy Compliance Report La Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc:Building Permit Revised 2014 a Location No. ! —�� Date ! / �5 . - TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ y'~`;'� Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check# �0 D 3` Building Inspector r , - NORTH . w: .. . . . t . ve- 'e O - R+ No. * - 2016 T Z - h ' yy ��h ver, Mass, T O LAN! _ CO[NIC MI S ll BOARD OF HEALTH Food/Kitchen PERMIT ��� LD Septic System THIS CERTIFIES THAT y� BUILDING INSPECTOR ..................... .. ............... ..........!! r .......... ........... ............... ....... ..... .... .... Foundation has permission to erect .......................... buildings on .... ....to#641 . .................. Rough tobe occupied as .......... ..... ...................... .... ... ......... ...................................................... Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes,and By-Laws relating to the Inspection,Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION TARTS Rough -T Service ..............:'....z. ......./............................................. Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises— Do Not Remove Final No Lathing or Dry Wall To Be Done . FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. CROSSROADS CONTRACTING OF DERRY, LTD. 15 Londonderry Road, Londonderry, NH 03053 603-434-1611 FAX 603-434-9391 PROPOSAL SUBMITTED TO: Heather McNeil and Justin Nealey Phone: 978-686-6717 WORK TO BE PERFORMED AT: 13 Union St. North Andover, MA DATE: January 16, 2015 EMAIL: h mcneil(a-hotmail.com justin.nealey(aD_gmail.com CONTRACTOR REGISTRATION NUMBER: 160986 SPECIFICATIONS THANK YOU FOR ALLOWING CROSSROADS CONTRACTING TO SUBMIT THE FOLLOWING PROPOSAL. WE WILL SUPPLY THE MATERIAL, LABOR AND EQUIPMENT TO PERFORM THE FOLLOWING WORK: INTERIOR REMODELING LEAD SAFETY FOR RENOVATION, REPAIR AND PAINTING 1. Determine if Lead-Based Paint is present using an EPA recognized test kit in all homes built before 1978: 2. If it is determined that Lead-Based Paint is present, all work will be performed according to EPA lead safe renovation guidelines. 3. Pricing to be determined and reported within 48 hours of test results. 4. Payment for lead testing to be made directly to the lead testing contractor per Massachusetts state law. DEMO Crossroads to remove and dispose of the following: 1. Tile flooring, baseboard trim, Closet door and casing, and window trim. 2. Toilet, sink, sink faucet,tub, tub/shower walls, and shower faucet. 3. Ceiling fan/light combination. 4. Suspended ceiling system. 5. Remove the existing steam radiator and save for reinstallation after paint is applied by Homeowner. Steam pipes are to remain in place during construction. FRAME 1. Frame in ceiling where the suspended ceiling is removed with 2x4 studs 16"on center. 2. Replace floor sheathing where damaged with plywood to match the existing subfloor height. Note:Replacement of unexpected water damaged framing material that may be uncovered is not included in this Proposal. ELECTRICAL Supply and install the following as per National Electrical Code 2011: 1. One(1)Customer supplied Vanity Light with single pole switch. 2. One(1) Panasonic WhisperLite Exhaust Fan Light(Model#FV-08VQL5)with two pole switch. Fan/light will be vented to the exterior. 3. One(1)dedicated 20A circuit for GFI receptacle. 4. One(1)combination Arc Fault—GFI dedicated circuit. r ' Page 2 Heather McNeil and Justin Nealey 13 Union St. North Andover,MA PLUMBING Supply and install the following: 1. One(1)36"X 21" Kemper Whitman Maple vanity and medicine cabinets per East Coast Lumber Design 1/10/2015. (Allowance= $860) 2. One(1)37"X 22" L-Series Cultured Marble vanity top with molded sink with 4"back splash. (Allowance=$505) 3. One(1) Kohler Alteo single handle fav faucet(K-45800-4-CP)in Polished Chrome finish. (Allowance = $140) 4. One(1) Kohler Bellwether 60x30 Cast Iron tub (K837WH1). (Allowance=$500) 5. One(1) Kohler Rite Temp valve(K-304-K-NA)with Alteo valve trim (KT-45110-4-CP),Alteo wall mount bath spout(K- 45131-CP), Forte supply elbow(K-355-CP), Mastershower metal hose(K-9514-CP), shower slide bar(K-9069-CP), and Forte handshower(K-10286-CP)in Polished Chrome finish. (Allowance=$475) 6. One(1) Kohler Cimarron(K3888-0)White Comfort Height®two-piece round-front 1.6 gpf toilet with AquaPistonTM flush technology and seat(K-4639). (Allowance=$250) Note: Included in this proposal is a total allowance of$860 for the vanity and medicine cabinets. Note:Included in this proposal is a total allowance of$505 for the vanity top. DRYWALL 1. Install %" moisture resistant drywall to the ceiling in the Bathroom. 