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HomeMy WebLinkAboutMiscellaneous - 1 MEADOW LANE 4/30/2018Date..... 4 ....... .... ... I ..................... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that)RA 4P -,"-a0 ... ............ ...... ................. �/ has permission for gas installation A ns cz-.,4 .......................................... ........ in the buildings of � o-, --) ... ............. ... . at ........ ........... M. -Pa w L- t -j .................................................................... . North Andover, Mass. Fee(O.)..� ..... Lic. No. ... ... I �-r . . ................................................. GASINSPECTOR Check # LWK MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY I North Andover I MA DATE 411512014 PER-M.I.T-# Z to JOBSITE ADDRESS 1 Meadow Lane OWNER'S NAME�� �i✓`- _ GOWNER ADDRESS Same IFAX TYPE OR OCCUPANCY TYPE COMMERCIAL[] EDUCATIONAL ® RESIDENTIAL❑ PRINT CLEARLY NEW: ❑ RENOVATION: ❑ REPLACEMENT: ® PLANS SUBMITTED: YES❑ NO❑ APPLIANCES 7 FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER (— BOOSTER j �- CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR _ FURNACE GENERATOR _ GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER 771 ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER .OTHER Replace 1 Gas Meter x and Pi ing as Needed INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES Q NO ❑ 1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ OTHER TYPE INDEMNITYE] BOND ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are a 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 c m fiance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUM BER-GASFITTER NAME Joseph Marino LICENSE #8736 I ATURE MP 0 MGF ElJP ❑ JGF ❑ LPGI ❑ CORPORATION [:]#3285C PART RSHIP❑# LLC ❑# COMPANY NAME: RH White Construction Co ADDRESS 141 Central St CITY I Auburn STATE= ZIPI 01501 TEL 1 (508) 832-3295 FAXI 508-926-4347 CELL 508-832-4614 JEMAILI JMarino@RHWhite.com ilk\ F w F z z 0 F U w a d z w a Z F] z o �❑d w } o W o � w d W N a � z a d o a a � U x F a a ui x w f- LL V) W F O z z � � o F w a z � d x x 0 a 1J4/UJ/21J14 14:U4 51 883 31b lbl KH WHl I t GUNS I HUG I HAUL 151/ 02 ® CERTIFICATE OF LIA,BILITI(iNS �1� DATE(MMlDD/YYYYJ U" �^��� Page 7. of 08/29/2013 THIS CERTIFICATE IS ISSUED ASA MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON TH6 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(jos)must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditionsof the policy, certain policies may require an endorsement. A statement on this certii7cate does notconferrights to the certificate holder In lieu of such endorsement(s), willia o£ Massachusetts, Inc. c/o 26 contusy Blvd. E. 0. Box 305191 NRChville, TN 37230-5191 R. X- white Construction Company, Inc. 41 Caner*l Street Y. 0. Box 257 Auburn, MA 01501 u�aurtGnl� Hrivi�uin+IGV VERAGE NAIC rF INSURERA:The Cbartor Oak fire Iaauran09 Company 25615-001 INSURERS:Travalmrs Property Casualty Cotgpany of Am 25674-003 INSURER C:NatiCAA1 Union Ping Insurance Company of 7.9445-001 INSURER 0;Travelere Indamni,ty Company 25658-DOl INSURER F: OVERAGES CERTIFICATE NUMBER:20287680 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN [$SUED TO THE INSURI INDICATED, NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER I CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBE EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. A