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Miscellaneous - 1049 SALEM STREET 4/30/2018
North Andover Board of Assessors Public Access Page 1 of 1 HORTq 'l+�rfh Andover Boar€a! of Assessors 'SSACHU`+�t roperty Record Card Parcel ID :210/104.D-0069-0000.0 FY:2011 Community: North Andover Location: _ !1053 SALEM STREET Owner Name: HOLLERAN, ROBERT S GAIL J HOLLERAN Owner Address: '1049 SALEM STREET City:.NORTH ANDOVER State:. MA Zip 01845 .F Neighborhood: 6 - 6 Land Area: 0.56 acres Use Code: ,1101-SNCL-FAM-RES-1Total Finished Area: j780,sgft Total Value: 242,500 243,500 Building Value:T _ 42,500 42,300 Land Value: ! _ -200,000 201,200 IMarket Land Value: 200,000 Chapter Land Value: 7[- ale Price: 1 'Sale Date: Y46/03/1990 .rms Length Sale A -NO -FAMILY Grantor: HOLLERAN. .ode: _ LAURENCE .ert Doc: a Book: 1-'3171 ~ Page: 763-66 t http://csc-ma.us/PROPAPP/display.do?linkld=1707304&town=NandoverPubAcc 10/21/2011 North Andover Board of Assessors Public Access Page 1 of 1 http://csc-ma.us/PROPAPP/display.do?linkld=1707304&town=NandoverPubAcc 10/4/2011 \ Date ....... f lk ............... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies rtifies that I Z: ................................ has permission for gas ............ in the buildings ..................................................................................... - -5 -,? North at ........ ... !.�4.-.E .. . ....... n. - No Andover, Mass. Fee3t . . ......... Lic. No. 7nY ......... t* ..................................................... GAS INSPECTOR Check # G TYPE OR PRINT CLEARLY MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING CITY I NORTH ANDOVER MA DATE AUG. 28, 2014 PERMIT JOBSITE ADDRESS 1049 SALEM ST. OWNER'S NAME JEFFCO INC. STAN OWNER ADDRESS I JEFFCO INC. STAN TE 978-609-3762 FAX OCCUPANCY TYPE COMMERCIALE] EDUCATIONAL Ej NEW: Ej RENOVATION: ® REPLACEMENT: APPLIANCES Z FLOORS- BSM BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOFTOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER RESIDENTIAL ED PLANS SUBMITTED: YES® NO® �0®®iLl 3 INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES E] NO �_ I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW �n LIABILITY INSURANCE POLICY E] OTHER TYPE INDEMNITY ® BOND El I 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. SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER ® AGENT 1 hereby certify that all of the details and information I have submitted or entered regarding this application are ^, Ie and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will b c6mpliance with all Perlin e visio the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME =JOHN LICENSE # 778 NATURE MP ® MGF ® JP ® JGF [] LPGI 0 CORPORATION ®# PARTNERSHIP ®# LLC ®# COMPANY NAME:j EASTERN PROPANE GAS I ADDRESS 1131 WATER ST. CITY I DANVERS STATE = ZIP 01923 TEL 1 800 322 6628 FAX CELL EMAIL 12e", h, mm1 sVI)II The Coin ni onwealth of Massachusetts Department of Industrial A cciden ts r Office of Investigations I 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: 131 Water St Danvers, MA 01923 Eastern Propane Gas, Inc Phone #: 978-750-6500 Are you an employer? Check the appropriate box: i . Q I am a employer with 45 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors h t d on the attached sheet 2. ❑ 1 am a sole proprietor or partner- ship and have no employees working for me in any capacity. N [o workers' comp. insurance required.) 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t is e These sub -contractors have employees and have workers' comp. insurance -1 We are a corporation and its officers have exercised their right of exemption per MGL c. 152, §1(4), and we have no employees. [No workers' comp. insurance requireu.j Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 1 I.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.0 Other Gas Fitting & Fuel Supply '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. ' -contractors and state whether or not those entities have .Contractors that check this box must attached an additional sheet showing the name of the sub employees. [f the sub -contractors have employees. they must provide their workers' comp. policy number. I ant an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Safehold Special Risk, Inc Insurance Company Name: Policy # or Self -ins. Lic. #: EWGCD000080614 Expiration Date: 03 / 15 / 2015 Job Site Address: I o K Ss (,° w- S j City/State/Zip: l(e.. A Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). 