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Miscellaneous - 1055 Salem Street (2)
`� �1 v� �� 'i L 1 1 `/ � r'/ 2� Date.. ...................................... NORTh TOWN OF NORTH ANDOVER 9 PERMIT FOR WIRING $SACMus�s This certifies h ��2� sc est at ................................................. ......................................................................... has permission to perform .. -. wiring in the building of........:a:{'..- ... C...f....................... . low � � �4 - �t .................................................................. ................................ ..North Andover, S. FeA§!!T.....Lic.No2. g. .' "........... ....:. . ... ... ............ E CIRICAL INSPECT Check# 12104 1 Commonwealth of Massachusetts Official Use Only Permit No Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev-1/071 (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(NEC),527 CMR 12.00 (PLEASE PRINT ININK OR TYPE ALL.INFORMATION) Date: 1-011- 121 City or Town of:'NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notic of his or r intention to perform the electrical work described below. Location(Street&Number) Q ; pt Owner or Tenant '�7L Telephone No. 3 Owner's Address e) ® X I Z Is this permit in conjunction with a building permit? Yes No ❑ (Chec Appropriate Box . Purpose of Building Utility Authorization - Existing Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters j New Service Amps 12 /Z QVolts Overhead Undgrd ❑ No.of Meters Number of Feeders and Ampacity / 2.2— I Location and Nature of Proposed Electrical Work: fjU/ h�(, -1 Q Completion of the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA _ No.of Luminaires Swimming Pool Above ❑ In- ❑ No.of Emergency Lighting rnd. grnd. Battery 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 InitiatinLy Devices Total No.of Ranges No.of Air Cond. Tons No.of Alerting Devices HeatPum NumbTons KW No.of No. of Waste Disposers P ..... . .. .....er................................................... N Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No,of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or E uivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. /41 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:) — Xcertify,under the ains d penalt'es of erVry,th t the infoznz�ztion on this application is true and complete. FIRM N l°� r v� G L° jJ LIC.NO.: 2-1 Licensee: no Signature� LIC.No.:,?—/ (If applicable,wter "exe t"in the license number line) Bus.Tel.No::�7R-_U79—i/I Address: f Z si • ® Z Alt.Tel.No. *Per M.G.L c.'147,s.57-61,security work requires Departinenf, f Public Safety"S' License: Lic.No. � OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent. Owner/Agent kPERMIT FEE:$ i 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 permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed v 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 M Failed '❑ Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass IN X11 Failed Re-Inspection Required($.)❑ Inspectors Comment Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass 0 Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: r Pass M Failed Re-Inspection Required($.) ❑ Inspectors Com nts Inspectors Signature: Date: FINAL INSPECTION: Pass M Failed Re-Inspection Required($.) ❑ Inspectors Comme 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.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly dividual): Name(Business/Organization/In � G( l e 1�1i��/ �a ��'V/ G S Address: 0 6 do 1 D 7 City/State/Zip:�U�� (l J� o 36 Z `�' Phone#: J 75 Are y an employer?Check the appropriate box: Type 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).* have hired the sub-contractors 2.El am a sole proprietor or partner- listed,on the attached sheet. F1 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. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.[JRoof repairs insurance required.]t employees.[No workers' 13.