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HomeMy WebLinkAboutMiscellaneous - 100 LISA LANE 4/30/2018 (2)i3 s�Y�- Date .. ..-Z..'..�?............ TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ...............t...�. j: �`�:.......... C...±-'.�.�.�....�..:......................:... has permission to perform ...... ......IVOR ...................................... wiring. in the building of..........s� L. t!CE ............... a ..... �::�©\`%........ ... �`^c:.... ,, North Andover, Mass. Fee... .... .--Lic. No...l.ar_1�� ........:...: 1 <f.......:. Check#' 122®2 -� Commonwealth of Massachusetts i Department of Fire Services a BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. 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 (MEC), 527 CMR 12.00 (PLEASE PRINT W INK OR TYPE ALL INFORMATION) Date: ? ef, z 40f/ City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of s orher Otention to perform the electrical wor described below. Location (Street & Number)01 'f�/� Z/J.�' Owner or Tenant Telephone No. 2Z, •- Owner's Address Is this permit in conjunction with a building permit? Yes ff No H (Check Appropriate Box) Purpose of Building I Utility Authorization No. %K S7 1 - Existing Service Amps / Volts New Service 2-P0 Amps / / ZOO Volts i J Number of Feeders and Ampacity Overhead ❑ Overhead ❑ Undgrd ❑ Undgrd n No. of Meters No. of Meters I Location and Nature of Proposed Electrical Work: Completion ofthe following table may be waived by the Inspector of Wires. No. of Recessed LuminairesF �Q il f No. oCe.-usp. (ae) ans (Paddle) S .. No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs ® Generators KVA No. of Luminaires 4/Swimming Pool Above ❑ In ❑ rnd. grnd. o. o Emergency Lighting Battery Units No. of Receptacle Outlets lQ6' No. of Oil Burners 0 FIRE ALARMS No, of Zones No. of Switches �X No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges �j .QS No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: Number """ Tons "'' ' ""' KW ' '""'"' No. of Self -Contained �s- Detection/AlertingDevices No. of Dishwashers S ace/Area Heating KW p g Local ❑ Municipal El Other Connection No. of Dryers Heating Appliances KW SecNr to. o Devic s or Equivalent No. of Water Heaters 64S KW No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent --] OTHER: Attach additional detail if desired, or as required by the Inspector of Wfres. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: 14e ZF?Ol 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 cove ge is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE [BOND ❑ OTHER ❑ (Specify:) I certify, under the pains andpenalties of perjury, that the information on this application is true and complete. FIRMNAME: ��0 /r//cC�"�"il//��' �y/�T _ LIC. NO. ��'�✓� Licensee:y//�i,Qf�� Signature -� `�� LIC. NO.: (If applicable, eyt r "exempt" in the license n i ber line.) L Bus. Tel. No.: / / ��� Address: it' `�i� r`9 Alt. Tel. No.:,S7�"Sl %'/6 *Per M.G.L c. 147, s. 57-61, security work requires Department ofTublic 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. R'7V 4 Z �) :3 153 ❑ 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. 0. Rule 8—Permit/Date Closed: *** Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Ins n Pass ' Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: `� lr<�', .. z L� Date: SERVICE INSPECTION: Pass M Failed Re- Inspection Required ($.) ❑ Inspectors Comment : r Inspectors Signature: PARTIAL ROUGH INSPECTION: Date: Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH ECTION: Pass Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: v �E j ,,? Date: 3 - .2 6 —1 FINAL INS ION: Pass Iva _ Failed 0 Re- Inspection Required ($.) ❑ Inspectors Commen Inspectors Signature: Date: ` DEB WEINHOLD ... TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual):lC Address: City/State/Zip:G���l-u7Z Phone #: &77) ��✓�J �� � Are y an employer? Check the appropriate box: 1. I am a employer with 3 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 o project (required): 6. El New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions I L ❑ Plumbing repairs or additions 12.0 Roof repairs 13.