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Miscellaneous - 11 EMPIRE DRIVE 4/30/2018
BUILDING FILE Date TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that . . has permission for gas installation . . ..st.+-I. . . . . . . . . . . . . . . . . . . . . in the buildings of. 014.0.�.C<<e, U'Aire-LU . . . . . . . . . . . . . at 4444 V\N pay.0 . lY.4-. . ,North Andover, Mass. Fee . Lic. No. . . . . . . . . . . . . . . . . . . . . . . ' GASINSPECTOR Check#(_ I (Q- 8683 :�p Z-I�) L�Zv11-:5 k,rA- 3 a MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY: 1614-L � .cQ"--.r MA. DATE:_6 -I - ( -S PERMIT# % I JOBSITE ADDRESS: OWNER'S NAME: bra"-,L()d� GOWNER ADDRESS: t L V S A V AA-C, TEL: FAX: TARE OR INT OCCUPANCY TYPE: COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL CLEARLY NEW:0 RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ APPLIANCESZ FLOOR— Bsmt 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 COCK MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ,T ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER 0 INSURANCE COVERAGE I have a current liabiliq insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 9 NO ❑ If you have checked YES,please indicate the type of coverage by checking the appropriate box below. LIABILITY INSURANCE POLICY Q� 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 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 appli74;;qLRE e with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUM BER/GAS FITTER NAME: 'STEPHEN C. GALINSKY LICENSE# 103411 COMPANYNAME: &ALW3Kq PLU1AA11 G + 14C*f-W& ADDRESS: P.Q. fax I'701 CITY: IJAVE79.HiL,L- STATE: m•A- ZIP: 01831 FAX: 4 621-4131 TEL: 9*79-37y- 1'2y3 CELL: 50V - 6tA- SgOy EMAIL: WVVW, mr (UMbe o� ,M MASTER 12� JOURNEYMAN❑ LP INSTALLER❑ CORPORATION [?f# 3 E 9t� PARTNERSHIP❑# LLC❑# 1��i� ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT#_ PLAN REVIEW NOTES Z /�� CG 7 1,51 Division of Professional Licensure: License Search Page 1 of 1 The Official Website of the Office of Consumer Affairs and Business Regulation(OCABR) Division of Professional Licensure Mass.Gov Mass.Gov Home State Agencies A-Z Topics Home>Division of Professional Licensure> 3 ONLINE SERVICES .......................... ... II Check a License Check A Professional License a Locate a Licensed Professional By the Division of Professional Licensure Online Address Change I Contact the Agency LICENSEE More... Name:STEPHEN C. GALINSKY REFERENCES& HAVERHILL,MA I RELATED INFO Disclaimer Regarding **This Licensee has additional Licenses,click here to view them.** Website License Searches _....__ _ Enforcement Process Glossary Licensing Board: PLUMBERS Et GASFITTERS Glossary of License Status License Type: MASTER PLUMBER Codes License Number: 10348 More... Status: CURRENT Expiration Date: 5/1/2014 Issue Date: 11/18/1986 Exam Date: School: This web site displays disciplinary actions dating back to 1993. This license has had no disciplinary actions taken during this time. i I The page above has been generated by the Division of Professional Licensure web server on Tuesday,May 07,2013 at 1:25:01 PM. ©2007-2011 Gommonwealth of Massachusetts Site Policies Contact Us http://license.reg.state.ma.us/pubLic/pubLicenseQ.asp?board_code=PL&type class=_M&li... 5/7/2013 09931 Date . TOWN OF NORTH ANDOVER 4 PERMIT FOR PLUMBING This certifies that . .-+-, .�- ", , , , , , , , , , , , , , , has permission to perform . . . . . . . . . . . . . . . . . . . . plumbing in the buildings of. . .Q.c:4 kjq . .�� LL L at At. . . .E!h.�►.�-�. . .