B C D D DES Y TYPE Or INSURANCE ADDIL SUB POLICY NUMBER GENERALLIA6ILITY EACH OCCURRENCE 2,000,000 VTC20Co 977RD948-13 X COMMERCIAL GENERALLIA111LITY MED EXP (Any oneperson). F 1p� 000 PERSONAL&ADV INJURY $ CLAIMS -MADE OCCUR GENERAL AGGREGATE $ 4,Q00 000 PRODUCTS -COMPIOPAGO L__,4, 000 000 $ GENLAGGREGATE LIMIT APPLIES PER; 2,000,000 POLICY PRO 7LOC BODILY INJURY(Peraccldent) AUTOMOBILE LIABILITY $ VTaC'AP 977K955A-13 ' x ANY AUTO AI,I,OWNED SCHEDULED —P-, 000, 000 $ XQ - TAC�Y LI AUTOS AUTOS HI;1CDAUTOS X NON -OWNED 1,000,000 E.L.DIBEASE-EAEMPI,QYFE $ 1,000,000 X 1,000,000 AUTOS Co Ded X Cgx1 Ded 99 000 7t UMBRELLALIAB X OCCUR EXCESS LIAa CLAIMS -MADE B38766140 X DED j[ RETENTIONS 10,000 WORKERSCOMPENSATION -LIABILITY V�RItTJ}� 62057185-13 t AND EMPLOYERS YY//Nt1 ANYPROPRIETORIPARTNFRIFXECUTIVEn NIA VTC21CUB 8208A71A-13 c OFFICER/MEMBEREXOLUDED7- Myandatmrydt In NH) UEt V K1IIB I IUN u d UPURATIONS below - -------- ��_,.•.�,. ••, ..., .. ••��•. ,....ami, nsv,u, . vm. upl RtllfltllRC dGOQO1,IN, )/1/2013 '9/1/2014 3/1/2013 9/1/2014 /1/2013 9/1/2014 /1/2013 19/1/207,4 /1/2013 9/1/a014 epaco CERTIFICATE HOLDER CANCELLATION Evidence of Inmurance REVISION NUMBER: _D NAMED ABOVE FOR THE POLICY PERIOD )OCUMENT WITH RESPECT TO WHICH THIS HEREIN IS SUBJECT TO ALL THE TERMS, LIMITS EACH OCCURRENCE 2,000,000 pqq TO RENTF,Q PR� I��B(Eeocemencrl „"� - 300,Q00 MED EXP (Any oneperson). F 1p� 000 PERSONAL&ADV INJURY $ 2 0 -. ,000 GENERAL AGGREGATE $ 4,Q00 000 PRODUCTS -COMPIOPAGO L__,4, 000 000 $ OMBI EDNGLEUMIT . ecc�Cent)SI$ 2,000,000 BODILY INJURY(Per person) $ BODILY INJURY(Peraccldent) tFrqur $ $ EACH OCCURRENCE L-5 1 000, 000 AGGREGATE —L —P-, 000, 000 $ XQ - TAC�Y LI E.L. EACH ACCIDENT $ 1,000,000 E.L.DIBEASE-EAEMPI,QYFE $ 1,000,000 El. DISEASE. POLICY LIMIT $ 1,000,000 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORILL!D REPRESENTATIVE Col1:4197604 TI)1:1694012 Ce7:t::20297680 ®1988-2010ACORD CORPORATION, All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD It Date.. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ......... ........ has permission to perform ............................. wiring in the building ofs. �.I—A�.. I -W. ......................................... j�z-_ at ..... I ....... ...................... North Andover, Mas s. Fee:-��..f ... Lic. No. 74 .......... -Jez� . ........... 'i�ECTRICAL INSPECTOR Check 10840 C.oandronraraith a��a33tu:/jft M DI BOARD OF FIRE PREVENTION REGULATIONS OfificialUse Oafy PermitNo. I D S & z cupancy and Fee tamed b*k APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK AU wo* to be pafam ed m ammbmcx with gmM l ?.ode (MSCI 527 Oa MOO (PLEMPMff"EVW OR i7PPEAU INFORIfM0j* Datan 3 / / -c 11.2 0r City or Town of: NO /� �V Q o U e R To the Inspector of Wires: By this application the undersigned gives notice ofhis or heri�tion to perfomztire electrical work demrfta below. Location (Street & Number) / /%L- 0a I Cyd ,U�s Owner or Tenant Sc T T C,,3 ,t, A: A! Telephone No. Owner's Address S IV n ti, is this permit in conjunction with a building permit? Yes ❑ No Q-- (Check A riate Bot)_ Purpose of BuRding_ Q W -.t_ I &I IItr'hf' y Anthu],. aI ion NO. f 7 Existing Service c o Amps 120 Volts Overhead [�" Un — dgrd ❑ No. ofineters % New Service v0 Amps t,6 I2 -t' Volts Overhead 0— Undgrd❑ No. ofMcen Number of Feeders and Ampacity Location and Nature of Proposed Elecbicat Work `S -e k (JI e e Crro C A n rsL No. ofRecessed Luminaires No. of Cell.