0l8`t s 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 S 1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify, under the pains and penalties of perjury that the information provided above is true and correct. Phone #: 97$756500 official use only. Do not write in this area, to be completed by city or town official. City or.'Town: Issuing Authority (circle one): 1. Board of Health 2. Building Department 6. Other _ Contact Person: Permit/License # 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector Phone #: NH477156 ® CERTIFICATE OF LIABILITY INSURANCE DATE 3/13/2014 Y) 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(ies) 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 Commercial Lines - 800-990-7465 (CA DOI # OG13561) Safehold Special Risk, Inc. 230 Commerce Way, Suite 230 Portsmouth, NH 03801 CONTACT Donna Desharnais NAME: PHONE 603-559 1361 FAx AIC No xt: AIC No. 855 529-7684 E ADDRESS: donna.desharnais@safehold.com INSURER(S) AFFORDING COVERAGE NAIC # INSURER A :HDI-Gerlin America Insurance Company 41343 INSURED Eastern Propane Gas, Inc. P.O. Box 1800 INSURER B: INSURER C MED EXP (Any one person) I s 5,000 INSURER D .INSURER E 1 GENERAL AGGREGATE $ 2000000 Rochester, NH 03866 INSURER F: COVERAGES CERTIFICATE NUMBER: f4419b4 RFVIStIr1N NI IMRFR• Crap hpinw 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. !NSR LTR I TYPE OF INSURANCE AIN DDLISUBR� POLICY NUMBER CY EFF I MM DI.,Y, POL'C EXP IMM DDIYYYY LIMITS A X COMMERCIAL GENERAL LIABILITY h CLAIMS -MADE I X OCCUR 1_1JPREMISES uI I EGGCD000080614 3/15/2014 3/15/2015 I EACH OCCURRENCE I $ zooa000 DAMAGE TO RENTED 250000 (Ea occurrence) I $ MED EXP (Any one person) I s 5,000 PERSONAL & ADV INJURY I $ 2000000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY JET LOC OTHER: 1 GENERAL AGGREGATE $ 2000000 PRODUCTS - COMP/OP AGG S 2000000 j $ A I AUTOMOBILE HINON-OWNED LIABILITY ANY AUTO ALL OWNED I SCHEDULED AUTOS !AUTOS HIRED AUTOS AUTOS EAGCD000092214 13/15!2014 3/15/2015 I COMBINED SINGLE LIMIT (Ea s 2,000,000 accident) !i BODILY INJURY (Per person) S BODILY INJURY Per accident $ I ( ) PROPERTY DAMAGE Per accident I S is I I UMBRELLA LIAB L! EXCESS LAB I OCCUR CLAIMS -MADE I I I EACH OCCURRENCE I $ I AGGREGATE s DED I I RETENTIONS S A AND EMPLOYERS' L ABILIITY ANY PROPRIETOR/PARTNER/EXECUTIVE YIN OFFICER/MEMBER EXCLUDED? �N (Mandatory in NH) If yes describe under ;DESCRIPTION OF OPERATIONS below N I A I EWGCD000080614 103/15/2014 103/15/20151 X I STATUTE 'ERT'_. I E.L. EACH ACCIDENT $ 1,000,000 i E.L. DISEASE - EA EMPLOYEE! $ 1,000,000 1 E.L. DISEASE - POLICY LIMIT I $ 1,000,000 i DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Evidence of coverage I+tIKIIYII:AItMULUtK - rANrFIIATIOKI Any city/town in Massachusetts SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE MA THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. MA AUTHORIZED REPRESENTATIVE I ne AuuKu name and logo are registered marks of ACORD ACORD 25 (2014101) (This cerlifirate replaces cBM1ifiWlek 7441310 issued m 311 312 01 4) U 1988-2014 ACORD CORPORATION. All rights reserved. W , - Date ...... 7 .. Jam.. q ............... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ....... 11.� n .......6 - Y / ...................................................................... has permission for gas. installation ..4 % .. r- -v—, in the buildings of ...................................... at.../ P.IV9 / -(/-Z- ..... . ...... !;�� ............................... Fee .IAQ;!.,. Lic. No. Z Check # 9397 ..................................................................... over, Mass. ............................ ji GAS INSPECTOR 1©6118 a Date !O.. 4. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that.:...!!'11........'.p...................................................:............. .......... has permission to perform .0. //„.... .................... plumbing in the buildings of.............................................................................................. at ... 1��........................................ .}.........., North ndover, Mass. Feed .�: �Lic. No. 42.140/.. ...... ! ............................................... o.. PLUMBINGI SPECTOR Check # +� -` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY �� ���� MA DATEPERMIT# JOBSITEADDRESS�pt NAME GOWNER s�;OWNER'S ADDRESS TE]FAX � TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL D EDUCATIONAL F1RESIDENTIAL rhal CLEARLY NEW:9. RENOVATION: El REPLACEMENT: PLANS SUBMITTED: YES Fil No E-J APPLIANCES 1 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- FIREPLACE FRYOLATOR FURNACE-- -- GENERATOR GRILLE I L INFRARED HEATER LABORATORY COCKS _. !-._ —( 1 I-- MAKEUP AIR MAKEUPAIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOFTOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER I. WATER HEATER - ._ �.