❑ Other !Any applicant that checks box#1 must also fill out the section below showing their workers' compensation policy information. Y -Homeowners who submit this affidavit indicating they are doing all work and then.hire outside contractors must submit anew affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. X am an employer that is providing woPkers' compensation insurance for my employees. Below is the policy and job site information. _ , , Insurance Company Policy # or Self -ins. Lic. #: 06--- 51 Expiration Date: / �/ Job Site Address: City/State/Zip: 1 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 DIP, for insurance coverage verification. X do hereby cert& under the pains and penalties ofperjury that the information provided above is true and corre�cctt. Signature: G/ ;� Date: 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 #: 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 may be submitted to the Department of Industrial i 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 bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth ofMassachusetts Department of Zndustdat .Accidents Office. of Investigatitans 6.00 Washington Street Boston, MA 021 It TOL # 617-727-4900 oxt.406 or I-877:MA.SSAFE Revised 5-26-05 Fax # 617-727-7749 www-mass,govldia J Date.... ................ TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that .......... ................................... .............. . .......... ............. has permission for gas,\installation .... ............. : ....... in the bulldl7s of 3. Zeke le C 9 9*1.tx ; ......................... ....................................... !�A . . .......... ; ........... at ...... /6.-0 ............. ............................................................... ,North Andover, Mass. Fee ... Z6... .... Lic. No. .6?�Z .......... GAS INSPECTOR Check #'7J -7. 9 9706 /650 , g.lq /'A/ 12411 L/ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY N. Andover MA DATE 11/2412014 PERMIT# l�(p ,. JOBSITE ADDRESS 100 Lisa Ln OWNER'S NAME Szekele Construction OWNER ADDRESS PO Box 27 Andover ITEL F 9784233193 FAX 1 0 OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL x❑ 'I''r PE O P'M7T NEW: xx RENOVATION: REPLACEMENT: PLANS SUBMITTED: YESE] NOQ ClXARLY APPLIANCES FLOORS —► BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIRE PLACE FRYOLATER FURNACE GENERATOR GRILL KIT INFRARED HEATER LABORATORY COCK MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER_ 1000UG LP TANK W/ PIPING X INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES 0 NO F1 IF YOU HAVE CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [fl OTHER TYPE INDEMNITY n BOND 0 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 F] 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 compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chatper 142 of the General Laws PLUMBER-GASFITTER NAME I Timothy Surdam LICENSE #FGF5103-J SIGNATURE MP ❑ MGF ❑ JP[] JGF LPGI[] CORPORATION X]# 164 PARTNERSHIP []# OLLC []# COMPANY NAME: Lorden Oil Co Inc j ADDRESS:j 69 Fitchburg Rd, PO Box 669 CITY: F Ayer STATE: MA ZIP 1432 TEL: 978-772-2000 FAX: 978-772-5956 CELL: EMAIL: /650 , g.lq /'A/ 12411 L/ �6ov 056-oiJ Nov 24 2014 12:26PM LORDEN 19787725956 P.1 C�D ®CERTIFICATE OF LIABILITY INSURANCE s�a2�2o�°°i W' 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(lies) 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 Braley &Wellington Insurance Agency 44 Park Avenue P . O. BOX 15127 Worcester MA 01615-0127 ARCONCT E Diane DeCaria PHONE (508)754-7255 FAx (508)797-3507 