[:1 Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. i Homeowners who submit this affidavit indicating they aie doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that checkthis 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: &erckam, "5 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. Ido hereby ce/rti under the pains and penalties of perjury that the information provided above is true and correct Signature: / Date: Phone# Official use only. Do not write in this area,to be completed by city or town official. 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-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 burn leaves etc.)said person is NOT required to complete this affidavit. L 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 CQUIMonwealthofMassachusetts Department of Industrial Accidents Qfftee of Investigations 600 Washington Street Boston,MA,02111 - Tel,#617-7274 e t - -- 9QQ .�.4Q6 0r 1-877:MASSA.FB _ Revised 5-26-05 Fax#617-727-7749 www-masS,govldla COMMONWEALTH OF MASSACHUSETTS: • `..� r o o • o o BOARD OF ISSUES THE FOLLOWING <LICENSE AS::A ® REGISTERED MASTER ELECTRICIAN r ((( f4f <r rZ �j_ ROBERT F CHANDLER 5 A AVE M" ; iH o3o79-z5o4 21465: A 07/314-.Lb- 53, 70 I A ' Date../-pz/` ...................... 10324 NORTH TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING sACHU This certifies that......... (Ile le— ............ ./............................................................ �A...............) has permission to perform.......2......e..,j...... 7---, d. plumbing in the buildings of .......T.P........ ........... ......................................................... at...... ff....... ...In.... .................................... North Andover, Mass. Fee.....�....Lic. No.l�?.7 ...... ..."0................................................................... PLUMBING INSPECTOR Check#A W -7jb " - MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK O. CITY _ C' MA DATE , RMIT# t JOBSITE ADDRESS D OWNER'S NAME P OWNER ADDRESS TEL[__ FAX TYPE OR OCCUPANCY TYPE COMMERCIAL Q EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: RENOVATION:P REPLACEMENT:© PLANS SUBMITTED: YES® NO© FIXTURES 7. FLOOR--' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 � BATHTUB _k= —( __ ==== —1 _ __f "_.__#NJ CROSS CONNECTION DEVICEDEDICATED SPECIAL WASTE SYSTEMDEDICATED GAS/OIL/SAND SYSTEM . DEDICATED GREASE SYSTEM _I E _( — DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN 311--1 _--J ..._._--__I FOOD DISPOSER i .--_ F f f i I i 4 I _—J -1 ..-_.-._I ......_._I 1 FLOOR/AREADRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK —I _I _ _f ___... .J _.___( .__-__! _.___1 .._._J ______( __._-.-,___.I .____j LAVATORY I _ -_—( _I ROOF DRAIN SHOWER STALL SERVICE I MOP SINK TOILET URINALm 1 ! _....._ __-- 1 _____1 ___..___I _.._.._ ._--._.._. __.__._ .-__._! WASHING MACHINE CONNECTION _I _ f 1 f .__._.._.4 � 1 _l I I I ......._€ .-... _1 .____j WATER HEATER ALL TYPES _ f WATER PIPING _ I -j -1=== OTHER _ I I I I - ---- I —I INSURANCE COVERAGE: 1 have a current liabilityinsurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES R NO _l IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Zg OTHER TYPE OF INDEMNITY D1 BOND DJ 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 n AGENT SIGNATURE OF OWNER OR AGENT QJ 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 ith all Pertine provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME _ P LICENSE# . z _ �SIGNATU E MPl�fl JP Q CORPORATION nJ# PARTNERSHIP®# _ LLC COMPANY NAME DDRESS I ---� r� CITY _ dlSe--- -- - -�STA E _. ZIP ®3�f' fll TEL FAX _ j CELL F— 11 EMAIL _ _ - -� ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES t" 1 ` Y,� CbMMONWEALTH 4 MASSAGHUSET_TS -x PLUMBERS AND GASFITTERS `-�' j LICENSED ASIA-MASTER PLUMBER s = ISSUES}THE`AB6VE;L<IGENSE TO r M TJIMDTHY C- CpYLE •, 4—C RWN HILL\ ROAD ` °> ATKINSON u�afNH03811 2273 x _ ,1`2741 05/01/14 167389 >' Date... OF . 0 TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION HU This certifies that ....A� .......... ................................................... J has permission for gas installation ............................ ....................... in the buildings oft..........:\,.T.- o ............................................................ at..... ......... North Andover, Mass. FeeM....... Lic. No.PV........ j�....................................................... GASINSPECTOR Check# 16 4 9042 lo r- A6 11011AII-3 •` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT R T TO PERFORM GAS FITTING WORK f Pl � `��C�- CITY �C'� _ MA DATE - PERMIT# G JOBSITE ADDRESS ,_1Lly _ _ =q11„ OWNER'S NAME . OWNER ADDRESS = 11 TEC -- -HFAXE-. TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW:R1 RENOVATION:0 REPLACEMENT:0 PLANS SUBMITTED: YES 0 NOE] APPLIANCES'l 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 INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT �� _ �— OVEN _ POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER I, UNVENTED ROOM HEATER WATER HEATER OTHER _ nil - INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YESV NO [� IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY no OTHER TYPE INDEMNITY 0 BOND F OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER Q AGENT Ell 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 com nce w all P inent provi ' of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUM BER-GASFITTER NAME _ LICENSE# IG RE - - - - MPU MGF 0 JP ® JGF D LPGI[ACORPORATION 0# PARTNERSHIP 0#=LLCA. 0# COMPANY NAME: ' Q ADDRESS VOA CITY STATE MZIP b TELA _ •f FAX CELL (QO _ _ �EMAIL ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INS PEC71ON NOTES Yes No ae S THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES .a The Commonwealth of Massachusetts Department of IndustrialAcci6hts 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): ` cy (� Address: ;YM (2 City/State/Zip: ��� (�( A# fl � Phone#: l T C� Are you an employer?Check the appropriate box: Type of project(required): 1. I am a employer with4. El am a E]general contractor and I 6. New construction employees(full and/or p���ime).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet.1 7• ❑Remodeling ship and'have no employees These sub-contractors have 8. [❑Demolition working for me in any capacity. workers' comp.insurance. g E]Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.El Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11. lumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12. Roof repairs . insurance required.] employees.[No workers' ' comp.insurance required.] 13.❑Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they Lire 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. — 4 E I I Insurance Company Name:. Policy#or Self-ins.L/ic.#: Expiration Date: Job Site Address: [jA �'l City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one=year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby certo under the pain nd penalties ofperjury that the information provided above is true and correct. Si ature Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - - Contact 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 employeiis 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 may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)"A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or'-permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Gommonw.ealth of A4-assachvsetts, Department of Industrial.Accidents Office of Investigations 600 Washington Street Boston}MA,02111 Tel.#61`x-727-4900 ext 406 or 1-877:MASSAFB Revised 5-26-05 Fax#€17-727.7749 WWW.Mass,govfdia q Date........ ........ OF NOR 7H,� °, TOWN OF NORTH ANDOVER . PERMIT FOR GAS INSTALLATION HU thiscertifies that .............................. .................................................... has permission for gas installation ...Y�r�. c,, ,- a� •.€.F.J......... in the buildings of..........................................(_............................................. ......:.. ............................................... at..... � ... ?,F,o,w..... ............................. North Andover, Mass. Fee, ..