�7(. . .. . . . . . . . . North Andover, Mass. Fee . Li c. No. . .1.Q.3` . . . . . . . . . . . . . . . . . . .b(Lti PLUMBING INSPECTOR Check# (o l \S � � 3 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY MA. DATE PERMIT# � _ JOBSITE ADDRESS A l A OWNER'S NAME ©rC14 (Jk(, POWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE: COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL C2- PRINT CLEARLY NEW: RENOVATION:❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO El FIXTURES 7 FLOOR- BSMT 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYS DEDICATED GAS/OIUSAND SYS DEDICATED GREASE SYS DEDICATD GRAY WATER SYS DEDICATED WATER RECYCLE SYS DRINKING FOUNTAIN DISHWASHER FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK 1 LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET ( Z URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES NATER PIPING ')THER INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which,meets the requirements of MGL Ch.142. Yes 9'No❑ IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY X OTHER TYPE OF INDEMNITY ❑ BOND ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. • CHECK ONE BOX ONLY: OWNER ❑ AGENT ❑ Signature of Owner or Owner's 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 m Knowledge and that all I Y 9 plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Ch er 115 of e G eral Laws_ PLUMBER NAME STEP4610 C_ GALIh3SKY SIGNATURE LIC# 103108 MP 2' JP❑ CORPORATION X# .3196 PARTNERSHIP ❑# LLC ❑# COMPANY NAME_ GIAWPSKY PLUMA M4\ . 61"TIO(Z ADDRESS: P.O. GGx 17OI CITY HAVCRRIIrL STATE M•A• ZIP 01%31 EMAIL N/ww. mriplymbef@- TEL 4'7V-32q- 1716 CELL .5508 a 50q-590 1 FAX q7$- AI- 4I 3i t .. 'a ROUGH PLUMBING INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES 9 ce lz Division of Professional Licensure: License Search Page 1 of 1 The Official Website of the Office of Consumer Affairs and Business Regulation(OCABR) Division of Professional Licensure Mass.Gov Mass.Gov Home State Agencies A-Z Topics Home>Division of Professional Licensure> ONLINE SERVICES ...................................... Check a License Check A Professional License € Locate a Licensed Professional By the Division of Professional Licensure Online Address Change _ Contact the Agency LICENSEE More... I Name:STEPHEN C. GALINSKY REFERENCES& HAVERHILL,MA RELATED INFO Disclaimer Regarding ""This Licensee has additional Licenses,click here to view them." Website License Searches Enforcement Process Glossary Licensing Board: PLUMBERS 8 GASFITTERS Glossary of License Status License Type: MASTER PLUMBER f Codes License Number: 10348 More... Status: CURRENT Expiration Date: 5/1/2014 Issue Date: 11/18/1986 Exam Date: School: I I I This web site displays disciplinary actions dating back to 1993. This license has had no disciplinary actions taken during this time. The page above has been generated by the Division of Professional Licensure web server on Tuesday,May 07,2013 at 1:25:01 PM. ©2007-2011 Commonwealth of Massachusetts Site Policies Contact Us http://license.reg.state.ma.us/pubLic/pubLicenseQ.asp?board_code=PL&type class=_M&li... 5/7/2013 Date... ..r' G�..3 � OF�►ORT�y, TOWN OF NORTH ANDOVER 9 PERMIT FOR WIRING $8,C11�J8E - This certifies that ...........,�. .... ./. .................................................................... has permission to perform ....��. r� � G�--5 —.' ..........................................:........................................ wiring in the building of........ .. lJ....... r.s •,h•�' at ......�`..........l'�'T�!!.~-........... � ,North Andove ass. o Fee,... .....................Lic.No$-rrl�.3r ................... .:............. 1 EC MCAL INSPEI jMR / .. Check# )3 3 6 11622 t 1 �f Commonwealth of Massachusetts Official Use Only Permit No. Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 leaveblank V —7— APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code Q1 EC 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: J 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 Telephone No.gJ�''- Owner's Address 2 ��" f Is this permit in conjunction with a building per it? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building i Utility Authorization No. b—a D Z d 3 7 - Existing Service A ps / Volts Overhead ❑ Undgrd❑ No.of Meters New Service 2&61 Amps /u/ / 2 yd Volts Overhead❑ Undgrd ©No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion of the following table maybe waived by the Ins ector of Wires. No.of Total No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA AboveIn- o.o mergency ig tingNo.of Luminaires Swimming Pool rnd. ❑ rnd. ❑ Battery Units No. of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones No.of Detection and No.of Switches No.of Gas Burners Initiating Devices Tota No.of Air Cond. l No.of Alerting Devices J.No.of Ranges Tons Heat Pump Number .Tons KW No.of Self-Contained No.of Waste Disposers Totals: Detection/Alerting Devices Municipal Other No.of Dishwashers Space/Area Heating KW Local❑ E]Connection Heating Appliances KW Security Systems'- ea No.of Dryers No.of Devices or E uivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent Telecommunications Wiring: No.Hydromassage Bathtubs No.of Motors Total HP No.of Devices or Equivalent OTHER: r 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: _S —,?,( /3 Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such covera m force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of perjury,that the information on this application is true and complete., ��3 FIRM NAME: . r // /—, LIC.NO.: Licensee: ay fyn a v/ Signature LIC.NO.: (If applicable,e r "exempin the license number line.) Bus.Tel.No. Zay Address: < Alt.Tel.No.: *Per M.G. c. 47,s.57-61,security work requires Department of Pub 'c 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. f - • .SJJJlI•lYJ ��(��A-(��7J].��.'I�S'.S.JLJ.�+'.�d ply®p7��i.yt�'(�('/'� .r.3,��J.J:�'UJ+..�.�.Rj.A.1lJ%J.®�.L� ,� t ' - �.u�:ll�.L,[C9.�.f8.¢.f.11.gl��.k'+YJ.l.k7'�" _. ..t ■ '�ssei j +'aileQ�j ] e-znspeetZoxteruzxecT( �O.OD)-j I xuctors'cefts: (X ,peeoxs' i a e xtoiitiaTs) abate �C'asse�•-- �C+`afTe$-,j �' � a2e�ns�ection,�'er�uixecl(��0.00)-•j �` . �Sts�ecto extts• IA (iii pectozs�;ign e- 'fiats) date 'assert—j � �+ailet�--I � �Ze�Sns�eetio�,xet�uixer�(��4.40)�j � • nspectoxs°comments: (inspectors' ignatuxe o inffial�s) Date ssecl-•jIA +'afle�• je xnspectio�xequirec�( OAO) j hectors'copnme x (Xnspectors'signa re- zn tials) pate r , `eco'—j � �'aile�f�-j �- 'ante�nsp ection xeguix'etl 050.0 D)�[ � - ectars'cwhments: • S ' • QtU—spectors,oignatme•-noxnifials) date ' r The Commonwealth of Massachusetts rn 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): Address: i City/State/Zip: Phone#: Are you 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. [_] I am a sole proprietor or partner- listed on the attached sheet. $ 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.El Electrical repairs or additions 3.❑ 1 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.❑Roof repairs insurance required.]i 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. i 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 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. Insurance Company Name: Policy#or Self-ins.Lic.