No ADoPE4111l ddecaria0braleywells ton rou .com INSURERS I AFFORDING COVERAGE NAIC A INSURERA:The North River Insurance Co 21105 INSURED Lorden Oil Company, Inc. P. 0. Box 669 Ayer MA 01.432. NSURERB :Travelers Indemnity Co. 94SURERC; INSURER 0: NSURERE: 1 NSURERF: 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. INSR1 LIR TYPE OF INSURANCE ADDL SUER POLICY NUMBER POLICY EFF POLICY EXP LIMITS dENERALUABILITY AUTNORREDREPRESENTATNE N. Andover, MA 01845 Diane DeCaria/DIANE EACH OCCURRENCE E 1, DDD, 000 DA MEI E e $ 100,000 X COMMERCIAL GENERAL LIABILITY MED EXP (Any one rsan) $ 51000 A CLAIMS -MADE FX OCCUR 503-773568-1 9/1/2014 9/1/2015 PERSONAL BADVINJURY $ 11000,000 GENERAL AGGREGATE S 2,000,000 GEN'. AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMPIOP AGG $ 2,000,000 $ POLICY JFCTPRO X LOC AUTOMOBILE LIABILITY COMBINED SINGLE 1,000,000 BODILY INJURY (Per person) $ A ANY AUTO ALL OWNED g SCHEDULED AUTOS AUTOS NON-01A'NED X HIRED AUTOS X AUTOS 33-735202-1 9/1/2014 9/1/2015 BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ P Underinsured motorist BI split $ 10D 000 I X Pollution X MC39O X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 51000,000 AGGREGATE $ 5, 00 D, 000 A X EXCESSLL48 CLAIMSMAOE 23-800415-8 9/1/2014 9/1/2015 DEPLX I RETENTION $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y I N ANY PROPRIETORIPARTNER1EXECUTNE� OFFICERMEMBEREXCLUDED? (Mandatory In NH) NIA XUB4956PS46-13 12/4/2013 12/4/2014 OTH- x OR IMITS PR E.L EACH ACCIDENT $ 3-000,000 E.LDSEASE- EAEMPLO $ 1,000,000 E.L DISEASE - POLICY LIMIT $ 1. 000 0 00 If yes describe under DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEMMLES (Attach ACORD 101, Additional Remarks Schedule, K mora space Is required) ACORD 25 (ZU10105) e+ lwv-.V .Y r. ......�..... .. ---- teJGn7S.'IAInnc% M T%— -1.— of AnnOn SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town Of North Andover 120 Main Street AUTNORREDREPRESENTATNE N. Andover, MA 01845 Diane DeCaria/DIANE ACORD 25 (ZU10105) e+ lwv-.V .Y r. ......�..... .. ---- teJGn7S.'IAInnc% M T%— -1.— of AnnOn Nov 24 2014 12:26PM LORDEN 19787725956 p.2 0 10453 This certifies that ..... V14. ........... Datea� (P.�Ii ... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ,has permission to perform ............. ......................... .. ....A P V I N ."A.............. V .......... ....... at ...... Torth Andover, Mass. plumbing in the buildings of ............ Fee.LD: Lic. NO' :hb ...................... ....... PLUMBING INSPECTOR Check # 0 P TYPE OR PRINT CLEARLY MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY!. MA DATE�P ZlJ/�PERMIT #61 JOBSITE ADDRESS i% a 0 .w r ...... WNER'SNAMEjs'Zkj OWNER ADDRESS I w Q TELL FAX 6 OCCUPANCY TYPE COMMERCIAL - EDUCATIONAL RESIDENTIAL NEW: (�� RENOVATION i REPLACEMENT: I PLANS SUBMITTED: YES ;w R N INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY r n OTHER TYPE OF INDEMNITY—BOND OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chaptar 14'L of !i;e Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER U 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 true and accurate Wthe best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in com nce t II inent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME_ LICENSE # GNATURE RPORATION#' % PARTNERSHIP#' LLC €,. M #? COMPANY NAME �j �h' Z ' ADDRESS CITYC STATE 7�� ZIP FAXC ELL EMAIL ' X12-�'k C4k, IL 1 Im P TYPE OR PRINT CLEARLY MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY Q � M MA DATE --m' ...?... PERMIT # JOBSITE ADDRESS NO � _ ,pyOWNER'S NAMEi4W , OWNER ADDRESS TEL FAX �.___..� nv��n OCCUPANCY TYPE COMMERCIAL ,:,A--' EDUCATIONAL RESIDENTIAL-;-- i� NEW: [3' RENOVATION: D REPLACEMENT: D PLANS SUBMITTED: YES j NO 11FIXTURES Z FLOOR— I BSM 11 12 I 3 I 4 I 5 I 6 I 7 I 8 I 9 1 10 I 11 I 12 I 13 I 14 CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR / AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER i INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES Z.