-SnspL (Paddle) Fanso. --r V erre ffv= No.o ormers HVA No, of Luminaire Outlets No. of Hot Tubs %[VA No.ofLmres SwhmmfmgPool e ❑d. ❑ 01 ANG�ency Ba IInits No. of Receptacle Outlets No. of On Burners FM ALARM No, of hones o. ofSwitches No. of Gas Burners N06 0 I1IMCn OR and N06 ofRanges Na of Air Cond. Total Tons o, of Alerting Devices No. of Waste Disposers P er ons a o mt$m SpacelArea Heating KW etection/Alertin Devices No. of Dishwashers Muni Local connection ❑ Other No. of Dryers Hez a Appliances KW security No. �' Heaters KW o. o o. o Na of ccs or ear Si Ballasts No.. o Devices or Egftalent No. Hydromassage Bathtubs No. ofMators Total lap Na of Devices or emt OTHER: izu"L saaauwaaraeim[ gaesuW4 eras regz&edhyfhehapectaroflfh+ec Estimated Value ofElectdcai Work (Nina required by ummc W policy ) Work to Start: Imspec tions to be requested in accordance with MEC Rule 14, and upon completion. 1 WMMCi: COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof ofliabMW insurance; inetudmg 'completed oPMEtiod" coverage or its substantial equivalent The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing offrce. CHECK ONE. BMIRANCE12 BOND ❑ OTMR ❑ (Specify:) I clY, under&ePaba andpenalfresofPerjwy, &&Ae infonnaffon on ff= appficadan is true mad complete FIItMNAMM-Buddy Electric Inc. UC.NO--12017 A Liam Vincent B. Landers JrSignature LIC .No, �3 84 E MMUcaW enter Wit" m ft kcww nwnber ime.) Ens. TeL No 9'7t=9'75=�"4 5 5 Address-. 24 Colgate_ Dr N.Andover, Ma 01845 Alt Tei.Nr� *Per M_G.i.. 0.147, s. 57-61, seem* work requhw Department ofPublk Safrty "S' License: Lic. No. OWNER'S RW3RANCE WAIVXR-. I am aware that the Licensee does not have tine Habtity incnrance coverage normany requited by law Bymy signature below. I hereby waivethis rent i amthe (check one) ❑ ownw [3owner'sageaL Owner/Agent Siguatare Telephone No. PE MTFEE• $ The Commonwealth of Massachusetts Print Form Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: ';L- L/ Col g 7 C (,1d,:57(_!101 Ire /-I 'C_ C)r C_ City/State/Zip: 5' Phone #: % ;75--�4l �5 Are you an employer? Check the appropriate box: 1. E? I am a employer with 4. ❑ I am a general contractor and I Type of project (required): employees (full and/or part-time).* have hired the sub -contractors 6. F1 New construction 2. ❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub -contractors have g. ❑ Demolition workingfor me in an capacity. Y P tY• employees and have workers' comp. insurance.$ 9. r-1 Building addition [No workers' comp. insurance required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have exercised their 11. ❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12. ❑ Roof repairs insurance required.] t c. 152, § 1(4), and we have no 13. ❑ Other employees. [No workers' comm. insurance reauired.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. fi Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. *Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and 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 workers' compensation insurance for my employees. Below is the policy and job site - information. Insurance Company Name: Policy # or Self -ins. Lic. #: 1) Expiration Date: %/a�� /c2 O/ 3 Job Site Address: Gf Cu/ Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. 