#: 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 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 and penalties of perjury that the information provided above is trite and correct Signature: Date: Phone#: Official use only. Do not write in this area,to he completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiplepermit/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 Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Fax# 617-727-7749 (Zevised 5-26-05 r" 7 205 Date. . .���/.!.�... .. .. i i NORTh TOWN OF NORTH ANDOVER Of 1q' a= o �D PERMIT FOR MECHANICAL INSTALLATION F F + i 9S SACH USE� ' I t f This certifies that .... ... . . . . . . . . . . . . . . . / . . . . . . . . . . . . . . . . . . has permission for mechanical installation . . . . . . . . . . . . . . . . . . . f f� in the buildings of . . ./. ��?�. . . . . . . . . . . . . . . . . . . . . . . . . . at . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. North Andover, Mass. Fee. . .. Lic. No..i 66 . . . . . . . . . . . . . . . . . . . . . . . . . . . . GASINSPECTOR � ITE:Applicant CANARY: Building Dept. PINK:Treasurer t S Commonwealth of yIassachusetts Sheet Metal Permit . -rmt: � .stir:nalC�Job CCS['. -75700 'e.:.I( Fee: Z Plans Sub nmc--': YES NO Ptans P.cviewc:_. YES vp Buzmicss -1cc:lsc - 1 n^IlSan, *-ICf.:ISC Sus:ntss iniormatior.: ^c 'J1.�, Joor,.C2LGr. !nTCrr,.suCn Afi : ONV r. 7 33 T etcnr.=.._ L? X137 ?hcE. ara�:c �tw[ ;maai Rezidential: __.._.. r.ai Sauare roocaa_••. ur...c. _. .. •: o� CaOC c um"er cr `::cer metal W'rrn :Ll be co naleiec: 14 C:ci vc'ItZ ?.t' Sala,-, 4e v INSURANCE COVERAGE: I have a current liability insurance policy or its equivalent,which meets the requirements of M.G.L Ch. 112 Yes i/ No If you have checked Yes,indicate the type of coverage by checking the appropriate box below- 113 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 Signature of Owner or Owner's Agent Owner I ❑ Agent By checking this box I hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and ataurate to the best of my!nowiedge and that all sneer metai work and installation performed under this permit issued for this application will be in compliance with all pertinent provision of the Massacnusetts Building Code and Chapter'12 of the General Laws. Duc inspection reouireo prior to insuiatitm installation:Yes No Progresslnspecaons Date Comments =final inspection Date Comments Type of License By: Master _itie ! ❑ Master-Restnckea ❑ Joumeyperson Permit Lam.. Joumevoerson-restricted Inspector Signature of Permit Approval Signature of Licensee License#: SHAT METAL PERMIT 02.19.11 A�'oR& CERTIFICATE OF LIABILITY INSURANCE �^ °M"DD'YYYY' ��' F12/28/2012 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. if SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT PRODUCER NAME: NORTH ANDOVER INSURANCE AGENCY, INC. (ACN Ne, Ext): (978) 686-2266 (A� Nal:(978) 68611. -6410 M.J. FOSTER INSURANCE SERVICES DRESS: cfernandez@nafins.com 163 MAIN STREET CUSTOMER ID 4R•A . Mechanical, Inc. NORTH ANDOVER MA 01845-2508 INSURERIS)AFFORDING COVERAGE I NAIC a INSURED INSURER A 1XI RI HANTS INSURANCE CO A-A Mlechanical, Inc. INSURER B :GUARD INSLJRAIQCE 16 Lomar Park INSURER C Suite 1 INSURER D IUFI IOFR F I ' Pepperell MA 01463- INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN_ IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. -61S—R I TYPE OF INSURANCE ISUBF POLICY EFF POLICY E%P LTR IINSR WVO POLICY NUMBER (MWDDlYYYY) IIMNUDD/YYYYI LIMITS A oenenA� Llwetrn y CCP91l3434 1/oi/Foie 101/01/201+ EACHOCCURRENCES 1,000,000 U>MAu IV c Iw 100,000 X COMMERCIAL GENE;AL LIABILITY DREMISEF I occurrence) CLAIMS4AADE X OCCUR / / / / MED EXP(Any one person) $ 15,000 ^EnG0HPL 3,1Dv IN,&)nY a 1,000,000 i GENEPAL AGGREGATE S 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER / / / / PRODUCTS-COMP/0?AGG 2,000,000 X I POLICY PRO LOC ! / / / / EBLIA S A (AUTOMOBILE LU1BLrry