­,NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW 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 1?2 of tiee 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 true and accurate tqthe best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in com nceqGWTURE inent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME..» �� LICENSE # MPr�JP CORPORATION 5jr�7 PARTNERSHIP#LLCr # COMPANY NAME 1.�f' l'� y. . �h'�� ADDRESS E. _. .. ....,.... m.... CITY, ,llJ/L/y// ��d/ir STATE' �%� ZIP (®� TEL i FAX / �0✓l,x PCELL EMAIL v�-e J � -1 ' 41 This certifies that PS..QV.� I P ..................*........-.t...I has permission for gas�stallation�� ....... ........ . .. ................ I ..... .................................. buildin in the gs of .............. :;�e ...... at ......:##.+ ..... Ael ................. ............... North Andover, Mass. Fee ... Lic. No.".................. ......... ................. ............ TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION Check #� b� S !) 9164 V\& �23 1 113 GAS INSPECMR Q_ eJ�' 3 � I tty"�'C' I r'% MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY MA DATE/Y%%Z/�' �WPERMIT# - JOBSITE ADDRESS 0� ..,. ,.__. :._._.. _. ' OWNER'S NAME GiOWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL, PRINT _ _mJ CLEARLY ./ NEW:'j RENOVATION: _A REPLACEMENT:..,...i PLANS SUBMITTED: YES .,,; NO I APPLIANCES Z FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER �mw.av COOK STOVE _ DIRECT VENT HEATER wi ..._ DRYER i IJJI __j FIREPLACE _ _' ? _ :.__ .. ..._..,. __.....? _._.,_ .,.,__ _? _ _ ? .... ... _..._ ..:•' .. FRYOLATOR FURNACE ` I GENERATOR i ,,, GRILLE s J, INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN i _. I i _. _ t �.I ._... POOL HEATER I ROOM/ SPACE HEATER i ROOF TOP UNIT TEST I i ., ...•_' ._ ------ UNIT HEATER UNVENTED ROOM HEATER ...... .... WATER HEATER ( [ ! J OTHER i r j 1 ............. g p INSURANCE COVERAGE have liability insurance a current policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES%= NO , 'I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY _,_ BOND J,._..( CIATIER'S'NSURANCE tMAIVER: ! am. !.ha! 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 ,,.,.j 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 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 complia with all P rt' t provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBE/R GASFITTER NAME / � �� ! LICENSE # � I NATURE MP ✓ MGF ,J JP I JGF LPG] CORPORATION PARTNERSHIP PARTNERSHIP LLC ,,, ..,_.i# _ _J# COMPANY NAME:T //77#t/C _j ADDRESS CITY xo&/! //vG"/y STATE l'�%r ...,I zip m�"� TEL ..., r.,.._... .._�....__, ._,_ __...... FAX%�CELL�7O%9EMAIL1 Q_ eJ�' 3 � I tty"�'C' I r'% 12 i 41 The Commonwealth of Massachusetts Department ofIndustrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/Organization/individual):. Address: 'g66��C City/State/Zip: 6d /G 1j,71*6 T" D1 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. ❑ 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. —1W101,kers' comp. insurance. [No workers' comp. insurance 5. U✓' 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.] 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. ®1 umbing 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. T Homeowners who submit this affidavit indicating they ace 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 their workers' comp. policy information. lam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. Policy # or Self -ins. Lie. #: Expiration Date: Job Site Address: Ciiy/State/Zip: . Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certo u r the pans andpfnaldes ofperjury, that the information provided above is true and correct. 