�.... Lic. No. .r ��� .:. ....... ..................................................................... GASINSPECTOR Check#- 9119 c 3o.Vo CIQ "( L S'3 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY I NORTH ANDOVER MA DATE I FEB.12 2014 PERMIT# JOBSITE ADDRESS 1055 SALEM ST. OWNER'S NAME EJEFFCO.INC. GOWNER ADDRESS JEFFCO.INC. ITE 978-609-3762STAN FAX TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL® RESIDENTIAL PRINT CLEARLY NEW: RENOVATION:® REPLACEMENT:® PLANS SUBMITTED: YES[] NO APPLIANCES Z FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER j 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 ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER I CONNECT TO A PLUMBERS 1 INSPECTED GAS LINE USING THE GAS FO C _ T INSURANCE COVERAGE j I have a current liability insurance 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 [D OTHER TYPE INDEMNITY ® BOND OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ® AGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this applicatqbe i nce wih all PMassachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME JOHN MARSHALL LICENSE# SIGNATURE MP® MGF® JP® JGF® LPGI CORPORATION®# HIP®# LLC®# COMPANY NAME: EASTERN PROPANE GAS ADDRESS 131 WATER ST. CITY DANVERS STATE MA ZIP 01923 TEL 1-800-322-6628 FAX CELL EMAIL V-1 d OIL )A, ,\ ��.�� The Commonwealth of Massachusetts . Department of Industrial Accidents 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): EASTERN PROPANE&OIL Address: 131 WATER STREET City/State/Zip: .DANVERS, MA 01.923 Phone #: 978-750-6500 Are you an employer? Check the appropriate box: Type of project(required): 1.❑✓ 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 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 workingfor me in an capacity. employees and have workers' Y p h'• 9. ❑ Building addition [No workers' comp. insurance comp. insurance.T required.]. 5. ❑ We area corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I LF] Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.]t c. 152, §1(4), and we have no GAS FITTING employees. [No workers' 13.R/1 Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. =Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: ENERGI Policy#or Self-ins.Lic.#: EWGCD000080613 Expiration Date: 03/15/2014 Job Site Address: 105 5 S% I Pte-. S4 City/State/Zip: O)oiJA Av Jc�,z✓ � Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).010%V 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 under the pains andpenalties ofperjury that the inform i n provided above is true and correct. Signature - — - - -- _ - _. 'Date*_. Phone#: 978-750-6500 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#: I I Ii i i ; i I , 00wllln�.)I'M F A L-f I I o mSSII(''II II IS F, r�i�l����:�►�o �„r� ��si►���t��yiett�� erny����. Wry `: ! i A1\111 laA Gl-i rr I I SUG AS AN 1J' GAS I1\1 VAI-1-FiR � it ISSLIES TI IF ABOVE I..IGFI'ISF I`L); 1CIIIII 11ARIIAI_I_ �1 j7 lilll ART STREF1 oI 11AhIVERS H 1, �� ! f � !f'� 77EI I1571�1 /1�L L[16113Q ( . i y ;yEyyy �wy r �;yWy , JI , �I F + II NH477156 y I® DATE(MM/DD/-) Ac�Ro CERTIFICATE OF LIABILITY INSURANCE 3/14/2013 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 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). . — --- -- — eNTAe _ PRODUCER ..'._.".. .- —_ Onna e5l�amal5 NAME: _ Commercial Lines—(800)99077465 -PHONEEt, 603-559-1361 No 855,529-7684 Wells Fargo Special Risks,Inc. ADDRIL don na.desharnais@wellsfargo.com 230.Commerce Way,Sulte.230 INSURER(S)-AFFORDING COVERAGE NAIC HDI-Gerlih America.lnsurance Company � Portsmouth, NH 03801 ` iNsuReliA: 9 41343 INSURED INSURER B Eastern Propane Gas, Inc. INSURER C .. 