2. Mud, tape and sand to a paint ready condition. Ceiling to have a smooth finish. 3. Patch and skim coat the reworked walls to create a smooth surface. TILE 1. Supply and install cement backer board and ceramic tile to the floor in the Bathroom in a straight set, non-pattern fashion. Note:$5.00 per square foot file and grout allowance for all areas.Additional borders,patterns,accent pieces,etc.will result in additional charges. TUB/SHOWER WALLS 1. Supply and install cement backer board to the walls above the new tub where the wall panels are to be installed. 2. Supply and install 60" high L-Series Cultured Marble panels with one large, and one small recessed niche to the walls above the new tub. INTERIOR DOORS and MILLWORK 44yo- Supply and install the following: G prom E 1. One(1) 18"x 80" pine interior door withtre"hardware and passage set. (Closet) 2. 5" pre-primed pine casing to the new door and existing window. 3. 5 '/2" pre-primed speed base baseboard in the Bathroom. PAINTING 1. Apply one coat of latex primer to all new and reworked drywall. 2. Apply two coats of latex interior finish paint to the walls and ceiling. 3. Apply two coats of latex interior semi-gloss to the doors, window and door casing, and baseboard trim. MISCELLANEOUS 1. Any changes needed due to building code issues that are not included in the scope of work outlined in this proposal, will be billed accordingly. 2. We will clean up and remove our construction debris, and leave the site vacuum clean. 3. Permits will be obtained by Crossroads Contracting and billed at face value to the customer. 4. $250 Partner Agreement retainer fee has been applied to the contract and is reflected in final price below. EIGHTEEN THOUSAND THREE HUNDRED AND SIXTY DOLLARS ($18,360.00) Page 3 Heather McNeil and Justin Nealey 13 Union St. North Andover,MA This form satisfies all basic requirements of the state's Home Improvement Contractor Law(MGL chapter 142A), but does not include standard language to protect homeowners. Seek legal advice if necessary. Any person planning home improvements should first obtain a copy of a"Massachusetts Consumer Guide to Home Improvement"before agreeing to any work on your residence. You may obtain a free copy by calling the Office of Consumer Affairs and Business Regulation's Consumer Information Hotline at 617-973-8787 or 1-888-283-3757. PERMIT NOTICE: 1. The following permits will be required to complete the agreed scope of work: a. Building Permit, Plumbing Permit, Electrical Permit 2. Permits will be obtained by Crossroads Contracting and the face value will be billed to the customer. 3. It is the obligation of the Contractor to obtain such permits as the Owner's Agent. 4. Owner's who secure their own construction-related permits or deal with unregistered Contractors shall be excluded from access to the Guarantee Fund provisions of MGL Chapter 142A. Total Contract Price and Payment Schedule: The Contractor agrees to perform the work, furnish the material and labor specified above for the total sum of: $18,360.00 Payments will be made according to the following schedule: 590.00 upon signing contract(not to exceed 1/3 of the total contract price or the cost of special order items, whichever is greater) 590.00 upon Start of PROJECT $4,590.00 upon Start of TILE $4,590.00 upon SUBSTANTIAL COMPLETION (Law forbids demanding full payment until contract is completed to both party's satisfaction.) The following material/equipment must be special ordered before the contracted work begins in order to meet the completion schedule. Not applicable. (Law forbids demanding full payment until contract is completed to both party's satisfaction.) The following material/equipment must be special ordered before the contracted work begins in order to meet the completion schedule. Not applicable. NOTE: Including all finance charges law requires that any deposit or down-payment required by the Contractor before work begins may not exceed the greater of(a)one-third of the total contract price or(b)the actual cost of any special equipment or custom made material which must be special ordered in advance to meet the completion schedule. Proposed Start and Completion Schedule: The following schedule will be adhered to unless circumstances beyond the contractor's control arise. Contractor will begin contracted work on: APRIL. 