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 #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, - express or implied, oral or. written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced -acceptable evidence of compliance with the insurance coverage required" Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) 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. Anew affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth ofMassachusetls Department of lndustrial Accidents Office oflavestigations 600 Washington Street Boston, MSA, 02111 Tel, # 617-727_4900 ext 406 or 1.-877-MASSAFE Revised 5-26-05 Fax # 617-727-7749 ww w-mass,govaa PJRAF-1 OP ID: RC ,4# o� CERTIFICATE OF LIABILITY INSURANCE 71TE(MMIDDIY 1 /13/20133 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 Main Street America Group - NEP New England Region Ke Box H 0 Keene, NH 03431 CONTANAME: C Appleby & Wyman Ins Svc Ctr HONE g66 253 0293 alc No ; 866-332776 A1C No Ext ADDRESS: ServiceCenter@MSAGroup.com MPS66323 Appleby & Wyman Ins Agency INSURER(S) AFFORDING COVERAGE NAIC p INSURERA:Main Street America Assurance 29939 _. �.^.., INSURED c:Pd RTaffi=Plumbing- Heating-" Inc. 8 Bridge Ln INSURER13: NGM Insurance Company 14788 INSURER C:AM Best Rating „A„ GENERAL AGGREGATE $ 2,000,000 Wilmington, MA 01887 INSURER D: INSURER E : B INSURER F: LIAaILITY ANY AUTO ALL OWNED SCHEDULED AUTOSrx AUTOS HIRED AUTOS NON -OWNED AUTOS 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 MAYHAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCEAIJULISUbil INSR WVD POLICY NUMBER POLICY EFF MM/DD/YYY POLICY XP MMIDDIYYYY LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE � OCCUR MPS66323 05/12/2013 05/12/2014 EACH OCCURRENCE $ 1,000,000 o R 500 000 PREMISESDAMAGE Ea occurrence $ , MED EXP (Any one person) $ 10,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRO - JECT LOC X1 POLICY JECT PRODUCTS- COMP/OP AGG $ 2,000,000 $ B AUTOMOBILE X LIAaILITY ANY AUTO ALL OWNED SCHEDULED AUTOSrx AUTOS HIRED AUTOS NON -OWNED AUTOS M1 S66323 05/12/2013 05/12/2014 COMBINED SINGLE LIMIT 1,000,000 Ea accident $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ PER ACCIDENT B X UMBRELLA LIAB EXCESSLIAB X OCCUR CLAIMS -MADE CUS66323 05/12/2013 05/12/2014 EACH OCCURRENCE $ 2,000,000 AGGREGATE $ 2,000,000 DED I X I RETENTION $ 10000 $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y /❑N OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes. describe under DESCRIPTION OF OPERATIONS below N / A WCS66323 05/12/2013 05/12/2014 X WCSTATU- OTH- LIMITSER E.L. EACH ACCIDENT $ 500,000 E.L. DISEASE- EA EMPLOYEE $ 500,000 E.L. DISEASE- POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS / LOCATIONS 1 VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) 978.688.9542 CERTIFICATE HOLDER CANCELLATION ACORD 25 (2010/05) O 1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town Of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Building Dept 1600 Osgood Street North Andover, MA 01845 AUTHORIZED REPRESENTATIVE 1*_P\ n'^� ciow ACORD 25 (2010/05) O 1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD - TS:,._ OF MASSACHUSETTS .. .................. s ,s"s i"Mi 11BE I RS AND GA F ;REGISTERED �jITTE AS A PLUMBING 'CORP ISSUES THE ABOVE LICENSE To, PAI J `RAFFI -'-RAFFI PLB & 'HTG'IN 8 B ". � - G LN M 9r8 -j WILM G T 0 NMA 01887—' 7 L5 i2 05/oi/14 168472 1 MA it LICENSE 99898 NH MASTER LICENSE #2479 OIL TECH. LICENSE 9027959 P. J. RAFF1 . PLUMBING & HEATING9 INC. Ill CC of MA 8 Bridge Lane Wilmington, MA 01887 (978) 657-7710 CID -..NWEALTH OF MASSAChus . ttTs PLUM ER N -GAS' LICENSEDAS_A_JOu FITTER S RAIEYM AN:PL.UmI3tRi d ISSUES THE E ABOVE CICENSE TO "PAUL"i RAFFI: 8BRIDGE LN WILMINGTON , ' M '1934'7 - TS:,._ OF MASSACHUSETTS .. .................. s ,s"s i"Mi 11BE I RS AND GA F ;REGISTERED �jITTE AS A PLUMBING 'CORP ISSUES THE ABOVE LICENSE To, PAI J `RAFFI -'-RAFFI PLB & 'HTG'IN 8 B ". � - G LN M 9r8 -j WILM G T 0 NMA 01887—' 7 L5 i2 05/oi/14 168472 1 MA it LICENSE 99898 NH MASTER LICENSE #2479 OIL TECH. LICENSE 9027959 60 -A --L4"'- 232 L4 ;2-ILk Date... %.7.,7 ...... . TOWN OF NORTH ANDOVER PERMIT FOR MECHANICAL INSTALLATION This certifies tha(.t^.