-.1 _--1 _ (L _-. .. _ - . �I OTHER - - - TINSURANCE COVERAGE I have a current liability nsurance policy or its substantial equivalent which meets the requirements of MOL. Ch.142 YES �FQ NO Ej I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY M OTHER TYPE INDEMNITY E] BOND 01 OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT [�II SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in complia th all Perti ision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUM BER-GASF ITTER NAME --- ^-- LICENSE # SIGNATUR MP W MGF Ej JP ® JGF Q LPGI © CORPORATION ©# PARTNERSHIP �],I# LLC E]#= COMPANY NAME. ADDRESS CITY pY�_ _ _� STATE ZIPL�� �� v` ]TEL FAX v_ CELL__ EMAIL z z 0 H W a w � r of z O �Fl W >- F- W O w O H a z ft W = � w < co a LLI O > w rr_ w CO z a a a U J H CL IL a x w 1- LL W H °z 0 a x The Commonwealth of Massachusetts - Department ofIndustrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Uf www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers " Name (B, Address: City/Stat Are you an employer? Check the appropriate box: 1.'tq-I am a employer with 4. ❑ I am a general contractor and I Type of project (required): " 6. E] New construction ' employees (full and/or part-time).* 2. El am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. 7. Remodeling ship and'have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance.9• ❑Building addition [No workers' comp. insurance 5. El We are a corporation and its 10. F1 Electrical repairs or additions required.] 3. ❑ I am a homeowner doing all work officers have exercised their right of exemption per MGL 11.[]'Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4), and we have no 12.❑ Roof repairs insurance required.] r employees. [No workers' 13.0 Other comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. -Homeowners who submit this affidavit indicating they a're 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 anal job site information. „ , , f Insurance Company Policy 4 or Self -ins. Lie. 9: Expiration Date: `��lem Job Site Address: l © 2 City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one=year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA. for insurance coverage verification. Y do hereby cert42 under the pains and penalties 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 CIerk 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 ofhire,- express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced -acceptable evidence of compliance with the insurance coverage required" Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit 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 Eno. 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 permithicense applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or' -permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of adustrial .Accidents OfUce of Investigations 600 Wasbington. Street Boston} MA, 02111 Tel, # 617-727,4900 at 406 o> 1-877�,MASS.AF13 Revised 5-26-05 Fax # 617-727-7749 www.mass,gov/dia i! MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY MA DATE '7 .a I PERMIT # JOBSITE ADDRESS Q `PWI OWNER'S NAME e 1 OWNER ADDRESS TEL --FAX TYPE OR OCCUPANCY TYPE COMMERCIAL Q EDUCATIONAL © RESIDENTIALV PRINT CLEARLY NEW: e RENOVATION: REPLACEMENT: Q PLANS SUBMITTED: YES 0 NOM FIXTURES Z FLOOR- BSM 1 2 3 4 5 6 7 8 1 9 10 11 12 13 14 BATHTUB iLEI ____..i =1 I—. I= _ ! ____. _ _ _I I _i CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOILISAND SYSTEM ! _ i _ - I I ( II I __I ( f DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN - _f --__--{ (--___-_f A= _ -_.-__._-) ---...__I ._____.t ___.._._►-..._....� __..__f _-.-.__ { _ G .._._.._` FOOD DISPOSER FLOOR/ AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK LAVATORY ► _1__I ..._ .- _ v f ._- -__.___1 _._.___.I ___._J __.____I ._._._� :__..__i .___.-_1 _. I. I € ROOF DRAIN __f SHOWER STALL (.__._ I rl (_ i 1 a 1 1 � f _. _..__ SERVICE/MOP SINK TOILET f -__ __I -- _,I URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER__._,._.______._�__.._________�� ( _f t .__._._._.! _._ ._1 ! —1 .___---_I __.-.__-_► ...__._._( I ( ! ..... ...... _( _____ (.____f __ ._ ...... _f _..__ _� _-___ _i __-__� I _ . I I I INSURANCE COVERAGE: 1 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 ® OTHER TYPE OF INDEMNITY 0 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 0 AGENT E-1 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 com fiance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME ` l . _ � LICENSE # SIGNATURE iVIP A JP CORPORATION D#©PARTNERSHIP--I # ; LLC COMPANY NAME _ -- ;ADDRESS I I CITY j ]S ATE((I' _� ZIP j TEL O 6 o�R`// l FAX—� CELL �� EMAIL o z y ❑ The Commonwealth o f Massach usetts - Department o, f IndustriglAccidents Office of Investigations 600 Washington Street Boston, MA. 02111 wwlvmass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/Organization/Tndividual): Address: y- LQ W (I ITN\A YAC y� 03 City/State/Zip: -1 11 S 1 Are you an employer? Check the appropriate box: - Typo of project (required): 1. ❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction employees (full and/or part-time).