2015 Contracted work will be substantially complete(At least 95%)on: MAY. 2015 EXPRESS WARRANTY—Is an express warranty being provided by the Contractor? Yes(all terms of the warranty must be attached to the contract.) Contractor warrants that Work will be of good quality, free from defects and in compliance with the requirements of the Contract Documents, as well as applicable local, state and federal laws, ordinances, rules and regulations. At the Owner's request Contractor shall promptly repair or replace defective work for a period of one year after the date of Work is substantially complete. All other statutory or common law warranties are specially disclaimed. Page 4 Heather McNeil and Justin Nealey 13 Union St North Andover,MA Subcontractors—The Contractor agrees to be solely responsible for completion of the work described regardless of the actions of any third party/subcontractor utilized by the contractor. The contractor further agrees to be solely responsible for all payments to all subcontractors for materials and labor under this agreement. Contract Acceptance—Upon signing, this document becomes a binding contract under law. Unless otherwise noted with this document,the contract shall not imply that any lien or other security interest has been placed on the residence. Review the following cautions and notices carefully before signing this contract. • Don't be pressured into signing the contract. Take time to read and fully understand it. Ask questions if something is unclear. • Make sure the Contractor has a valid Home Improvement Contractor Registration. The law requires most home improvement Contractors and Subcontractors to be registered with the Director of Home Improvement Contractor Registration. You may inquire about contractor registration by writing to the Director at One Ashburton Place, Room 1301, Boston, MA 02108 or by calling 617-727-3200 or 1-800-223-0933. • Does the Contractor have insurance? Check to see that your Contractor is properly insured. • Know your rights and responsibilities. Read the Important information that follows on this form and get a copy of the Consumer Guide to the Home Improvement Contractor Law. You may cancel this agreement if it has been signed at a place other than the Contractor's normal place of business, provided you notify the Contractor in writing at his/her main office or branch by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the third business day following the signing of this agreement. See the attached notice of cancellation form for an explanation of this right. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. (Two identical copies of the contract must be completed and signed. One copy should go to the homeowner. The other should be kept by the Contractor.) Homeowner's Signat ton actor Sig ature / la C)//-5- /r;,�//� Date I j Date JB/INT/PB4 Contractor Arbitration The Home Improvement Contractor Law provides Homeowners with the right to initiate an arbitration action (as an alternative to court action) if they have a dispute with a Contractor. The same right is not automatically afforded to a contractor, however. The Contractor would have to resolve any dispute he/she has with a Homeowner in court unless both parties agree to the optional clause provided below. This clause would give the Contractor the same right to arbitration as is afforded to the Homeowner by the Home Improvement Contractor Law. The Contractor and the Homeowner hereby mutually agree in advance that in the event the Contractor has a dispute concerning this contract, the contractor may submit the dispute to a private arbitration firm which has been approved by the Secretary of the Executive Office of Consumer Affairs and Business regulation and the consumer shall be required to submit to such arbitration as provided in Ma achusetts General L chapt Horn wners SignatuW Co tractor' i at j ure Page 5 Heather McNeil and Justin Nealey 13 Union St. North Andover,MA NOTICE: The signatures of the parties above apply only to the agreement of the parties to alternative dispute resolution initiated by the Contractor. The Homeowner may initiate dispute resolution even where this section if not separately signed by the parties Homeowner's Rights A Homeowner's rights under the Home Improvement Contractor Law(MGL chapter 142A)and other consumer protection laws(i.e. MGL chapter 93A)may not be waived in any way, even by agreement. However, Homeowners may be excluded from certain rights if the Contractor they choose is not properly registered as prescribed by law. Homeowners who secure their own building permits are automatically excluded from all Guaranty Fund provisions of the Home