�. 4�� .j !`i.— ............. ...... . has permission for mechanical installation4 4 v . r, in the buildings of Q1<e !...lam �`� ? tti �? rY..... • • • . at ...�.t?(?. !F. .`> . I s,,,/. ? j sA Nom' North AAndover, Mass. Fee, .J . Lic. Nok..i.�.... .... '.... 114—�i*/ )� LZ GAS INSPECTOR Y V\! WHITE: Applicant CANARY: Building Dept. PINK: Treasurer i ' Callahan A/C & HEATING SERVICES i 91 Belmont Street i No. Andover, MA 01845 978-689-9233 Installation & Service • Furnaces / Boilers / HW Heaters • Central Air / Ductless Systems . Air Cleaners / Humidifiers • Metal Fabrication / Gas Piping • Planned Maintenance Programs • Plumbing / Plumbing Service • 24 hour Emergency Service License #: MP -15212, PC -3532, MS -564 Your Comfort is our Business Kevin McDonald sales@callahanac.com Fax: 978-689-7550 Commonwealth of Massachusetts Date: P — �4 %/ Estimated Job Cost: $ ,006 Plans Submitted: YES NO Business License #9 Sheet Metal Permit Permit # � 3 CR Permit Fee: $ 0�z J Plans Reviewed: YES NO Applicant License # 0404 Business Information: I Property Owner / Job Location Information: Name:C4 { tf,141 . (4uS Name: �Ze-Kej 1 A Street: �j ��. Street: C) v City/Town: city/Town:r Telephone:C �7g'q)8:) 2;233 Telephone: Photo I.D. required / Copy of Photo I.D. attached: YES —Cz' NO Staff Initial J-1 M-1- nrestricted license J-2 / M -2 -restricted to dwellings 3 -stories or less and commercial up to 1.0,000 sq. ft. / 2 -stories or less Residential: 1-2 family ✓ Multi -family Condo / Townhouses Other Commercial: Office Retail Industrial Educational Institutional Other Square Footage: under 10,000 sq. ft. _jZover 10,000 sq. ft. Number of Stories: ` Sheet metal work to be completed: New Work: i/ Renovation: HVAC —L�Metal Watershed Roofing Kitchen Exhaust System Metal Chimney / Vents Air Balancing Provide detailed description of work to be done: -.Y1 err✓ INSURANCE COVERAGE: I have a current liabilitv insurance policy or its equivalent which meets the requirements of M.G.L. Ch. 112 Yes No ❑ If you have checked Yes, indicate the ty a of coverage by checking the appropriate box below: A liability insurance policy Othera of indemnity El Bond F]typ tY OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 112 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 Owner's Agent By checking this box❑, 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 sheet metal work and installations performed under the permit issued for this application will be in compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws. Date Duct inspection required prior to insulation installation: YES NO Progress Inspections Comments Final Inspection Date Comments By_ Title y - Title Cityrrown Permit # Fee $ Inspector Signature of Permit Approval ❑ Master , ❑ Master -Restricted ❑Journeyperson Signature of Licensee ❑Journeyperson-Restricted License Number: 10?Y01� ❑ Check at www.mass.gov/dpl OP ID: PS '4C --"N "- CERTIFICATE OF LIABILITY INSURANCE D I TYPE OF INSURANCE GENERAL UABIL.ITY X COMMERCIAL GENERAL LIABILITY CLAIMS4IADE a OCCUR CONTRACTUAL LIAB 11101/DDlYY`(Y) uo1f2o13 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 North Andover Insurance Agency Phone: 878-686-2266 M.J. Foster Insurance Services Fax: 978-686-6410 163 Main St. North Andover, MA 01845 Stephen Sullivan CONTACT PHONE FAX AIc No): &P - ADDRESS: CUSTOMER ID o, PRODUCER CALLA -1 INSURERS AFFORDING COVERAGE MAIC s INSURED Callahan A C and Heating Services, Inc. Callahan Air Conditioning and INSURER A: PEERLESS INSURANCE COMPANY INSURERe:GUARD INSURANCE COMPANY Heating, Inc. INSURER C: INSURER D: 91 Belmont Street North Andover, MA 01845 INSURER E: INSURER F: COVERAGES CERTIFICATF Nl1MRFR: D=%1101nu ul I1mr!) n 1\L•IVIVI\ 111VIrl1 Ln. 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. tNSRADDLISUB LTR A I TYPE OF INSURANCE GENERAL UABIL.ITY X COMMERCIAL GENERAL LIABILITY CLAIMS4IADE a OCCUR CONTRACTUAL LIAB POLICY NUMBER CEP4016154 PCUCY EFF AM/D 09/25/2013 POLICY EXP MMMO 09/25/2014 LIMITS EACH OCCURRENCE I S 1,000,00 _ PREMISEacaxrarU s 100,00 MED EJP (An .,Dram) $ 5,00 PERSONAL & ADV INJURY S 1,000,00 GENERAL AGGREGATE S 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY X PRO LOC PRODUCTS - COMPIOP AGG S 2,000,00 g A AUTOMOBILE UABIUTY ANY AUTO BA4544035 0912512013 09/25/2014 COMBINED SINGLE LIMIT $ 1,000,00 (Ea accident) BODILY INJURY (Per person) S NX ALL OWNED AUTOS BODILY INJURY (Por accident) I S X SCHEDULED AUTOS HIRED AUTOS PROPERTY DAMAGE (Fefacsidant) s X NON -OWNED AUTOS S A � X UMBRELLA UAE X OCCUR EXCESS UAB CLAIMS -MADE CU8809334 09/2512013 I 09/2512014 �a EACH OCCURRENCES 5,000,00 AGGREGATE s S,000,OO DEDUCTIBLE � I s — RETENTION S I 8 WORKERS COMPENSATION AND EMPLOYERS' LIABILITY IN OFER Y PROTIEMBER EXCLUDED EO�� Y�N tM"I "a—ry�lUH� DESCRIPTION OF OPERATIONS below N / A i FWC4�1731 09/2512013 09123/2014 S WC STATU- OTH- X E,L EACH ACCIDENT S 500,00 E.L. DISEASE - EA EMPLOYEE $ 500,00 E.L DISEASE - POLICY LIMIT , $ 500,00 I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Ad(ltlonal Remarks Schodulo, If more space h required) t'Mn-rICIn Ar111-1 --.. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN TOWN OF NORTH ANDOVER ACCORDANCE WITH THE POLICY PROVISIONS. fax # 978 688-9542 BLDG. INSPECTOR AUTHORIZED REPRESENTATIVE 1600 OSGOOD STREET NORTH ANDOVER MA 01845 ©1988.2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD Page 1 Residential Heat Loss and Heat Gain Calculation 2/25/2014 In accordance with ACCA Manual J Report Prepared By: Callahan A/C & Heating For: Szekley Construction (1st Floor) 100 Lisa Lane North Andover, MA 01845 Design Conditions: Lawrence Indoor: Outdoor: Summer temperature: 70 Summer temperature: 87 Winter temperature: 70 Winter temperature: 0 Relative humidity: 50 Summer grains of moisture: 95 Daily temperature range:Medium Building Component Sensible Latent Total Total Gain Gain Heat Gain Heat Loss (BTUH) (BTUH) (BTUH) (BTUH) Infiltration 2,746 3,994 6,740 13,241 Ceilings 5,976 0 5,976 10,817 Windows 10,264 0 10,264 10,404 Floors 1,138 0 1,138 6,392 Duct 0 0 0 5,102 Walls 1,284 0 1,284 4,366 Fireplaces 0 0 0 3,606 Glassdoors 1,546 0 1,546 1,790 Doors 119 0 119 403 Skylights 0 0 0 0 Misc 1,200 0 1,200 0 People 1,500 1,150 2,650 0 Whole House 25,773 5,144 30,917 56,121 (2.5tons ) HVAC -Calc Residential 4.0 by HVAC Computer Systems Ltd. 888 736-1101 Load calculations are estimates only, actual loads may vary due to weather and construction differences. Page 1 Residential Heat Loss and Heat Gain Calculation 2/25/2014 HVAC -Calc Residential 4.0 by HVAC Computer Systems Ltd. 888 736-1101 Load calculations are estimates only, actual loads may vary due to weather and construction differences. In accordance with ACCA Manual J Report Prepared By: Callahan A/C & Heating For: Szekley Construction (2nd Floor) 100 Lisa Lane North Andover, MA 01845 Design Conditions: Lawrence Indoor: Outdoor: Summer temperature: 70 Summer temperature: 87 Winter temperature: 70 Winter temperature: 0 Relative humidity: 50 Summer grains of moisture: 95 Daily temperature range:Medium Building Component Sensible Latent Total Total Gain Gain Heat Gain Heat Loss (BTUH) (BTUH) (BTUH) (BTUH) Infiltration 3,082 4,483 7,565 15,184 Windows 13,606 0 13,606 12,985 Walls 2,599 0 2,599 8,834 Ceilings 4,157 0 4,157 7,098 Duct 0 0 0 4,410 Skylights 0 0 0 0 Glassdoors 0 0 0 0 Doors 0 0 0 0 Misc 0 0 