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HomeMy WebLinkAboutMiscellaneous - 11 GREEN HILL AVENUE 4/30/2018 11 GREEN Hi�AVENUE 210/022.0.0111- 0000.0 Date....!...` ...................... 0 p TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION • i ;: k // oo .......... ..V This certifies that ..... ` .. .... ... C- ............... Q has permission for gas installation ....,1.. s ��.. —44 in the buildin sof...... .d ........ ........................................................... .... at................ . . � .. ................. . ..........., North Andover, Mass. ........................................ Fee W!. Lic. No. jo........ .! '....:................................................ GASINSPECTOR Check# ((D`N© 925.4 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK - CITY I North Andover MA DATE411512014 ^ PERMIT# JOBSITE ADDRESS 11 Green Hill Ave OWNER'S NAME .............. GOWNER ADDRESS Same TE FAX TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL® RESIDENTIAL PRINT CLEARLY NEW:® RENOVATION:Ej REPLACEMENT: PLANS SUBMITTED: YES® NO[] 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 INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM 1 SPACE HEATER c ROOF TOP UNIT TEST { UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER _ Replace 1 Gas Meterx and Piping as Needed INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Q NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY El 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 t e 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 co p iance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME 1,Joseph Marino LICENSE# 8736 IG ATURE MP El MGF® JP® JGF LPGI CORPORATIONE]# 3285C PARTNERSHIP®# LLC # COMPANY NAME:j RH White Construction Co ADDRESS 141 Central St CITY I Auburn STATE MA ZIP 01501 TEL (508)832-3295 FAXI 508-926-4347 j CELL 508832 4614 EMAILI JMarino@RHWhite.com 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 .M1 Q�UIt�iO_NitUEALTH OF MASSs Wig ,�t`�.t��U��� U -SER•S AND GASFIT`E.1 S `r AS'!A.-MAkSTER F.LIr ISSUES TH '%IBQVE'LiG6NSE J D S E H `D S 'A-R.I No ro' 3:.=:F1?R;INGTf1N ST W�RGS:TER ivila 0 a _4j ? 31•<p<j_:; - _ 05/01/14 ', I'lt(17=T: • .-.. _.- t ...1_ •- • r....,..... .. .-.-....fir •.. 'Gl®�tJ1M_o EALTH OF tU�ASSACt 3S.E_:r- ' ice:• - ..-'.I `PL-M. -BERS AND GASFIT-.ERS - .-: '• ; =� t ` 44 • � -_ - ld`�EfV�`E"D AS A JC1_U.RNE'Y11!!J. N`��l.:U14�iC�' 'TSSUESTHE ABOVELIOENSETC} '=3- Fi4RR -�h1G-to N ST• -' _ s 05/01/1 •-s •~ • �r i • i U.!/ LUL" LY.UY 1\II WI1LIL VU1YUII\UUI fHUL_ UL/ UL AL�® CERTIFICATE OF LIABILITY INSURANCE page 1 of 1 08/29/2013 THIS CERTIFICATE IS ISSUED ASA MATTER OF INFORMATION ONLYAND 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: It the certificate holder is an ADDITIONAL INSURED,the 110604es)must be endorsed. If SU13ROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does notconferrights to the certificate holder in lieu of such endorsement(s), PRODUCER CONTACT willim of Massachusetts, Inc. PHONE c/o 26 csr,tury Blvd. No_Exr� 877-9457376 PAX NO). 888-467-2378 P.. G. Box 305191 DMoRE&s 0Art Eiicatp illia.Com Nashville, TN 37230-5191 INSURER(-)AFFORDING COVERAGE NAIGv INSURERA: The Charter Oak Fire Insuranog INSURED Company 25615-001 R. X. white Construction Company, Inc. INSURERS:TrSVOIArs property Casualty co pany of Am 25674-003 41 Cantral Street INSURERC:Nati0MA1 Union Fire Insurance Company of 7.9445-001 P. 0. Box 257 Auburn, MA 01501 INSURERD;Travelera Indemnity Company 25659-001 INSURER E,; INSURER F; COVERAGES CERTIFICATE NUMBE=R:20287680 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. IJZL NSR TYPEOPIN$URANCE DD' SUB] P POLICYEFF POLICY EXP 4LIGY NUMBER LIMITS A GENERAL LIABILITY VTC2000 977X9948-13 9/1/2013 9/1/2014 EACH OCCURRENCEd F_ 2,000,000 X COMMFRCIALGENERALLIABILITY DDqqMM r� !