* 2. ❑ I am a sole proprietor or partner - have hired the sub -contractors listed on the attached sheet. � �� E] Remodeling ship and'have no employees working for me in any capacity. These sub -contractors have workers' comp. insurance. 8. ❑Demolition 9, ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions required.] 3. ❑ I am a homeowner doing all work officers have exercised their right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4), and we have no 12.❑ Roofrepairs insurance required.] employees. [No workers' 1311 Other comp. insurance required.] 'Any applicant that checks box#1 must also fill out the section below showing their workers' compensation policy information. Homeowners who submit this affidavit indicating they ire doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workersco Ppensation insurance for my employees. Below is the policy and job site information. (DIV Insurance Company Name: ®p � F( Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: _�>a f t" M _)!7h City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as wellas 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 maybe forwarded to the Office of investigations of the DIA" for insurance coverage verification. X do hereby cern rider the and penalties ofperjury that the information providedd above is true and correc . Si ature Date: r — f o l 0 Official use only. Do not write in this area, to be completed by city or town official. City or Town: PermitUcense # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - Contact Person: Phone Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract ofhire, 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 phonenumber(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. De advised that this affidavit may be submitted to the Department of Industrial Accidents for confnznation 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 he. 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 (ifnecessary) 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 homeowner or citizen is obtaining a license or pernut 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: Tho CoXx►monwDalth of MassarhmIotts Depaftent ofMustr al .Accidents Office ofIavestigatlons 600 Washington. Stxoet Boston} MA 02111 . TQI, # 617-727-4900 oxt 406 oz 1-877_MASSAFE Revised 5-26-05 Fay ,# 617-727-7749 W 101 .0 Date.. TOWN OF NORTH ANDOVER PERMIT FOR WIRING J. This certifies that .. ....... ........................... has permission to perform ........1'' ..,) ..... k.(N-e-� ................................................................. .................................................... wiring in the building of ........ �J-P-... -, at o h Andover Mass ........................ ........................................... .Fee6c�b x ... Lic. No.Z. ..... . .. ... . ........................... ..... ........... ..... . ...... .. ELE*CiiiICAL INSPEC� Check # 12511 Commonwealth of Massachusetts Offii cial Use Only Department of Fire Services Permit No. 1� 1l Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. l/07j (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 INMK OR TYPE ALL INFORMATION) Date: -7 4 — f 4/ .City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) Owner or Tenant Owner's Address Is this permit in conjunction with a building permit? Yes W No LJ (Check p ox) Purpose of Building Utility Authorization No. } % 3 %,3 F 1-/ J - Existing Service Amps / Volts New Service 490Amps %IO/ g0volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Overhead ��Undgrd ndgrd ❑ No. of Meters Overhead ❑ No., of Meters Completion of the following table maybe waived by the Inspector of Wires. No. of Recessed Luminaires No. of Cell: Susp. (Paddle) Fans No, of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ElIn- El rnd. rnd. 0. o mergency Lighting Batte Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: Number Tons KW ......................Detection/Alerting No. of Self -Contained Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KW Heaters 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 97res. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability i rance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such cove e is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) —1i hcertrfy, under thepains anenalties of erju , that the information on his application is true and complete. FIRM N r-: e e 6 LIC. NO.: -2 Licensee: �, t Signature LIC. NO.: 21 q,6 f (If applicable, nter "exe t" in the license number line. o,[ Bus. Tel. No.. 7 , %1j1 Address: 2 � N t70I5rD 2 Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lie. 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. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the Pf permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shall -be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is -to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012. ❑ Rule 8—Permit/Date Closed: ***Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection Pass 0 Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: chn Inspectors Signature: D e: PARTIAL ROUGH INSPECTION: Pass M Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass 0 Failed 0 Re- Inspection Required ($.) ❑ 4 Inspectors C m ents: r o Inspectors Signature: Date: FINAL INS ION: Pass Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: p„ Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com 4� The Commonwealth of Massachusetts Department ofIndustrigl Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Uf www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le0bly Name (Business/Organization/Individual):���CQ �'�� �� if G OAC �� V f C. Address: P�, ld� 2-- City/State/Zip: JehA 0 3 Q _ZF Phone #: ZD it AVyo,,an employer? Check the appropriate box: 1. a employer with �_ 4. ❑ I am_ a general contractor and I employees (full and/or part-time).* have, Wred 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.] 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.❑ Plumbing repairs or additions 12. ❑ Roof repairs 13. ❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. T Homeowners who submit this affidavit indicating they a're doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. ii 5 Insurance Company Name:. Mf f%�h Policy # or Self -ins. Lie. #: Expiration Date: Job Site Address: City/State/Zip: „Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one=year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cert i under the pains and enaldes ofperjury tha. ermation provided above is true and correct. Signature:_-- - - Date:-- - ! 7f — 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 Informati®n and Instructions - Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or. written." An employer'is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who.has not produced -acceptable evidence of compliance with the insurance coverage required" Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit 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 of Massachusetts Department off dustrial Accidents Office of Investigations 604 Washington Street Boston} MA 02111 `1'e1, # 617-727-4900 ext 406 or 1-877:MASS.A.k'B Revised 5-26-05 Fax # 617-727-7749 www-mass.gov/dia L 5 O Date..- .� tl.�......... . of Na RT ,1ti TOWN OF NORTH ANDOVER t PERMIT FOR MECHANICAL INSTALLATION A This certifies that � i ... �cY1?.. =.!'1 I t? fi� `a. has permission for mechanical installation .. .. .............. in the buildings of . , i E' .CC. `- :'......................... at ?''�... �' �' �.°. ..... • , North Andover, Mass. Fee. :Zf 'j' f. Lic. No.:�T�l.... 4.... .............. •1 .. GASINSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer A Commonwealth of Massachusetts Sheet Metal Permit Date: estimated Job Cost: $ ���0 Plans Submitted: YES NO; Business License Permit #� Permit Fee; $ �U Plans Reviewed: YES NO Applicant License # �� 3 Business Information: Property Owner / Job Vocation Information: Name: ��4��� S os 0 �%r�I;KS hKa �"`5' Name: Street: S -S S W Street:5� I 1 City/Town: i.i s 5kr�, CIty/Town: Telephone;_���S> SM r9- 03 Telephone: i Photo 1,D, required / Copy of Photo I.D; attached: YES NO Staff Cn)tlnl (: 7 7 / IVY -Y -unrestricted license J-2 / M -2 -restricted to dwellings 3 -stories or less and commercial up to 10,000 sq. ft. / 2 -stories or less Residential: 1-2 family V-'— Multi -family Condo /Townhouses Other Commercial: Office Retail Industrlal educational Institutional Other Square Footage: under 10;000 sq, ft, over 10,000s q. -ft. Number of Stories: 3 Sheet metal work to be completed: New Work: Renovation: HVAC Metal Watershed'Roofing _ Kitchen Exhaust System .Metal Chimney /Vents Air Balancing Provide detailed description of work to be done: �j. s i�•11 �M, cyJ R r w� 'OLY' o-cR Alt -r ��� j� — �"� °Y �(C.v V a -S. arm ,tX t' wv�(� V�°�'�`4 ca( COVERAGE: I have a current liability insurance policy or its equivalent which meets the requirements of M.G.L. Ch. 112 Yes g?'No ❑ If you have checked Yes, indicate the type of coverage by checking the appropriate box below: A liability insurance policy H� Other type of indemnity ❑ Bond ❑ 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 boxM(I'hereby certify that all of the details and information 1 have submitted (or entered) regarding this application are true and accurate to the best of my knowledge and that all 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 Date Duct inspection required prior to insulation installation: YES NO Progress Inspections Comments Final Inspection Comments Type of License: By ❑ Master Tide ❑ Master -Restricted CitylTown Joumeyperson Permit# Signature of Licensee ❑Joumeyperson-Restricted Fee $ License Number: 323 Check at www.mass.00vldol Inspector Signature of Permit Approval rf� t `.a '• 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): 1` l 11 i S a c �1 I J �j /� ro h Address: S S S U 0 V(V�, st , City/State/Zip: I -e w ks, v, MA 0 1 -8-) (0 Phone #: 9 I y L-( U 3 Are you an employer? Check the ap 1. �m aa employer with ty ropriate box: 4• EJI am a general contractor and I Type of project (required): employees (full and/or part-time).