0 0 Fireplaces 0 0 0 0 People 1,500 1,150 2,650 0 Floors 0 0 0 0 Whole House 24,944 5,633 30,577 48,511 2.5 tons HVAC -Calc Residential 4.0 by HVAC Computer Systems Ltd. 888 736-1101 Load calculations are estimates only, actual loads may vary due to weather and construction differences. Callahan A/C & HEATING SERVICES 91 Belmont Street North Andover, MA 01845 www.callahanac.com 978-689-9233 TO: Szekely Construction, Inc. P.O. Box 27 Andover, MA 01810 PROPOSAL PROPOSAL #: 107967 DATE: 1/23/2014 REP: KJM JOB LOCATION: 100 LISA LANE NORTH ANDOVER, MA 0 DESCRIPTION Total INSTALLATION OF NEW HEATING AND AIR CONDITIONING SYSTEM (GAS PIPING AND ELECTRICAL NOT INCLUDED) CONSISTING OF THE FOLLOWING:(FIRST FLOOR) A_CARRIER MODEL # 59SC5A080S17--10 GAS FIRED 95% HOT AIR FURNACE 80,000 BTU B_CARRIER MODEL # 24ABB33OA003 13 SEER 30,000 BTU CONDENSER (R410A) C_CARRIER MODEL # CNPVP3014ACA COIL D_ALL NECESSARY REFRIGERATION PIPING E_ELECTRICAL BY OTHERS F_GAS PIPING BY OTHERS G_PVC FLUE AND COMBUSTION AIR PIPING THROUGH SILL PLATE TO OUTSIDE H_30 x 30 CONDENSER PAD [PRECAST] I_CONDENSATE PUMP AND PIPING J_INSULATED AND SEALED DUCTWORK WITH FLEXIBLE BRANCH LINES TO REGISTER K_CENTRAL RETURN REGISTER FOR FIRST FLOOR L_APRIL AIR HEATING AND COOLING MODEL #8463 DIGITAL THERMOSTAT M SUPPLY REGISTER FOR EACH ROOM INSTALLATION OF NEW HEATING AND AIR CONDITIONING SYSTEM CONSISTING OF THE FOLLOWING:(SECOND FLOOR) A_CARRIER MODEL # 59SC5A060S 14--10 GAS FIRED 95% HOT AIR FURNACE 60,000 BTU B_CARRIER MODEL # 24ABB33OA003 13 SEER 30,000 BTU CONDENSER (R410A) C_CARRIER MODEL # CNPHP3014ACA COIL D_INSULATED AND SEALED DUCTWORK WITH FLEXIBLE TAKEOFFS E ELECTRICAL BY OTHERS INCLUDING LOW VOLTAGE WIRING PAYMENT TERMS SEE PAYMENT SCHEDULE Total All material is guaranteed to be as specified. All work to be completed in a workmanlike manner according to standard practices. Any alteration or deviation from above specifications involving extra costs will be executed only upon written orders, and will become an extra charge over and above the estimate. All covered by Workman's Compensation Insurance's. Equipment warranty by manufacturer. Contractors labor warranty for one year. AUTHORIZED SIGNATURE: DATE: CUSTOMER ACCEPTANCE: DATE: ** A signed copy of this proposal and deposit must be received for us to schedule this installation. (This proposal may be withdrawn by us if not accepted within 30 days.) Authorized dlaire' Partner in Comfort -3 Page 1 ' Callahan A/C & HEATING SERVICES 91 Belmont Street North Andover, MA 01845 www.callahanac.com 978-689-9233 TO: Szekely Construction, Inc. P.O. Box 27 Andover, MA 01810 PROPOSAL PROPOSAL #: 107967 DATE: 1/23/2014 REP: KJM JOB LOCATION: 100 LISA LANE NORTH ANDOVER, MA 0 DESCRIPTION Total F_NEW APRIL AIR DIGITAL HEAT/ COOL MODEL # 8463 THERMOSTAT G_SUPPLY REGISTER FOR EACH ROOM H_CENTRAL RETURN REGISTER I_PVC FLUE THROUGH ROOF J_GAS PIPING BY OTHERS K_SHEETMETAL PERMIT L_REQUlRED DRAIN M ALL NECESSARY REFRIGERATION PIPING PAYMENT SCHEDULE: _ FIRST PAYMENT DUE UPON COMPLETION OF THE ROUGH 10,000.00 BALANCE DUE UPON COMPLETION 9,000.00 PAYMENT TERMS SEE PAYMENT SCHEDULE Total $19,000.00 All material is guaranteed to be as specified. All work to be completed in a workmanlike manner according to standard practices. Any alteration or deviation from above specifications involving extra costs will be executed only upon written orders, and will become an extra charge over and above the estimate. All covered by Workman's Compensation Insurance's. Equipment warranty by manufacturer. Contractors labor warranty for one year. AUTHORIZED SIGNATURE: DATE: CUSTOMER ACCEPTANCE: DATE: ** A signed copy of this proposal and deposit must be received for us to schedule this installation. (This proposal may be withdrawn by us if not accepted within 30 days.) Authorized AD111aire, Partner in Comfort Page 2