28 industrial Way INSURER D: . - . .. INSURER E .. ... : .. Rochester,NH 03867 . INSURER F: COVERAGES CERT.IFICATE`NUMBER:`.5736801-HAVE BEEN ISSUED REVISION NUMBER: See below. :TH'tS.:IS.T.O CERTIFY THAT..THE POLICIES'OF INSURANCE LISTED BELOWU D 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...SUBJEGT. TO ALL:THE TERMS, EXCLUSIONS AND'CONDITIONS=OF%SUCH POUC1ES:11MIT8 SHOWIJ•MAY HAVE BEEN.REDUCED BY PAID CLAIMS:' INSR _. ADDL SUBR - POLICY.EFF POLIEY EXP .LTR-. - TYPE OF 1145URANCE POLICY,NUMBER � -- MM/DD/YYYY MMIDDIW.YY � -,,LIMITS .. . . .. - GENERAL LIABILITY EACH OCCURRENCE $ 1 000,000 A EGGCDOOD080613 03/15/2013 03/'1512014 DAMAGE TO RENTED X COMMERCIAL GENERAL LIABILITY. __. .. PREMISES Ea occur'.".) ccurrence $ 250,000 CLAIMS-MADE OCCUR P(Any one Person) $ -MED EX .Excluded PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS=COMP/OP AGG $ 2,000,000 $ POLICY JECT PRO- LOC COMBINED SINGLE LIMIT A AUTOMOBILE LIABILITY EAGCD000080613 03/1512013 03/15/2014 IEa accident $ 100,000 X ANY AUTO - BODILY INJURY(Per person) $ ALL OWNED SCHEDULED - BODILY INJURY(Per accident) $ AUTOS AUTOS PROPERTY DAMAGE NON-OWNED $ Per accident HIRED AUTOS AUTOS $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ $ ! DED RETENTION$ X WCSTATU 0TH-' WORKERS COMPENSATION .EWGCD000080613 - 03/15/2013 03/15/2014 A AND EMPLOYERS'LIABILITY - Y/N - 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE - - E.L.EACH ACCIDENT - $ OFFICER/MEMBER EXCLUDED? N/A 1,000,000 (Mandatory,in NH) - .. - E:L.DISEASE-EA EMPLOYE $ K es describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE POLICY LIMIT $ A Excess Auto EXAGD000080713 3/15/2013 3/15/2014 1,900,000 excess of$100,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) - Evidence of coverage CERTIFICATE HOLDER CANCELLATION I Any city/town in Massachusetts 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 REPRESENTATIVE 9« .� The ACORD name and logo are registered marks of ACORD ©1988-2010 ACORD CORPORATION. All rights reseryed. ACORD 25 (2010/05) .(7bisrcNfiole rePlaces.reNficalek3736]na'«Mm+a _ —^-------------- /1404:1?PM JEFFCOINC 19784759075 Page 1 -Y 1ieidi a � G� OA�� `�o• ;�o NCO o. �9 LO T 70 04 S.F. �G AREA---16,8 ti NO 291.00' N/F NEW ENGLAND POWER COMPANY PLOT PLAN PROPOSED HOUSE CONSTRUCTION IN NORTH ANDOVER, MA OF DRAWN FOR � G STE H JEF'FCO 7 SCALE: 1"=40' DATE- JANUARY 27, 2014 ��•^� R TM 1040 TL 70 s t 1`2714 STEPHEN Et R.L.S DATE ss p�,CsTKR ENGINEERING SERVICES 987!—2B IIANDOVEP' MASSACHUSETTS 01810 Igy S4ID'^ 0. a 4� 1/1404:12PM JEFFCOINC 19784759075 Pagel o _Y 1ifta n � � L G' 9 2 0, dj°��' ti c#\ fo �' LOT 7© : AREA=1.6,804 S.F. cq 291.QQ' N/F NEW ENGLAND POWER COMPANY PLOT PLAN PROPOSED HOUSE C0NSTRUCTI0N IN NORTH ANDOVER, MA KOF1} DRAWNFOR ° sTe H M0 7 SCALE: 1"=40' DATE: JANUARY 27, 2014 TM 1040 TL 70 /97/14 Da E MRIMACK ENGINEERING SERVICES STEPHEN E. R.L.S. ��66 PARK STREET 9971--28 ANDOVER, MASSACHUSETTS 01810 r,��_ 1 SEASONAL 4. DATUM BASE IS U:S.G.S. NIGH WATER 4za .. - _ _ - .17. -- PLAN. -- BENCHMARK IS SEWER'N ROOF INFILTRATOR DETAIL STABILIZED CONSTRUCTION ENTRANCE ELEVATION=,4!9.13 N.T.S. - -- . - - - - N.T.S. 5. WETLANDS DELINEATED E 6. ALL NON PAVED AREAS TO BE DISPOSED:(Df AT BOUND _ )LE .. : ... ... •BENCMARK .. NAIL TO BE SET . IN UP ELS 54.00 - .. - OP. 1560 AL. _ CONSTRUCTION Si N011 PR G SEPTIC TANK JTOUR. ..S'�R (MO THIO '� .PROP 00T d N I RATOR 1.) PRE-CONSTRUCTION MEETING IN - - 2.) INSTALLATION OF EROSION C _ 40��1 - PROP ��u p a '� 3.) CLEAR GRUB AND INSTALL 4.) DEMOLISH (/ XIS PROP.x N (H-20) z/ 00 5.) FOUNDATIONFKCA AT ONSE E IN. ` � .: INSPECTION 5p .. 6.) _UNDERGROUND UTILITY, SEPTI PORT INSPECTION,AND BACKFILL. - ` PROP. 7.) UPON HOUSE COMPLETION, H B.) FINAL LANDSCAPE AND PAVIA si v0 BUFFER ZOVE tel` P v - '7. n .9.) UPON SITE STABILIZATION, FII P'.PROP'STABILIZIED / r 3. 3p % f,• CONSTRUCTION _ - 1T / I _ _ ENTRANCE /P ti _ fT•.f PILE - . / .• OAR " IL PROPOSE STOCKPILE A '.i� �• , " I - 5' PROP.COMPOST FILTER SOCK ONE WALL .. uv5] z ' 'iNYy `I'• ,a`'Sr G� LIMIT-OF:WORK (SEE DETAIL) �. 1 PROP.RAZE LOT !OSG� �.. (15'x4('- O F. SL - / SD' NO BUILD ZONE "`^� WEWNGS (16 804 S.F.) r _ EXI D �.y _ %IKr5 _ � 291.00' o W 7-7`-- PROP.EROSION (51L wCEBPRR1ER ( i (SILT.FEN.. ..NOF NEW ENGLAND POWER COMPANY ...