Improvement Contractor Law. The Contractor is responsible for completing the work as described, in a timely and workmanlike manner. Homeowners may be entitled to other specific legal rights if the Contractor guarantees or provides an express warranty for workmanship or materials. In addition to guarantees or warranties provided by the Contractor, all goods sold in Massachusetts carry an implied warranty of merchantability and fitness for a particular purpose. An enumeration of other matters on which the Homeowner and Contractor lawfully agree may be added to the terms of the contract as long as they do not restrict a Homeowner's basic consumer rights. If you have questions about you consumer/Homeowner rights, contact the Consumer Information Hotline(listed below). Execution of Contract The contract must be executed in duplicate and should not be signed until a copy of all exhibits and referenced documents have been attached. Parties are also advised not to sign the document until all blank sections have been filled in or marked as void, deleted, or not applicable. One original signed copy of the contract with attachments is to be given to the Owner and the other kept by the Contractor. Any modification to the original contract must be in writing and agreed to by both parties. Contracted work may not begin until both parties have received a fully executed copy of the contract, and the three day recision period has expired. Additional Information If you have general questions or need additional information about the Home Improvement Contractor Law or other consumer rights, or if you wish to obtain a free copy of"A Consumer Guide to the home Improvement Contractor Law" contact: Consumer Information Hotline Office of Consumer Affairs and Business Regulation 10 Park Plaza, Room 5170 Boston, MA 02116 (617)973-8787 or 1-888-283-3757 If you want to verify the registration of a Contractor or if you have questions or need additional information specifically about the Contractor Registration component of the Home Improvement Contractor Law, contact: Director of Home Improvement Contractor Registration Bureau of Building Regulations and Standards One Ashburton Place, Room 1301 Boston, MA 02108 (617)-727-3200 or 1-800-223-0933 For assistance with informal mediation of disputes or to register formal complaints against a business, call: Consumer Complaint Section Office of the Attorney General 617-727-8400 AND/OR Better Business Bureau 508-652-4800 508-755-2548 413-734-3114 w I , ' 1 I I OPM s, ----------- �-- 1 !JLII • _� _ �� I f_ I i I I { I I I i 1 1 I I 1• i ( I i j : i (! i , I _ _ - I I i I ( ! ! 09 \,/>Y\ ..-. a i r _.J_ i CROSS-2 OP ID:SG CERTIFICATE OF LIABILITY INSURANCE DATE(MMroD/YY 11/1812014 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Planright Insurance-Salem NAME: Jason M Mlocek 224 Main Street Suite 3C aCNN E11:603-890-6439FA No):603-890-6521 Salem,NH 03079 E-MAIL Jason M Mlocek ADDRESS:jason@santoinsurance.com INSURER(S)AFFORDING COVERAGE NAIC k INSURER A:Peerless Indemnity Ins Co 18333 INSURED Crossroads Contracting of INSURER B:Excelsior 11045 Deny Ltd 15 Londonderry Road Unit 6 INSURER C:Netherlands 24171 Londonderry,NH 03053 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUBR I POLICY EFF POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER MMIDD/YYYY MM/DD/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 CLAIMS-MADE X OCCUR BKS55672507 11/01/2014 11/01/2015 PREMISES Ea occurrence $ 300,00 MED EXP(Any one person) $ 15,00 PERSONAL&ADV INJURY $ 1,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,00 POLICYFK JECOT- F3�1 LOC PRODUCTS-COMP/OP AGG $ 2,000,00 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ 1,000,00 B ANY AUTO BA8814314 11/01/2014 11/01/2015 BODILY INJURY(Per person) $ ALL OWNED LX SCHEDULED BODILY INJURY Per accident $ AUTOS AUTOS ( ) HIRED AUTOS NON-OWNED PROPERTY DAMAGE AUTOS Per accident $ $ UMBRELLALIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION PER )TH- C EMPLOYERS'LIABILITY �,/N X STATUTE ER C ANY PROPRIETOR/PARTNER/EXECUTIVE C8875773 11/01/2014 11/01/2015 E.L.EACH ACCIDENT $ 500 00 OFFICER/M(Mandatory In ER EXCLUDED? �N/A E.L.DISEASE-EA EMPLOYE $ 500,00 (Mandatory in NH) 3A: MA NH If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,00 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached N more space Is required) Jan Jacome as elected to be excluded from work comp coverage. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN For Information Only ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of IndustrialAccidents b 1 Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): Crossroads Contracting Address: 15 Londonderry Rd, Unit#6 City/State/Zip: Londonderry, NH 03053 Phone#: 603-434-1611 Are you an employer?Check the appropriate box: Type of project(required): 1.❑I am a employer with employees(full and/or part-time).* 7. E]New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. N Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.Q I am a homeowner doing all work myself.[No workers'comp.insurance required.]: 10 E]Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions S.N I am a general contractor and I have hired the sub-contractors listed on the attached sheet 13.E]Roof repairs These sub-contractors have employees and have workers'comp.insurance.: 6.n We are a corporation and its officers have exercised their right of'exemption per MGL c. 14.❑Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing ipor/rers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Peerless Indemnity Insurance Co Policy#or Self-ins.Lic.#: WC8875773 Expiration Date: 11/1/15 Job Site Address: 13-15 Union St City/State/Zip: N. Andover, MA 01845 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official Ci Town:City or w 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#: r Office of Consumer Affairs and Buslness Regulation 10 Park Plaza - Suite 5170 ` Boston, MassachWetts 02116 Home Improvement C, tor Registration Registration: 160986 Type: Private Corporation Z Expiration: 9/17/2016 Tr# 256801 CROSSROADS CONTRACTING O iu JAN JACOME 15 LONDONDERRY RD. #6 LONDONDERRY, NH 03053 K Update Address r ss ani return card.Mark reason for change. SCA 1 0 20M-05/11 Address [] Renewal R Employment Lost Card .+a, r✓�e (�+Or�7.7raIJ'/SCUL'p'l�✓t 6f��,gJJ2c�ccJe�1 -\ Office of Consumer Affairs&Business Regulation License or registration valid for individul use only OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: egistration: ,; 60986 Type: Office of Consumer Affairs and Business Regulation Expiratio n: 9/x0:1:6Private Corporation 10 Park Plaza-Suite 5170 Boston,MA 02116 CROSSROAQS COt* -_-_,= i ' rDERRY LTD JAN JACOME 15 LONDONDERRY 1,; LONDONDERRY, NH 03 '53 Undersecretary Not ali without signature i Massachusetts -Department of Public Safety Board of Suild;ny Regulations and Standards Construction Superiisor License: CS-104779 NICHOLAS A CO 4-IrltjJff, 12 BIRCH ST LITCEMLD NISI 03� ' Expiration Commissioner 06/04/2016 i SUBCONTRACTOR/SUPPLIER LIST Owner: Justin Nealy 13- 15 Union Street N. Andover, MA 01845 Contractor: Crossroads Contracting 15 Londonderry Rd#6 Londonderry, NH 03053 603-434-1611 Electrical Sub: Border Electric PO Box 461 Londonderry, NH 03053 603-860-2617 Plumbing Sub: Shanley Plumbing 71 Pleasant St Danville, NH 03819 603-382-0933 S:Sales.Subcontractor.Supplier List(template).xls Date.. ..j. .. . . .. . . .. . ... . . ,+ORTH Of „ao '.'. 0 0 32 TOWN OF NORTH ANDOVER ° PERMIT FOR GAS INSTALLATION y SACHUSE�� r -- This certifies that r r � ��,� --k. . . . . . .. _ has permission for gas Inst llation . .tl :? .. . . . . . . . . . . . . . . . . . . . . in the buildings of . ""-z"Y`` . . . . . . . . . . at / . . . . y. . . . . . . . . . . . . . . , N/rth Andover, Mass. Fee! . . . Lic. No/'.4 //. . . . :I: ! .f_. . . . . . . . . GAS INSPECTOR'' Check# .33 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) ler4'k �� '� . Mass. Date 3 /jPermit Building Location 13 1h%i o/U Owner's Name 1 C A/P� Type of Occupancy New p Renovation Q Replacement p Plans Submitted: Yesp No p N ¢ • Isr fA SC 2 ¢ Ion ¢ul N ¢ O = F w � N. W i o u F' < ¢ 0 O F < m y F- y W O C d C s t- ¢ N t7 w W S = t/f O T. W N! 1X W = C) Yr yr < ¢la JAI 61j OK W D O F- = rt F z f. w w O >. W t- W A 1„. w Y < w < c r > O m Z O Z O N S < w > sus—BSMT. --` BASEMENT � 1ST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR STH FLOOR 6tH FLOOR TTK FLOOR STH FLOOR r Installing Company Name_&YJ,`�b/p it��., b�-T,,,c Check one: Certificate Address 1; y �«.�e v:e a �-�2 210Corporation >i L-e,-V<� /nom• el,q p. Partnership Business Telephone p Firm/Co. Name of Licensed Plumber or.Gas Fitter INSURANCE CO RAGE: I have a curren lability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes No O If you have checked yes, please Indicate the type coverage by checking the appropriate box. A liability insurance policy Other type of indemnity❑ Bond O OWNER'S INSURANCE WAVER: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner[] agent El I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that ail plumbing work and installations performed under the permit i"for this application X11 be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the n 7rP By T License: 7 Plumber Signature of Licensed Plumber of Cas Fitter True st-rtter ster License Number City/Town Journeyman APP� I NL Date. ..