(An RENTED - PRE�Igaoceulnnvr300_Q04 CLAIMS-MADETOCCUR MED EXPy one Breen10000 PERSONAL&ADV INJURS 2 00Q,000 GE_NERALAGGREGATE 4,Q Q O 0 0 0 LAGGREGATFLIMITAPPLIESPER; PRODUCTS-COMPIOPA000 000 POLICY PR0. LOCB AUTOMOBILE LIABILITY VT.TCAP 977K955.A,-7.3 9/1/2013 9/1/2014 OMBI en SINGLELIMIT accNdent S 2,000,000 X ANYAUTO EODILYINJURV(Perpereon) $ A(1 ('9 ED SCHt:DULED BODILY INJURY(Peraccldon!) $ AUT08 AUTO$ X HIRED AUTOS X NON-OWNED AU108 eraccident S X Ca Dad X Coll Ded S C UMBRELLA 1,10 OCCUR BE87661.40 9/1/2D13 9/1/2014 EACHOCCURRENCE $ q1,000-,000 EXCESS LIAR CLAIMS-MADE AGGREGATE L-9,000,000 DED I g IRETENTIONS 10,00 1 S D WORKERS COMPENSATION VxR1CUB 8205 .165-13 9/1/2073 9/1/2014 X O - AND EMPLOYERS'LIABILITY 7DI�Y Q D ANY PROPRIETORIPARTNFRIEXECUTIVE N NIA VTC21CUB A203.A71A-13 9/7,/2013 9/1/3014 E.L.EACH ACCIDENT 1,000 000 OFFICERIMEMSEREXCLUDED7 LL`JJ ((�t��yyyy��en 4J68�, aUM E.L.DI8EASE-EAEMPI,QYEE S 1,000,000 UEg KII•I IUN ud VNERATIONB helew E.,I.,DISEASE-POLICY LIMIT S 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(TT1HCl1 Acord 101,Addltonel Remarks Schedula,I/more ep eee le raquirad) 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. Evidence of =nmuxance AUTHORIZED REPRESENTATIVE Co1144197604 7:p1:1694012 Cea:t:20287680 ©1988-2010ACORD CORPORATION.All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD Date... ...���. , ................... OF NORT1y.1 . TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION 88�cMus� This certifies that .......... ..................'v` V- has permission for gas installation .........:............................................................... ... in the buildings of.'--- ':.1 a. .. �..... at..... ......... ................ ......... North Andover,Mass. a Fee...�....:..- ..." ... Lic. NoOA5.y. ........ �.�'`..................................................... GASINSPECTOR 41 41 Check# 9291 h ` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK I _ CITY _ �/C: � MA DATE f PERMIT# "1 ZGI JOBSITE ADDRESS 1 - civ _ OWNER'S NAME GOWNER ADDRESS P TELrFAX TYPE OR OCCUPANCY TYPE COMMERCIAL _I EDUCATIONAL PST [ ® RESIDENTIAL®— CLEARLY NEW:[Q. RENOVATION:® REPLACEMENT:B3--- PLANS SUBMITTED: YES El N08— APPLIANCES 7 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER =1==j _ __LEZ=( _. J== =1 1.. ._ BOOSTER ==J - === —CONVERSION BURNER ==F COOK STOVE DIRECT VENT HEATER ------- DRYER FIREPLACE FRYOLATOR (�— FURNACE J GENERATOR.(_ GRILLE .INFRARED HEATER [------f LABORATORY COCKS (- . MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNXENTED ROOM HEATER 1 WATER HEATER OTh R .......... ..........._......... ...................._. INSURANCE COVERAGE I have a current liability nsurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Ilff NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY LV9 OTHER TYPE INDEMNITY [j BOND E 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 Of SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME Liti^ /f ✓ LICENSE#/� _J SIGNATURE MPGF El JP® JGF 0 LPGI CORPORATION©# PARTNERSHIP®# LLC®# COMPANY NAME: ADDRESS CITY STATE ZIP ITEL FAX CELL P .j ' EMAIL ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NPTES Yes No THIS APPLICATION SERVES AS THE PER ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES I I The Commonwealth of Massachusetts - Department ofIndustriglAccidents Office of Investigations Uf 600 Washington Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lezibly Name(Business/Organization/Individual): — rn P11i M_ Address: City/State/Zip: 404 r Phone#: Are you an employer?Check the appropriate box: Type of project(required): ❑ I am a general contractor and I ' 1.