* have hired the sub -contractors 6. ❑ New construction 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub -contractors have g. ❑ Demolition working for me in any capacity. employees and have workers' 9. Buildingaddition ❑ [No workers' comp. insurance comp. insurance.$ required.] 5. ❑ We are a corporation and its 10.❑ 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 12.0 Roof repairs insurance required.] t c. 152, §1(4), and we have no 13. ❑ Other h V A L employees. [No workers' comp. insurance reauired.l *Any applicant that checks box 91 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 contractor; must submit a new affidavit indicating such. lContractors 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. 7 am an employer�Trng workers' cor"irpensation insurance for riry employees.-�eZow3s �iepolicy and job she- ------------- - -- information. Insurance Company Name: N -e-& SS Policy # or Self -ins. Lic. #. W 0 0 1 13 10 U Expiration Date: lD 3 021 Job Site Address: I Ch i Side -v-, S h City/State/Zip: A� � ���� /�) A Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify !n #r the pains and penalties of perjury that the information provided above is true and correct. TT5MI-LiiO3 Official use only. Do not write in this area, to be completed by city or town offuiaL City or Town: Permit/License # Issuing Authority (circle one): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person• Phone #: Client#:53676 1.111_LISFRAN2 D1'YY,ACOR®M CERTIFICATE OF LIABILITY INSURANCE 7/01/20.3 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 AF17013DED BY 1.1 -IE 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 tiro terms and conditions of the policy, certaln policies may require an onclorsernent. A statomont on this certificate loos not confer rights to the certificate holder in liou of Such ondorsement(s). PRODUCER CONTACT HUB International New England PHONE - - - 299 BallardVale St !+lc, r»II_ �7f3 G57-5100 -- j..h�, N�1: (JG6_ /t15-7959 E-MAIL nee.cie tlflCateS hLII)Illterllational.corn Wilrnington,MA 01887 APAR�Ss.. - -... _...� _ -... __..._..... .. 97(3 65%_5.100_..___....._.—_INSUI2ER(SIAfFORi)INOCOVERAGE NAICII -- -- - INSIIRERA; Inde ondence CaSUaltY 1115 CO _ ...- .... _._ . INSURED - Hillis Corp iNsuRERB: DBA Frank's Heating Service iNsuaeRc; 555 Woburn St INsuaeao: Tewksbury, MA 01876 INSURER E: INSURER F: � COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: FI -IIS IS TO CI:=R'rIFY THAT THE POLICIES OF, INSURANCE LISTED BELOW HAVE nEEN ISSUI=D TO DIE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENTWITI I RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED I-IEREIN IS SUBJECT TO ALL THE TERMS, h:XCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR - - _.... ... ... _ .. --- .. .. ....... . L'I 12 TYPE OF INSURANCE AODI SUB POLICY EFF POLICY EXP . .. .. .......__INSR.WVR POLICYNUMBCR ,..(MM1UDfYYYYI (MMI(111JYYYY) LIMITS, GENERAL LIABILITY I'AC:II000UnRENCE $ COMMERCIAL GENFRAL LIABILITY _.. .... . ... . ................... _...._.. -... _- DAMA('F'[0 RENTL"D _C'l3LM1�E?l o4ru(rlJpceL.. $ .I CLAIMSMADE I _ -- I OCCUR MED EXP IAB ann )arson) S (TENT- AGGRECA11; LIMIT APPLIES PER: PULICYI I PRO LOC I LOC JECT AUTOMOBILE LIADIIfrY ANY AUTO AI.L OWNEN SCHEOULFD AlJf06 AUTOS IJOWOWNLD PIII'il"D AUTOS rnr. UMBRELLA LIAR I OCCUR EXCESS LIAB CLAIMS -MADE DED 12ETENTION S A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIE-_TOR/PARTNER/EXECUI'IVP Y I N OFrlCER/MFMBFR EXCLUDC )?N I A (Mandatory In NH) --N- If yes, describe under .,.- .. .IJCSRIPI:ION Of: OPFRATIONS below WC 1001.13'100bril PEIt50NAl_ K ADV IN.1l1RY $ (I, :NE -RAI_ AGGREGA IIS E AGGREGATE $ b 6/30/2013 06/30/201 IIWr.sTAlu- 01 --.1.I:DRYIIMLI:&.�.__ �Lft... ----- ( �.-tn01ncr..nxrlr $600 000 E.L. DISEASE EA EMPLOYEE $600 000 E.I_. DISEASE - POI ICY LIMIT $50Or000 �.._..__. _ ...... ... ...... .. .... ._ ... .... ... .... ...._. DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Altach ACORD 101, Additional Remarks Schedule, If more space Is req(ilred) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE .POLICY PROVISIONS. AUTHORIZED REPRESENTA'IIVE © 1988-2010 ACORD CORPORATION. All rights reservecl. ACORD 25 (2010/05) 1 of 1 The ACORD namo and logo are registorocl (narks of ACORD #S951290/M94921 £I DK004 PRODUCTS - COMPIOPAGG E - $ COMDINFD SINGLE LIMIT f -a ar:culeilt UUOILY INJURY (Per person) $ fjooll.Y INJURY (Per accident 5 PROPERTY DAMAOF $ Woufl cWyng S I:ACIIOCCIIRRI;N(:I? $ AGGREGATE $ b 6/30/2013 06/30/201 IIWr.sTAlu- 01 --.1.I:DRYIIMLI:&.