�1. j�. .`.. .. . NORTH OF ,.,tip TOWN OF NORTH ANDOVER • PERMIT FOR GAS INSTALLATION ,h ' �9SSACMUSF-S•( �d This certifies that ? (. . . . .1. ./. . . . . . . . . . . . . . . . . . . has permission for gas installation . . . !; . . . . . . . . . . . . . . . in the buildings of . .�i. s'. . .�?.� ti. �. . . . . . . . . . . . . . . . . . . . . . . . at .�.. . . . . .�. . . . . . . ., North Andover, Mass. Lic. No.cI.7 . . . . . . ��. !�. . . . . . . ASINSPECTOR Check# 1 ' 4262 r ' i NIASSACHUSErIS UNIFORM APPUCATON FOR PERMTr TO DO GAS FITTING (Type or print) Date �a/�X NORTH ANDOVER,MASSACHUSETTS // Building Locations 13 Ilynion. cl E-• Permit# Y 2''C-L Amount$ Owner's Name deo-toner New Renovation Replacement 10 Plans Submitted Ij � a v� U `. Ix F F O W 04 6T4U F z F Z W W C) W F W U w w F a O x W A C7 O U C4 A o0, F O SUB -BASEM ENT B A S E M ENT 1ST. FLO O R 2ND . FLOOR 3RD . FLOOR 4TH . FLOOR 5TH . FLOOR 6TH . FLOOR 7TH . F L O O R 8TH . FLOOR (Print or type) C©one: Certificate Installing Company Name AnAove-r 9M< . 4 RtA. CA., I r,c. Corp. 2t 2- Address O Partner. usmess Te ep one ( g7py �oq,s_$3g j El Firm/Co. Name of Licensed Plumber or Gas Fitter Cje cx!.4 INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes 10 No If you have checked yes'please ndicate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity ❑ Bond Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the 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 ❑ I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts Stat:/0 s Code and C pre 42 of the General Laws. By: 'Signature o icensed Plumber Or Gas Fitter Title Plumber &3 City/Townas Fitter License NumBer Master APPROVED(OFFICE USE ONLY) 0 Journeyman Location 13 No. c) (93 Date —Cc;� R,aR'h TOWN OF NORTH ANDOVER � R 9 ; f Certificate of Occupancy $ • i 9 CMuBuilding/Frame/Frame Permit Fee $ sAst Foundation Permit Fee $ Other Permit Fee $ TOTAL $ V Check # CyG� nil(11AI � 5 Z Z 9 B ilding Inspector F o , TOWN OF,NQM ANDD :,VER Y, BUILD TNG DEPARTMENT &PLICATION TO CONSTRUCT REPAIR.RENOVATE; OR DEMOLIS$A ONE OR TWO FAMILY,DWELLING r w 3IlILDING PERMIT NUMBER: DATE ISSUED ,IGNA'IIM: Building Commissioner r of Buildings Date ECTION 1-SITE INFORMATION 1..1 Property Address: L.2 Assessors 42 Map and Parcel Number. O f' Map Number Parcel Number 1.3 Zoning Information: 1.4 ProperlyDime�ons rl (,A)min District AArea 5 BUILDING SETBACKS(ft) Front Yard Si Yair ; Rr Yard R' Provide Prdvided Provided wnor'sly M QLC,ao. sa) 1.3. Flood Zone InNornm wn lr= , dic d Private ❑ Zone Outside blood Zone 0 Mo nicipal ❑ S Oa Site Disposal SyDtem" a ;CYTON 2tdPER 'Y OWN$RSHP/AUTHORIZED;AGYw� Owner of Record €' s I a ti me.( t) Address for Sei . rotor Telephone Owner of Record 7 C ame Print Address for Service: O tature Te) hone m MONO=CONSTRUCTION SERVICES �p Licensed Construction Supervisor. Not Applicable p nsed Constructi(In Supervisor: 'v �� 7 lT Q �./�. d� LicenseNumber reSs Mn Expiration-.Date ature Telephoneic a�. tegistered Home Improvement Contractor Not' p ®. pony Name Registration Number r ess � ell cture Expiration Date Tele hone G) A � SECTION 4-WORKERS COMPENSATION(AtP.L. C 152"§ 2546)'' ' Workers Compensation Insurance affidavit must be completed and•.submitted with this application.'. Failure to provide this affidavit will;result 1 in the denial of the issuance of the-building permit Signed affidavit Attached Yes.....,.A.. No........0 SECTIONS Descri tion of`Pro -sed Vitork checicalla livable Nety Construction 0 Existing-Building ❑ Repat(s) . tllterahons(s) 0 Addttion D Accessory Bldg, ❑ Demolition 0 Other ❑ Specify Brief Description of Proposed Work: SECTION 6 ESTIMATED CONSTRUCTION COSTS ' Item Estimated Cost(Dollar)to be Completed by permit applicant. A. :Building (a) .Butlding Permi7Fee -, 2 Electrical (b) Ir§hmatdTotal Conshvghon 3 Plumbing Buildmg P pp#fee°(.):(b) 4 Mechanical QffAC .5 Fire:P.roteetion f ., Y 6 Total 1+2+3+4+5 Check Number �.. 