^ &FILTER SOCK)e---s--m -) /. .. . WETLAND BY BASBANES ASSOCIATE E 'AL1/RAFI 100X" _ IN CONTROL FABRIC SD TO 4,-6" WOODEN 3-6"SILTA PON CONTROL FABRIC COMPOSTE FIL 7ER SOCK PER DETAIL. SILT FENCE - - 3'-0"ABOVE EXIST/NG GRADE " . GRADE FILL (6""HIGH) 4•-6^ + TO EDGE - 7'_6'. WOODEN ^� _ 5 + WE7LA .. . • BELOW STAKES ". `. ., ': ��. � _ � .- �- _ ZM OF GRADE._ i. ,- .. o,Zy'vlwmMw� 'ya SCAL£:.AS Sh NO. DATE BY REVISIONS: o NEMCHENOK y ASSESSORS M, SILTATION CONTRO FFNCF ncreu v9o .SPW .. NOT TO SCALE _ .. SS/DNAL ENG\ II 66� ANDOVER, Commonwealth ®f Massachusetts Sheet Metal Permit Date Permit# Estimated Job CosA G 9 6 Permit Fee: Plans Submitted: YES NO Plans Reviewed:- YES NO I � Business License# 9 Applicant License# 7;?3 i Business Information: Property Owner/Job Location Information: Name: � i1 S �c p A �f&A`S ad Name: 1e ��C 0 Street: S's sV) Sk' Street. 1 U s S 1 City/Town: (' �r City/Town: !v o���" � ks� y D�� rm tall Telephone: (91'16 �S("`�y03 �9,��1�S'o1�4`( Telephone: Photo I.D. required/Copy of Photo I.D. attached: YES NO Building Type: ' Residential: 1-2 family t/ Multi-family Condo/Townhouses Commercial: Office Retail Industrial Educational Institutional .Building Cubic Footage: under 35,000 cu. ft. ✓over 35,000'cu. ft. '?Sheet metal work to be completed: New Work: Renovation: Chimney Vents HVAC Metal Roofing KitchenExausys tem tovide,brief description of work to be done: 04Y ��n•c•-c-c s �y� � N t��^ A)c 226 Date.A j'. . . ........ NORTH TOWN OF NORTH ANDOVER PERMIT FOR MECHANICAL INSTALLATION �9SSACHUSEt4 This certifies that .-.% .0.�. . . . . . . ? 1 ?• "` S °� has permission for mechanical installation !t( .�... . . . . . . . . . . . . . . in the buildings of ..... . . . . . . . . . . . . . . . . . • • • at ���� . . :)(1,1 w) • '- • • • , North Andover, Mass. Fee. . �Lic. No- . . . . . . . . . 1f! � GAS INSPECTOR i \ WHITE:Applicant CANARY: Building Dept. PINK:Treasurer C l.n lr- 7 l_., 7 i' commonwealth ®f Massachusetts Sheet Metal Permit Date 1 (� Permit# Estimated Job Cost: \G 06 Permit Fee: $ � Plans Submitted: YES t" NO Plans Reviewed: YES NO Business License# 9 Applicant License Business Information: Property Owner/Job Location Information: Name: 1 nA // Name: Street: SSS 1''� �^�r �� Street: )U 5 S City/Town: ks L t, City/Town: ,N o 4 / wly-( D�� W, C¢lt Telephone: 91���S 1'`�y03 l9��� detY Telephone: Photo I.D. required/Copy of Photo I.D. attached: YES NO Building Type: f. Residential: 1-2 family Multi-family Condo/Townhouses Commercial: Office Retail Industrial Educational Institutional Building Cubic Footage: under 35,000 cu.ft. L--�over 35,000 cu. ft. Sheet metal work to be completed: New Work: Renovation: HVAC Metal Roofing Kitchen-Exhaust System Chimney/Vents Provide brief description of work to be done: .��<< .,-..., 0 t.-I0 . C4Y �,�5 �v�� ��� ,SIC , a 04-L A k INSURANCE COVERAGE: I have a current liability insurance policy or its equivalent which meets the requirements of M.G.L.Ch.112 Yes[RI'No❑ If you have checked Yes,indicate the type of coverage by checking the appropriate box below: A 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 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 ,1 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.. Progress Inspections Date Comments r Final Inspection Date Comments i Type of License: 3y ❑ Master title ❑Master-Restricted ;ityTrown permit Journeyperson Signature of Licensee # ElJourneyperson-Restricted License Number: ��3 -ee$ Check at www.mass.gov/dpl ispector Signature of Permit Approval r Sheet Metal Commercial Guidelines/Life Safety/Critical Systems Inspection Checklist Yes No N/A„ Set of stamped engineering documents and detailed description of mechanical system to be installed has been provided J All workers performing sheet metal work onsite has valid Massachusetts sheet metal license All sheet metal work being perfoixned with proper journeyperson-to-apprentice ratios . Fire dampers with access door properly installed and checked for operation Smoke and combination fire/smoke dampens with access doors properly