�.__ �Lft... ----- ( �.-tn01ncr..nxrlr $600 000 E.L. DISEASE EA EMPLOYEE $600 000 E.I_. DISEASE - POI ICY LIMIT $50Or000 �.._..__. _ ...... ... ...... .. .... ._ ... .... ... .... ...._. DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Altach ACORD 101, Additional Remarks Schedule, If more space Is req(ilred) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE .POLICY PROVISIONS. AUTHORIZED REPRESENTA'IIVE © 1988-2010 ACORD CORPORATION. All rights reservecl. ACORD 25 (2010/05) 1 of 1 The ACORD namo and logo are registorocl (narks of ACORD #S951290/M94921 £I DK004 �O/7 CJ �-=- CERTIFICATE OF LIABILITY INSURANCE DATE (MMrCCMYY) I OW7/2013 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 pollcy(lea) 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 endorsernentfs), PRODUCER FEDERATED MUTUAL INSURANCE COMPANY HOME OFFICE: P.O. BOX 328 OWATONNA, MN 55060 rnN AY , CENTER A�"jt[�T C — � k. Ems 888-333-4949 507-446-4664 i • CLIENTCONTACTCENTERftFEOINS 0 INSUREfRIS)AFFORDIgaLDYMALE NAIC 1 INSURER A: FEDERATED MUTUAL INSURANCE COMPANY 13935 INSURED HILLIS CORP 360-541.7 555 WOBURN ST TEWKSBURY, MA 01876 INSURER B; 06/30/2014 INSURER C: _ $1,000,000 INSURER D: $100,000 INSURER E: PERSONAL d ADV INJURY INSURER F: GENERAL AGGREGATE l UVGRHUCO CEFiIIFICATE NUMBER: 0 REVISION NUMBER: 0 IHI5 IS r0 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. PRI TYPE OF INSURANCE ADR S R POLICY NUMBER MId/ODY EFF YI POLI Y XP LIMITS GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE � OCCUR A GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY P LOC N N 9385795 06/30/2013 06/30/2014 EACH OCCURRENCE _ $1,000,000 �03MMtS XQAENTCD E 1l Flpcuffi00fl)_ MED EXP (Any one person) $100,000 PERSONAL d ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 PRODUCTS • COMPIOP AGG $2,000,000 AUTOMOBILE LIABILITY X ANY AUTO ALL A AUTOS OWNED AUTOSULED HIRED AUTOS NON -OWNED AUTOS N N 9385794 06/30/2013 06/30/2014 MBINED SINGLE LIMIT $1,000,000 BODILY INJURY (Pe(parson) BODILY INJURY (Per errldenl) PROPER -Y DAMAGE IL X UMBRELLA LIAB A EXCESS LIAR X OCCUR CLAIMS -MADE N N 9385796 06/30/2013 06/30/2014 EACH OCCURRENCE $3,000,000 AGGREGATE $3,000,000 DED RETENTION WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETORIPARTNERIEXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A I7LIM�Ts 0H - 0 TOR1 R E.L. EACH ACCIDENT E.L. DISEASE - EA EMPLOYEE E.L DISEASE -POLICY LIMIT DESCRIPTION OF OPERATIONS / LOCATIONS /VEHICLES (Allach ACORD 101, Addillonal Remarks Schedule, II mora space Is required) CA 00 SHOULD ANY OF TI4E ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, AUTHORIZED REPRESENTATIVE ©1088.2010 ACORD CORPORATION, All rights reserved, ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD Sheet Metal Residential Guidelines / Inspection Checklist Yes No N/A V� Detailed description and sketch of sheet metal system to be installed has been provided / y All workers performing sheet metal work onsite has valid Massachusetts sheet metal license All sheet metal work being performed with proper journeyperson-to- apprentice ratios y Equipment sized per heating / cooling load calculations Duct work sized per manual "D" calculations Bath / shower rooms contain mechanical exhaust fan vented outdoors Electric dryer exhaust properly installed maximum total run 35'-0" maximum flexible run 8'-0" Flexible duct runs installed 14'-0" maximum length Volume dampers installed for each supply air branch duct Ductwork installed using proper gauges and hangers Ductwork / plenum connections sealed substantially airtight Ductwork insulated by means of external covering or internal lining New/clean - properly sized filter installed (final inspection) — Testing and Balancing report complete (final sign -off) UNWEALTH OF M ASSACHtiApTyc Load Short Form Awllx�1w 8 ':�; -.�:� first HEATING SERVICE Franks Heating Service 555 Woburn St, Tewksbury, MA 01876 Phone: 978-851-4403 Fax: 978-851-0398 For: Jeffco 1049 salem st north andover ma, Andover, MA 1 Htg Clg Outside db (°F) 1 88 Method Inside db (°F) 70 75 Construction quality Design TD (°F) 69 13 Fireplaces Daily range - M Inside humidity (%) 30 50 Moisture difference (gr/Ib) 28 28 HEATING EQUIPMENT Make Carrier Trade CARRIER Model 59S P 5A060E 17-14 AH R I ref 4744731 Efficiency Heating input Heating output Temperature rise Actual air flow Air flow factor Static pressure Space thermostat 96.5 AFUE Area 60000 Btuh 58000 Btuh 54 OF 973 cfm 0.039 cfm/Btuh 0.50 in H2O Job: Date: May 14, 2012 By: Michael Hillis Infiltration Simplified Tight 1 (Tight) COOLING EQUIPMENT Make