❑ I am a employer with 4. g 6. n New construction employees(full and/or part-time).* have hired the sub-contractors 2. a sole proprietor or partner- listed on the attached sheet. E]Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. g, ❑Building addition [No workers'comp.insurance 5. El We are a corporation and its required.] officers have exercised their 1011 Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL I L❑Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t employees.[No workers' 13.❑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 are 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. lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. Policy#or Self-ins.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 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. X do hereby cert' der al n Ities ofperjury that the information provided above is true and correct. SignaturV , Date: i46 Phone#: ��� 6?` iO7 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#: r' 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 " . p oyer 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." . g re q Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current Policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)"A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. 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 COMMORMalth of Ma Dopartment of l dustrial Accidents Office of Investigations 604 Washington.Street Boston}MA.02111 `Fel,#617-727-4900 ext 406 on 1-877,MASSAF.B Revised 5-26-05 Fax#617-727-7.749 wwmass,govfdia COMMONWEALTH OF MASSACHUSETTS PLUMBERS AND GASFITTERS LICENSED AS A MASTER PLUMBER ISSUES THE ABOVE LICENSE T0: i RICHARD T BOWMAN 6 HORNE ST BRADFORD MA 01835-8024 134'49L6 05/01/14 183401 I I <`=COMMONWEALTH 4F MASSACHUSETTS -- �'�� PLUMBERS AND GASFITTERS LICENSED AS A JOURNEYMAN PLUMBER "ISSUES THE ABOVE LICENSE TO: � I I� RICHARD T BOWMAN 6 HORNE ST I� I BRADFORD MA 01835-8024 25201 05/01/14 183400 17 Zz,1"919 r The Cfficial lr4ekist;4: of the OfficeoilCcnsu3rer Affairs and Business l�eguiux.on ( ABR) Division of Professional Licensure Mass.Gov Mass.Gov Home State Agencies A-Z Topics Home) Division of Professional Licensure) ONLINE .......................................................................................:_.........................................................................._.............................................................................................,._...._ SERVICES I Check A Professional License Check a License i Locate a Licensed By the Division of Professional Licensure Professional Online Address i Change ! SEARCH CRITERIA I Contact the Agency Profession: Plumber �} ItrE; License Number: 13496 } } NEW SEARCH { } REFERENCES & LIC. ; RELATED INFO LIC. BOARD LIC. TYPE NUMBER NAME CITY/STATE LIC. STATUS i Disclaimer Regarding ! f Website License I Plumbers Et Master RICHARD T. 3 BRADFORD, Current. License jGasfitters Plumber {13496 I BOWMAN `MA scheduled to be Searches ;printed Glossary of License Plumbers Et Journeyman RICHARD T. FOXBORO _. i Y 13496 Expired Status Codes Gasfitters Plumber t MADDEN MA i i Plumbers Et Apprentice 4 13496 ROBERT L. 1 ! t SAUGUS,MA Current ; s Gasfitters Plumber STILL I Your search has resulted in 3 licenses ; r S �.1�t i r.. t.' Sl'-.t 1 .o-... _ .s: 1_ :Sl'i3.c Aek) _. _f':r Yr ::,i;w i...:{ O 2007-2011 Commonwealth of Massachusetts Site Policies Contact. Us