installed- actuator checked for proper operation(May also be verified by fire department during . fire alarm testing) Duct smoke detectors with access doors properly located (May also be verified by fire department during fire alarm testing) Smoke/atrium exhaust systems installed and operation verified (May also be verified by fire department during fire alarm testing) Stair pressurization systems installed(where required)and operation verified(May also be verified by fire department during fire alarm testing) Grease/kitchen hood exhaust system installed with all seams and connections welded airtight with properly located cleanouts.Proper cld`ances, fire rated enclosures and pressure testing required: r SF��lie reply.-aint3 installed 0ibi required of1 equipment and du n.orY Duct penetrations in fire'ratc %vall and flaprs sealed' Metal roofing systems installed watertight using proper materials and fasteners Flexible duct runs installed 6'-0"maximum length Ductwork installed using proper hanger spacing,hanger stock,threaded rod and angle iron Ductwork/plenum connections sealed substantially airtight Ductwork insulated by means of external covering or internal lining Volume dampers installed for each supply air branch duct New/clean-properly sized filters installed(final inspection) Testing and Balancing report complete(final sign-off) ti Sheet Metal Residential Guidelines/Inspection Checklist Yes No N/A Detailed description and sketch of sheet metal system to be installed has been provided All workers performing sheet metal work onsite has valid Massachusetts sheet metal license All sheet metal work being performed with proper joumeyperson-to- ` apprentice ratios 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 ductruns 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-oft) AC(DRE) �---� CERTIFICATE OF LIABILITY INSURANCE IL1TE(MNINLYYYYY) MV/Z013 FTHIS CERTIFICATE IS ISSUED ASA MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. Tf•IIS 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 mODUCER,AND THE CERTIFICATE HOLDER, ' IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the Pollcy(leS)must be endorsed, It SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A Statement on this certiflcato does not confer rights to the certificate holder PRODUFEDERATED ER AC�� !:=zm FEDERATED MUTUALINSURANCECOMPANYHOME OFFICE:P.O.BOX 328 I N 1.081, 8-333.4�J 9507.446 A664 OWATONNA,MN 55060 �&ja;_CLIENTCONTACTCENTERFF..DINs_,�0M _ INSUREMLAFFORI)JNG COVERAGE tI It INSURER n:FEDERATED MUTUAL INSURANCE COMPANY 13935 INSURED360-541-7 HILLIS CORP INSURER B: 555 WOBURN ST INSURER c: TEWKSBURY,MA 01876 f INSURER D:' I INSURER E; f INSURER r: COVERAGES CERTIFICATE NUMBER:0 [,,; I ,r i REVISION NUMBER:0 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. I R TYPE OF INSURANCE ADR n ) POLICY NUMBER MSY F P01.1 Y XP LIMITS GENERAL LIABILITY j. EACH OCCURRENCE �1,ODD,D00 X COMMERCIAL GENERAL LIABILITY I DAMAGE PIIEMIBEJ?I I�q DENTED �'IOO,000 F --- CLAIMS-MIADE OCCUR I 1 s HIED EXP(Any one person) A N N 9385795 �' 0613012013 06/30120,14 PERSONAL A ADV INJURY $1,000,000 itI I ' GENERALAGGREGA'rE. ;2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: + tt; VV�; : i #? PRODUCTS-COMP/OP AGG $2,000,000 X POLICY P�• LOC E EIi II J --C ( — AUTOMOBILE LIABILITLAUTOS r �^ - QMBINED SINGLE LIMIT X ANY AUTO —,61,000,000 1 + II t BODILY INJURY(Per person) ALL OWNED l _ A AUTOS INN 9385794 �1 06/30/2013 06/30120.14' BODILY INJURY(Per auldant) — HIRED AUTOS I 1 1• +" PROPER DAMAGE I r X UMBRELLA LIAB IX OCCUR EACH OCCURRENCE `(,3,000,000 A EXCESS LIAR CLAIMS-MADE N N_ 9385796 I ! 