1 do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Phone #: 9% P 3;7 6-- O 7)� ->- Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Loc�tion No. — 503 Date ORTH ANDOVER pancy $ mit Fee $ Fee $ Fee $ Water Connection Fee $ TOTAL $ L/ Build'ing I'nspector Div. Public Works PERMIT NO. I l 5d APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS. PAGE 1 110i AP 4-40.LOT NO. 2 RECORD OF OWNERSHIP ;DATE BOOK ;PAGE ZONE I SUB DIV. LOT NO.I 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 ILDIN 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 SEE BOTH SIDES PAGE 1 FILL OUT SECTIONS 1 - 3 PAGE 2 FILL OUT SECTIONS 1 - 12 t 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 PERMIT GRANTE (kze 19 ' ,r%Y - 91905 3 PROPERTY INFORMATION LAND COST EST. BLDG. COST rJ i1 C� EST. BLDG. COST PER SQ. FT. EST. BLDG. COST PER ROOMBLDG. COST PER ROOM SEPTIC PERMIT NO. 4 APPROVED BY OWNERTELJ C.1 CONTR. TEL. # • �" �J CONTR. LIC. # H.I.C. # `� l ,o INSTRUCTIONS SEE BOTH SIDES PAGE 1 FILL OUT SECTIONS 1 - 3 PAGE 2 FILL OUT SECTIONS 1 - 12 t 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 PERMIT GRANTE (kze 19 ' ,r%Y - 91905 3 PROPERTY INFORMATION LAND COST EST. BLDG. COST rJ i1 C� EST. BLDG. COST PER SQ. FT. EST. BLDG. COST PER ROOMBLDG. COST PER ROOM SEPTIC PERMIT NO. 4 APPROVED BY OWNERTELJ C.1 CONTR. TEL. # • �" �J CONTR. LIC. # H.I.C. # `� l ,o BUILDING RECORD 1 OCCUPANCY 12 SINGLE FAMILYSTORIES MULTI. FAMILY �- OFFICES APARTMENTS CONSTRUCTION 2 FOUNDATION S INTERIOR FINISH d 1 2 13 PINE CONCRETE CONCRETE BL'K. BRICK OR STONE P _ PIERS PLASTER DRY WALL _ UNFIN. 3 BASEMENT AREA FULL FIN. B'M'TAREA _ 1/1 1/2 1/1 FIN. ATTIC AREA _ NO BMT FIRE PLACES _ HEAD ROOM MODERN KITCHEN 4 WALLS I 9 FLOORS CLAPBOARDS B 1 2 3 _ _ _ DROP SIDING WOOD SHINGLES CONCRETE EARTH ASPHALT SIDING ASBESTOS SIDING VERT. SIDING _ HARMWD COMMON ASPH. TILE STUCCO ON MASONRY STUCCO ON FRAME 11 BRICK ON MASONRY BRICK ON FRAME ATTIC STRS. & FLOOR _ CONC. OR CINDER ELK. WIRING STONE ON MASONRY STONE ON FRAME SUPERIOR I -I POOR ADEQUATE NONE 10 PLUMBING 5 ROOF GABLE HIP BATH (3 FIX.) _ GAMBREL MANSARD TOILET RM. (2 FIX.) FLAT SHED WATER CLOSET _ ASPHALT SHINGLES LAVATORY WOOD SHINGES KITCHEN SINK SLATE NO PLUMBING _ TAR & GRAVEL STALL SHOWER _ ROLL ROOFING MODERN FIXTURES _ TILE FLOOR TILE DADO 6 FRAMING I 11 HEATING WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. TIMBER BMS. & COLS. STEAM STEEL BMS. & COLS. HOT W'T'R OR VAPOR WOOD RAFTERS _ AIR CONDITIONING _ RADIANT H'T'G UNIT HEATERS 7 NO. OF ROOMS GAS OIL B'M'T 2nd _ 10 13rd ELECTRIC NO HEATING THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA- RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. 4' C r�v o Q w CD CD 0 C2 Z =r. N O d .Or Cl) N =r CL.+ a o' Co H O C CD co _ C2 tC O d O H n Cl) =r = n o CA C2 ca off: .: CO CD CM , m: m O y N = d O. • C H O Q CL N qw: atcoH Hm`- .' O CD C2 � 3 H ,. 'fl O CD CD O H CD 0 to CD '* O CD d: mss: c O eF --F ti n m m C42 4 p tz 'TI CO2 C r`(D� r y� r r'7 0 r S r .'7 .'T' 0 r- �' 10 CD - O Q Z w. CD O �. T ):loco. o p o ; Q o . cr -v CDo CD o C may. D, p C* c CD CO) .Cl CD Z o CD 3 0 c CQ C r�v o Q w CD CD 0 C2 Z =r. N O d .Or Cl) N =r CL.+ a o' Co H O C CD co _ C2 tC O d O H n Cl) =r = n o CA C2 ca off: .: CO CD CM , m: m O y N = d O. • C H O Q CL N qw: atcoH Hm`- .' O CD C2 � 3 H ,. 'fl O CD CD O H CD 0 to CD '* O CD d: mss: c O eF --F ti n m m C42 4 I E z tz 'TI r`(D� r y� r r'7 0 r S r .'7 .'T' 0 r- �' C)COD �. •o Cn 0 rDIt y d I E