Carrier Trade BASE 16 PURON AC Cond 24ABC630A"`30 Coil CNPV*3117A"+59'P5A060E17"`14 AHRI ref 4744731 Efficiency 13.0 EER, 16 SEER Sensible cooling Latent cooling Total cooling Actual air flow Air flow factor Static pressure Load sensible heat ratio 23360 Btuh 5840 Btuh 29200 Btuh 973 cfm 0.049 cfm/Btuh 0.50 in H2O 0.96 ROOM NAME Area Htg load Clg load Htg AVF Clg AVF (ft2) (Btuh) (Btuh) (cfm) (cfm) liv 196 2993 2606 117 129 lav 68 1407 844 55 42 kit 254 2070 2148 81 106 break 198 2474 2448 97 121 foy 180 2309 2322 91 115 din 195 2216 2620 87 129 fam 589 11327 6733 445 332 first d 1680 24796 19722 973 973 Other equip loads 0 0 Equip. @ 1.00 RSM 19722 Latent cooling 1 909 -AI n A/nen I nA7ALI nrA074 n77 n7'] Calculations approved byACCA to meet all requirements of Manual J 8th Ed. i htsoft® 2014 -Jun -1015:57:14 wr 9 Right -Suite® Universal 2013 13.0.13 RSU10062 Page 4 ACCK ...edyefrco - 1049 salem st north andover ma.rup Calc = MJ8 Front Door faces: N :,-, Load Short Form ` 2nd attic floors HEATING SERVICE Franks Heating Service 555 Woburn St, Tewksbury, MA 01876 Phone: 978-851-4403 Fax:978-851-0398 For: Jeffco 1049 salem st north andover ma, Andover, MA Job: Date: May 14, 2012 By: Michael Hillis HEATING EQUIPMENT Make Carrier Trade CARRIER Htg Clg Infiltration Outside db (°F) 1 88 Method Simplified Inside db (°F) 70 75 Construction quality Tight Design TD (°F) 69 13 Fireplaces 1 (Tight) Daily range - M Inside humidity (%) 30 50 Moisture difference (gr/Ib) 28 28 HEATING EQUIPMENT Make Carrier Trade CARRIER Model 59SP5A040E14-10 AH R I ref 4744693 Efficiency Heating input Heating output Temperature rise Actual air flow Air flow factor Static pressure Space thermostat 96.5 AFUE Btuh 40000 Btuh 39000 Btuh 44 OF 800 cfm 0.039 cfm/Btuh 0.50 in H2O COOLING EQUIPMENT Make Carrier Trade BASE 16 PURON AC Cond 24ABC624A**30 Coil CNPH*3117A**+59*P5A040E14**10 AH R I ref 4744693 Efficiency 12.5 EER, 15.2 SEER Sensible cooling Latent cooling Total cooling Actual air flow Air flow factor Static pressure Load sensible heat ratio 19200 Btuh 4800 Btuh 24000 Btuh 800 cfm 0.045 cfm/Btuh 0.50 in H2O 0.91 183 ROOM NAME Area (ftz) Htg load (Btuh) Clg load (Btuh) Htg AVF (cfm) ClgAVF (cfm) attic 685 7284 4600 286 207 bed1 183 2839 2969 111 134 bed2 161 2476 2131 97 96 atrium 227 1751 2944 69 132 bath 72 899 839 35 38 m bath 92 943 843 37 38 wic 60 1134 189 45 9 3272 120 147 mas Calculations approved byACCA to meet all requirements of Manual J 8th Ed. 2014 -Jun -10 15:57:14 wrightSO W Right -Suite® Universal 201313.0.13 RSU10062 Page 2 ACCP, ...ectyetfoo - 1049 salem st north andover ma.rup Calc = MJ8 Front Door faces: N It 2nd attic floors d 1756 20374 17788 800 800 Other equip loads 0 0 Equip. @ 1.00 RSM 17788 Latent cooling 1751 'M-rAIC 4ACOn onn onn v1/ "1 I/JV GVJI`f IAJJ.7 VVV VVV Calculations approved byACCA to meet all requirements of Manual J 8th Ed. wrightsoft® Right-Sufte® Universal 201313.0.13 RSU10062 ACCA ...ectyeffoo -1049 salem st north andover ma.rup Calc = MJ8 Front Door faces: N 2014 -Jun -10 15:57:14 Page 3 •yr-M HEATING SERVICE Load Short Form Entire House Franks Heating Service 555 Woburn St, Tewksbury, MA 01876 Phone: 978-851-4403 Fax: 978-851-0398 For: Jeffco 1049 Salem st north andover ma, Andover, MA Job: Date: May 14, 2012 By: Michael Hillis HEATING EQUIPMENT Make n/a Trade n/a Htg Clg Infiltration Outside db (°F) 1 88 Method Simplified Inside db (°F) 70 75 Construction quality Tight Design TD (°F) 69 13 Fireplaces 1 (Tight) Daily range - M Inside humidity (%) 30 50 Moisture difference (gr/Ib) 28 28 HEATING EQUIPMENT Make n/a Trade n/a Model n/a AHRI ref. n/a Efficiency n/a Htg load Heating input 0 Btuh Heating output 0 Btuh Temperature rise 0 OF Actual air flow 0 cfm Air flow factor 0 cfm/Btuh Static pressure 0 in H2O Space thermostat n/a 973 COOLING EQUIPMENT Make n/a Trade n/a Cond n/a Coil n/a AHRI ref. n/a Efficiency n/a Htg load Sensible cooling 0 Btuh Latent cooling 0 Btuh Total cooling 0 Btuh Actual air flow 0 cfm Air flow factor 0 cfm/Btuh Static pressure 0 in H2O Load sensible heat ratio 0 973 ROOM NAME Area Htg load Clg load Htg AVF Clg AVF (ft2) (Btuh) (Btuh) (cfm) (cfm) 2nd attic floors d 1756 20374 17788 800 800 first d 1680 24796 19722 973 973 Entire House d 3436 45170 37322 1773 1773 Other equip loads 0 0 Equip. @ 1.00 RSM 37322 Latent cooling 2660 TnTAI C linnon 1 n I I I D 1110 Calculations approved byACCA to meet all requirements of Manual J 8th Ed. ,^wri htsoft� 2014 -Jun -1015:57:14 9 Right -Suite® Universal 201313.0.13 RSU10062 Page 1 ACCK ...edeffco -1049 salem st north andover ma.rup Calc = MJ8 Front Door faces: N i t el co C �t = X 00_ 00 fr �I n � / 3 !I � v s 0 � su .0 x O � cn 0 rn O CD W co co o � C N�ca, \ ' (D P � OCC'N d V (D 00 C V O N (� N O O p 6 N C I. 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