06/30/2013 06!30/2014 I AGGREGATE $3,000,000 DEO I RETENTION --— 1 WORKERS COMPENSATION W �77'pp 11 TF_ AND EMPLOYERS'LIABILITY TQII�LIMl75 Eft ANY PROPRIETOR/PARTNER/EXECUTIVE — L"•.L.EACH ACCIDENT OFFICER/MEMBER EXCLUDED? NIA I 11r (Mandatory In NH) f it f;_.: ' 1 E.L.DISEASE•EA EMPLOYEE If yas,descrlbe under 4 k DESCRIPTION OF OPERATIONS below I ` �'t�4�'" j E.L DISEASE•POLICY LIMIT r DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Allach ACORD 101,Addlllonal Remarks Schedule,it more space Is requlrod) CERTIFICATE HOLDER CAeNCELLATION t SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE ;JEXPIRATION DATE' THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, ,): AUTHORIZED REPRESENTATIVE I ©1988-2010 ACORD CORPORATION,All rights reserved, ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD , I , Client#: 53676 HILLISFRAN2 AC®RDW CERTIFICATE OF LIABILITY INSURANCE FA7/0112(MM)0DIYYYY) 013 i 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 polley(les)mUSt be endorsed.If SUBROGATION IS WAIVED,subioct to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confor rights to the certificate holder in Ilou of such ondorsemont(s). PRODUCER CONTACT FILIB International New England I PHONE—..____.--_--.-- FAx 078 657-5100 ) 066-A r 9 299 Ballardvale Stnlc,No _7,i-795J--- E•MnIL nee certificates-alhubinternational.corrt ADpREss;.—. . '. ------ Wilmington, MA 01IIII7 INSURER AFFORDING COVERAGE _--------N---AICI) 978 657-5'100 . _—..._.__-_.__. .1..l-- _—_. ---__.. _.-.._ __.--- iNSURERA•Independence Casualty.Ins Co INSURED INSURER B Pliilis Corp - --— - ----- - -- - _ ....._ ._.._. INSURER C; DBAFrank's Heating Service I. -_.___.—_.................... ._....... __......_._....._._... .. ......_...__._..._.......... ._.....----._._,_.....__.._ INSURER D: 555 Woburn St d' -------�------------__- ----- ------......._ --------- __ i � INSURER E Tewksbury, MA 01876 -------______-_.----_._--------____-- ---.---_._.-..__--------...-._.__. INSURER F COVERAGES CERTIFICATE NUMBER: t REVISION NUMBER: __ TI-IIS IS TO CER-1-11-Y THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE 13EEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPEC I' TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE IAFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMIS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDLSUBR - -1-- - -- POLICY EFF POUCY EXP TYPE-OF INSURANCE .^_INSR.WVI2 _--PaLICY NUMBER_— LIMITS GENERAL LIABILITY ['ACI-.I OCCURRENCE $ COMCLAIMISIMADEIRA_LLIOCCUR _MR�MtSI' �nyonelrosnnL- -- -.--.....__.._- ... ..._...... ..-_....._.---_....--- i PERSONAL d ADV INJURY $ - --- GENERAL AGGREGATE s GEN'L AGGREGATE LIMIT APPLIES PER: I PRODUCTS-COMP/OP AGO :4__.__-__-.._......................... -- l . POL1.Y $ I . .. .JEGI .._..L _ LLOD_. ._... -.--. --I --- I - — AUTOMOBILE LIABILITY COMBINED SINGt.I:I IMI T _ ANY AUTO BODILY INJURY(Por person) ..._...._.._.. .__ __ ------ AUTOS .._ _ ALL OWNED SCHEDULED I ' BODII..Y INJURY(Per accident) $ ...-_ AUTOS nuros I , _. NON-OWNED i I PROPLRTY DAMACF HIRED AUTOS AUTOS �_ $ (II�To�cigenl) �......._-_..._.. .. .. .,.. .....,.... UMBRELLA LIAD OCCUR EACH OCCURRENCE $ .. EXCESSLIAB _CLAIMS-MADE I AGGREGATE _A..._..---;.._..__._ VUC1001'13'100 OG/30/1 DCD I LRETENTION$_.—.--YIN+-__.._--_..__._._.____. WORKERS COMPENSATION � WC STAI'll- Ul'I-I- 2013 06/30/20'1 AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE-_._._-. E.L_EACI-I ACCIDENT_____ _ s50O,000_ OFFICER/MEMBER EXCLUDED? I N Ni A - - ---- (Mandatory In NH) . I I E.L.DISEASE EA EMPLOYEE $500 000 If yes,describe under DESCRIPTION OF OPERA TIONS below._—____,. . __ ___ t L DISEASE POLICY.LIMIT Is60O,OOO,_ i _--' DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space Is required) I CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE 'ri-IEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE wiTI-I THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 1088-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of 1 The ACORD name and logo aro registorod marks of ACORD #S951290/10949218 DKOOA M�AS�SxACHVSzETT1S' � DRIVER TV 9 4d NUMBE&'--7 j!F•��'' w 9 ` 15 DD 08 70.2010 Rev 07.152009 i t _ j = - CQ-Z,, HEALTH OF'MASSACHUSETT.S SHEET METAL WORKERS t AS`A JOURNEYPERSON—UNRESTRICTED r �. ISS77 UES THE ABOVE LICENSE TO I TIMOTHY 99R`ePALME T; I w' 112`L0W€LL AVE r �. F NAVERHILL MA ,0"1832 371D" : l t 373:1 09/28/14 257754 :j