'TY(SN'ja OWNER AU M&M" ZATION TO BE CO M PLEA D WHEN'%. OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I' as Owner/Authorized Agent of subject property Hereby authorize to act on My behalf;in all matters relative to work authorized by this/building permit application. Signature of Owner Date ? SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION I' as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and belief J Print Name Si ature of Owner/Agent Date NU.OF STORIES ' SIZE 'BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 2 No 3 SPAN DRvffiNSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIIv1NEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE Nov 26 01 07:55p John Lanzafame 9750461 p. 1 es�at�al&Comn1ereja/Roo • • Licensed&Insuredhdo Propoat • Roof Leak Experts • (97p8)k794-3883 1-800-WAIT`4 US f -- ' Proposal Submitted To IFMTM .4Rhone Date % Street 1 �' is " OCA r % 4 7 %'•-. ob City,State$Zip code o 11 < Job Phone We Propose hereby to furnish and labor in acco_ anec with specifications below,for the s of: _Dollars All materiel is guarantccd to be as specified.All wait to be completed in a workmanlike Authorized manner according to standard practices.Any alteration or deviation from speeificWoas bo- s low involving extra cosy will be executed only upon written amsSignature: extra charge over and above the estimate.Allaffinenacrits 'and will become is or delays beyond our control,Owner to carry tornado andel othernenecessary insaccurance. Nom:Tis proposal jliC... Our workers are fully covered by Workmen's Cote Compensation Insvranec, withdrawn by us if not accepted within_days. We hereby submit specifications and estimates for: -D-2 `G °l< •�/- r3 �%tom? /.:d=� :Yi-^�.�;r .!-�:� .�-;`�-- cat/.- ' � T `4 L��G��`�•`� G.1GY �i°.s :%7/J /�/.�' /P✓SU.��G'�� �t��r�i �% r'' y Acceptance of Proposal-The above prices,specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified.Payment Signature: will be made as outlined above. Date of Acceptance: Signature: ���V� �� ! Q_-___�/ �� �` cls•�f1r� ���, 13 "T If- a/t-;�61, J ra (11-7,>ff-I f -4PA' ' TOWN OF NORTH ANDOVER HORTr�. Office of the.Building Department �2oee A' O m Community Development and Services 27 Charles Street. it North Andover,1Massaebusetts01845 °°9,•�;Kx; „r'• 3�Ss^cKus t D. Robert Nicetta, Telcj)hone(978)688-9545 Buil(ting+C'otnrttissiaaner FAX(978)688-9542 DEBRIS DISPOSAL FORM In accordance with the provisions of MGL c 40 s 54, and as a condition of building permit# the debris resulting from the work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 11, s 150a. The debris will be disposed of at/in: (Site location) Signature"of eTr t applicant Date Michael McGuire,Local Building Inspector James Decola,Electrical Inspector James Diozzi,Gas/Plumbing Inspector F r4 Town of Andover Ow��M-•re,H+ �� � � No. c163 9' o�oo ONo�A COC MICLA MEwI0� ` dover, Mass., ORATED P �5 S BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System THIS CERTIFIES THAT V .t BUILDING INSPECTOR .... ......................... .. r ....... ...................................................................... ,,//�� Foundation has permission to erect. t �..l ......... buildings on. , ....VI �G/V,.,.,..,. Rough D ei.. � tobe occupied as..... .... ... .0........... ......................................... .................... .......................... Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to th Inspectio Alteration and Construction of Buildings in the Town of North Andover. ,q/a r? 5"If *VOW PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTION STATS ELECTRICAL INSPECTOR Rough � ....... .................................... Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To BeDone FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. 3 .?::.i•nvf!.-'l.+.:i:•frl fhKi%:!:?-:Y++:f::::•: ....:.....;,r,.r;>::-va::or:%:.ti••:{,�!jh�%::i'rrtrr.•:;?•ii::,:.` Yr - .:../, .... ... •,;kt?•�:-r-::•:�x::>::�•i::::t>-it;:t;;:;:->!- ..::,.::. :: tff:: .k- 6..�iww►.., :: .;;': .:. -. .[.' :. >"3ti:.'t::'is:% ::':;:: Y•''te•`?<::.':r .i:;•::i';'?::'• DATE (MMID .. :::v:v...•.. :...:::u vi�:�}::.w�nN�?u:.wy,H.:?:?::N.v.+vx::n �..:n ..�:xi'::is int} ..w..• .?{:p}v:.v::.v:tn('n?? .............. ,. .;,:.,:;: .::......................,,n>r:r:.,.n.� ... .:.. :.,.::.::...:.::....::.::,::.»+:.rt•::,::;:.,.$....... 11/06/2001 ::::r:.vvi:.v:r.w::u:,...:n;•,::.vv...............•!•.. ...........:... .........::.^?r?:.:::tii:rift}:.Y4;•Q:ii PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Lennox Insurance Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE P. O. Box 462 HOLDER. THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Lynnfield, MA 01940 COMPANIES AFFORDING COVERAGE commy Savers Property&Casualty Insurance Company INSURED All Under One Roof/Pest In Peace COMPANY e 70 Jefferson St North Andover, MA 01845 COMPANYPANY COMPANY D - ..:........:. t,..:rr r ,:.:sana,+.,:•:rurf/.:VF.•io-...:{..:: ,rn;;::::,:;,;t:..... ..�x .:k..`.: .�.....:.:..:: t n .nvr.r.:frrr %�.fE!'•r!:L::i%t{t; ::: :`:,:;:t';v: „:.,,,..: .r..:. !ry:....;;th.. ': :. ..-....,,...,....:....::.... :+••;•, mr.rrr ..,.�nii7riiiy::cr:%::::::::::.n:..:.:,..:,:.:... !.t..wrx?rr;+»•t--........... ,,..,:.,:.. ..,,-«::. :•J.f ::.». . .ry 7....n::::::::::.r:rrrvr:r:rr:rrii r ......l..:k-:K:v.:xv»vvxr++-y:•...!:.,,.::.w..x :.xix.n r. ...... ,.:...a .:...,.. f,.h:.... r N ::rrr.�.:..:.. ++..v.nw,:..�i.r...: ... ... ..lJ'1C`'i' li ril i ,�iY�'li rk ......................w............l..i:?:.-i:fi:ii:..........?:r,.[x:.::•:?r.:;?4i:;;-.v::n.f.:r..ft...f f i:;fn.:: :{,.,.r:.,....w, :,:y..��r v r:r. r.Y...: rr.rr...::.v.�..n x.. n uv.:E..:..?{. F r 1 lli ifii •'i f.: > ;r{{{ia!•f..........�•ffii.x,..r�.n.+�k.,.l..,N/.•...,r?..uf.•....?:.r. :..r.<f.,...•,tta�:2;f!Srl.7,tt5'-?`;^:t'5;r`�'•cn-.;t �Sl�f;: <%�: ,6< t�it.:5^i%':�:r�:°:i�;: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED,NOTVNTHSTANDINGAWY REQUIREMENT,TERM OR CONORION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT-TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POUGES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS: LT TR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION DATEMM10 LIMITS ( D/YY) GATE (MMlDD/YY) GENERAL LIABILITY GENERAL AGGREGATE S COMMERCIAL GENERAL LIABILITY PRODUCTS-COMPRWAGG. S CLAIMS MADE F OCCUR PERSONAL SAOV.INJURY S OWNERS S CONTRACTOR'S PROT - EACH OCCURRENCE $ FIRE DAMAGE (A—rw S MED.EXPENSE w—w ' S AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLEUMIT S ALL OWNED AUTOS BODILY INJURY S SCHEDULED AUTOS (Per person) HIRED AUTOS _ SODILYINJURY S NON-OWNEDAUTOS (Peracddeat) PROPERTY DAMAGE S GARAGE LIABILITY AUTO ONLY_EAACCIDENT ANY AUTO OTHER THAN AUTOONLY: arr•: EACH ACCIDENT ' AGGREGATE EXCESS LIABILITY �H OCCURRENCE S UMBRELLA FORM AGGREGATE SI OTHER THAN UMBRELLA FORM WORKER'S COMPENSATION AND - _ ::::,:::.,.:.. ...,�;,,iv;,:: EMPLOYERS'LIABILITY !DRY.LIMITS ER MEMO=% ?S?i > 5 ...... €L PAC"ACCIDENT $ IUU' THE PROPRIETOR/ INCL AR0000776 11(09/2001 11/09/2002 ELDISEASE-POLICY LIMIT $ 17000 PARTNERS/EXECUTNE OFFICERS ARE: EXCL EL DISEASE-EA EMPLOYEE S ' OU OTHER i DESCRIPTION OF OPERATIONS/LOCATIONSIVEHICLESISPECIAL ITEMS lar ..... .r .,. .........:.,:r..::::.�:::::::...::rr::::......::::,.r........rr.......r.............r..r......:.rSr...,•...•::r........::.......:•.,-:•.:�.:,?•.w.f:frhari.t»>......r.::r:...:::.:x�.�:::::•:rb:?�;:•%+•??.. .... +�•a?.2:fi:.•: SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE .r EXPIRATION DATE THEREOF,THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CER nFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABQJTY OF ANY KIND UPON THE COMPANY,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENjATNE i ,�<?kr ""f'3r/.;`>f,''• i;Ts`'%i 1 rxtv.::yr:k:y✓••t: ..,.....:.,c...._......:_...•.,-�:rc.�," .......:....: :.,.......::.tF.►.rXY!ff'I?�'t'V:ilirtAv�ta+inlit%ianrt:'::.:...;?.?:i MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT T O GASFITTIH' G � (Print or Type) NORTH ANDOVER Mass. Date / Lev l Liilding 'Location Permit # . Owners Nameust� New 77 Renovation Replacement Plans;. ,p FIXTURES of N Q 07 oC ,O ,0 = us us of sett V Co .e S .W o uull C '4 a z " `o tca - a to W w p e 4 = us !- N Q vI a oLU s x �- in a y tu W z x z I" W -t ocus F x C, 1�- z J F' x F. W w O O T u. N V ..i I- W Z d W < cc ; .ham y. (4 m = O W O: tr = o ma ��. U. za a c�a. '�t v y a a. N o SUR-8SMT. aasEMExT 1ST FLOOR /l 2ND FLOOR 3RD FLOOR I 4TH FLOOR ` STH FLOOR 6THFLOOR 7TH FLOOR 8TH FLOOR (Print or Type) Check one: Certificate Installing Company Name ANDOVER PLBG. & HTGCo. IN .,5:;�j Corp. 9199 _ Address 20 AEGEAN DR. UNIT # 10 Partner. METHUEN, MA. 01844 Firm/Co. Business Telephone: 978-685-8383 Name of Licensed Plumber or Gas Fitter rF(1R(;F I Apn.;F Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy � Other type of indemnity D Bond Insurance Waiver: 1 , the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance coverages. Signature of owner agent of property Owner 17 Agent I hctcby cereify glut all of the dctsilr and information I have submitted (or cntercd)In above applieatioa are true and atxuratt:to the best oltny �_nowicdgc and tlut ati plumbin; work and Insallatioas perfomtcd undcr'Pcrmit iuucd for this applieatiaa will•be to mplianw with all petttamt provisions of tho biaraachuscus State Gas Code and Chapter l4:of tho Central Laws. — By YPE LICENSE: Pl umber Title itter Sig ature of Licensed city/Town• aster Plumber or Gasfitter ourneyman 9983APPROVED (OFFICE USE ONLY) License Number