HCAOOO0008 D1/01/2013 101/01/2014 COMBINED SINGLE LIMIT 1,000,000 (Ea aceloonn ANY AUTO BODILY INJURY(Per person) 5 ALL OWNED AUTOS BODIL"INJURY(Far accltlert) S X SCHEDULED AUTOS PRO-EPTY DAMAGE X I HIRED AUTOS I / / / / (PeracCden,l I{XNON-OVvNED AUTOS A'1 X u69RELLA LDAs F`n OCCUR i CUP9145434 101/01/2013 X)1/01/2014 ;aCHOCCURRENCE $ 1,000,000 EXCESS UAB i I I / / I / / CLAIMS�MADE AGGREGATE S 1,000,000 HnF:n[ICT IRI F RETENTION . S S B WORKERS COMPENSATION IIAWC466048 1/01/2013 )3 a /2014 X i TOR 'C ST MIT OTF- AND EMPLOYERS' LIABILITY ANY PROPRIETORPARTNEWEXECUTIVE Y/N / / / / E L F OFFICGm. Q.136 Gleujorm, - ❑ NIA EACH ACCIDENT_ $ 500 000 (Mandatory In NH) / / / E.L DISEASE-EA EMPLOYE S 500,000 II yes.describe under DESCRIPTION OF OPERATIONS below / / / / E.L.DISEASE-POLICY LIMIT S 500,000 1 / l DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD IDI. Additional R—wks Scnedule. t more space is mqura4) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE.DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. R.A. MECHANCTAT,, INC. 16 100110R PARK AUOMmnMD RVReleNTATIVe SUITE 1 PEPPFREILL MA 01463- ACORD 25(2009/09) ©1988-2009 ACORD CORPORATION. All rights reserved. I NS02 5(200909) The ACORD name and logo are registered marks of ACORD ..... .. ...... .. ............ DRIVER'S LICENSE KUM 1.00 NON .. ......... .4-9- AtD J 6T,'MAMMOTR RE DRAC-JT.MA 01825-AUC COMMCNWEAL7'ri OF MASSACH12SE7 ZZ SmIE-T' MET' AL INOPKERS AS A FriS7E;-UNREEz7RIC7-ElD !Sslj=-z--Ir;.=-ABCVE-!CENSE:7C: DONALD J 3 Ul L L E 7 7 657 MAMMOTH RD DRACUT MA 01826 -4349 4688 07/28/14 ZZE 13 9 I I _ I 1A 1 , J c ib 7,1 Ferrarme� far. FA ME-C:4,AN1CAL INC azge 1 r-� 15 LGMAR PARK �igrn-Ssutt°J'Jnivc�m 1AA Q i i63 7.1.17 R�U11 D7 M1aLG•t111:21:1-13 Fherte 97S SE�i Z Fie 3i 8�=j�u0 C_^.ae mens:nd Zemn9-wLANV.. Mmei==td®act.cm nneSsc /uL r..ts�-�q"" �I-.r 1 „ t t - 1,.-I ._.. ...-. ` 1_,1•�;,p.�1iy ' Cxlf-�.��•clt��t�.4 i. I J.:���J r � [i I ii � �'1' `f,t,� rrt � 's I , n bl •f a '�i v ' �I f'j r•�fl C I I l'1 (n CJ !1 rt u1 v,❑ Y of U' .. .._ lu "• is �-.f'� .. 1, • i�•K .. �:-7 X11�•_j:--.�-fit ; .__— 1�: .��, u The Commonwealth of Massachusetts - Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, lllA 02111 � ✓' www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LeLyibly Name (Business/Organization/Individual): Address: 7 k ;) City/State/Zip: J �,�',-- ;i ,��y'�;�' Phone ;t: Are you an employer? Check the appropriate box: Type of project (required): 4. I am a general contractor and I 1. I am a employer with ❑ 6. New construction employees (full and/or part-time).* have hired the sub-contractors proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling 2.❑ I am a sole ro P P ship and have no employees sub-contractors These have 8. Demolition o ❑ working for me in any capacity. employees and have workers' Q Building addition [No workers' comp. insurance comp. insurance. required.] 5. ❑ We are a corporation and its I0.❑ Electrical repairs or additions re 3.❑ I qu a homeowner doing all work officers have exercised their 11.7 Plumbing repairs or additions r right of exemption per MGL , mysel�. [No workers' comp. _� 1_.❑ Roof repairs I t c. 152, 1(4). and we have no insurance required.] � employees. [No workers' 1317, Other j comp. insurance required.] *Anv 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.policv number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self-ins. Lic. P r L 1 ! - <- iration Date: #: ��% , � � �/�` , �. Ex 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 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby nder the p -and p naliies 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#: