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Miscellaneous - 119 AUTRAN AVENUE 4/30/2018
- � -119 AUTRAN AVENUE 210/045.D-001 8-0000.0 1J MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ugCITY NORTH ANDOVER. _ __ _ _ MA DATE ._05111/2016 ]PERMIT# JOBSITE ADDRESS 119 AUTRAN AVENUE OWNER'S NAME POWNER ADDRESS __ __ - _ -_-- -- TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL El EDUCATIONAL [I RESIDENTIAL E] PRINT CLEARLY NEW:E3 RENOVATION:El REPLACEMENT: PLANS SUBMITTED: YESE] NO[] FIXTURES 7 FLOOR— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM _-- _- DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN -71 - - _ FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) - - -- KITCHEN SINK Nil LAVATORYROOF DRAINSHOWER STALLSERVICE/MOP SINK TOILET URINAL - WASHING MACHINE CONNECTION _-_ WATER HEATER ALL TYPES WATER PIPING OTHER JJPE LINE - - INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES] NO Ej IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY E] OTHER TYPE OF INDEMNITY E] BOND Q 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 E] AGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in co jince 'th all ertinent pro 's'on of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME I John M Brophy Jr LICENSE# 20052 SIGNATOR MPEJ JPEI CORPORATION Q# PARTNERSHIPEJ#�� LLCQ# COMPANY NAME BrophyPlumbing&Heating ADDRESS 384 Summer Street Rear CITY Manchester STATE MA ZIP 01944 TEL 617-755-9089 FAX CELL 617-755-9089 EMAIL bro_hyplumbing@comcast.net ' The Commonwealth ofMassachrtsetts, .Department oflndustrialAccidents X Congress Street,Suite 100 - '< Boston,MM 0.2X14-2017 www rnass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHPlease Print LORITY. , A licant Information �Y', e 'bl Name(Business/Organization/tndividual): [� / uuf tti' Address: c� �� J 1 c�cA�- � G!� �v'.,— / 7� c� 3 City/State/Zip: AO MC t S 7 f� Phone#: Are you an employer?Check the appropriate box: Type of project()Vequired): 1. I am a employer with t employees(full and/or part-tone).* 7. [�New construction 2. . I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 3..❑I am a homeowner doing all work myself[No workers'comp.insurance required.]t 9. EA Demolition <1 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 0 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. • 12..dumbing repairs or additions 5. I am a general contractor and I have hired the sub-contractors listed on the attached sheet. ❑ 13.�]Roof repairs These sub-contractors have employees and have workers'comp.insurance.$ 6.F1 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.[)Other 152,§1(4),and Nye have no..employees.[No workers'comp.insurance required.] *Any applicant that checks Box 41 must also till 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. iContractors 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,%ey must provide their workers'comp.policy number.' .ra'man employer that is providing workers'compensation insurance for my employees.'Below is the policy and job site information. Insurance Company Name: ' J, (/- Policy#or Self-ins.Lie.#: U i3 j / ! ;7 7,"'Y15 15 Expiration Date: Job Site Address: l C �� t Ili ' " �� City/State/Zip: r I,- Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby certify un e p s`a� enalties o erj r7'that the informationprovided above is true and correct. Si ature: / Date: ✓ t 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.EIectrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: i Information and Instructions Massachusetts General Laws chapter 152 regaires 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'iMre, expres's 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 enferprise,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 bd deemed to be an employer." i 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 foi•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' compensatioii policy,please call the Department at the number listed below. Self insured companies should'enter'their ' self-insurance license number on the appropriate line. City,or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. Anew affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Departments address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia Client#: 21847 JOHNMBROPH1 ACORDTM CERTIFICATE OF LIABILITY INSURANCEDATE(MM/DDIYYYY) 5/12/2016 ,THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed.If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: HUB International New England PHONE 978 657-5100 FAX 978-988-0038 A/C,No,Ext): A/C,No 299 Ballardvale St E-MAIL ADDRESS: Wilmington, MA 01887 978 657-5100 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Travelers Casualty Co of CT 36170 INSURED INSURER B:Travelers Indemnity 25658 John M Brophy Jr dba Brophy Plumbing 384 R Summer St INSURER C: INSURER D: Manchester, MA 01944-3294 INSURER E: 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 CONTRACTOR 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. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSR WVD POLICY NUMBER MM/DD/YYYY MM/DD A GENERAL LIABILITY 68000513742063 11/17/2015 11/17/2016 EACHOCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES ERENTED occcur ence $300,000 CLAIMS-MADE 4 OCCUR MED EXP(Any one person) $5,000 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 X PROJECT D LOC $ A AUTOMOBILE LIABILITY 680005G742063 11/17/2015 11/17/201 EeaBINEDtSINGLE LIMIT $1,000,000 ANY AUTO BODILY INJURY(Per person) $ ALL OWNEDSCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ DED RETENTION$ $ B WORKERS COMPENSATION UB5G74877415 11/17/2015 11/17/201 X WCSTATU- OTH- AND EMPLOYERS'LIABILITY Y/N TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVEE.L.EACH ACCIDENT $500,000 OFFICER/MEMBER EXCLUDED? � N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) Certificate Holder is an additional insured on the general liability policy as respects to operations of the named insured when required by executed contract prior to the loss/claim. CERTIFICATE HOLDER CANCELLATION Town of North Andover SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 120 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. North Andover, MA 01845 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD #S1608476/M1495734 DKO04 j, IDr-wPoir* doverma.viewpointcloud.com/#Jrecordsf20284of North Andover, MA Q I Search bmission received Your request is in progress ay 12,2016 at 10:47am We'll let you know of any updates via email.Feel free to check the status at any time by coming back to this page. Plumbing Permit Review In Progress I I Permit Fee -- —9Prnt Payment ,, I Permit Issuance Document G , s s Map dale 0=16 Google Applicant Location Jack Brophy 119 AUTRAN AVENUE,NORTH ANDOVER,MA Owner BURKINSHAW,ROBERT Attachments Nlo Files- Primary Contractor Search for your contractor using the search bar below.Either the Firm's Name or licensee#is required. Firm's(Business)Name Plumber's Name(Licensee) John M Brophy Thursday, May 12,2016 10:57 AM Libe tLiberty Mutual Insurance y Mutual. New England Region Central Property Unit INSURANCE 75 Sylvan Street Danvers,MA 01923 Tel:(800)566-0323 September 16,2015 Town of North Andover Attn: Building Inspector 120 Main Street North Andover,MA 01845 Re: Property Address:119121 Autran Ave,North Andover,Ma 01845 Policy Number: H3221214893502 Underwriting Company: Liberty Mutual Fire Insurance Company Claim Number:032510241-0001 Date of Loss: 8/21/2015 Attn: Town/City Official Pursuant to M.G.L. c. 139, � 3B, please be aware that a homeowners insurance claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or causes the condition of a building or other structure to render Mass. General Laws, Ch. 143, 5 6 applicable. You are required to notify Liberty Mutual by certified mail in accordance with Mass. General Laws Ch. 175, 599, if you intend to initiate proceedings designed to perfect alien pursuant to Mass. General Laws, Ch. 139, 5 3A &B, or Mass. General Laws, Ch. 143, § 9, or Mass. General Laws, Ch. 111,5 127B. This letter should not be construed as a waiver or estoppel of any of the terms,conditions or defenses afforded by the policy or applicable law. Please direct your notice to the attention of the undersigned and include a reference to the above captioned property address,policy number,claim number,and date of loss. Sincerely, Liberty Mutual Support Liberty Mutual Insurance New England Region Central Property Unit 1-800-566-0323 i Location AJ-", +'j No. Date 1 / • - TOWN OF NORTH ANDOVER • Certificate of Occupancy $ �,. Building/Frame Permit Fee $ Foundation Permit Fee $ „ ' Other Permit Fee $ okxo � TOTAL $ Check# 2689 5 BuildingInspector TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: 1-'7 IMPORTANT: Applicant must complete all items on this page LOCATION ! �. � r''c �. [cry _.- Print / ce PROPERTY OWNER _ v 13 CIZ Print 100 Year Old Structure yes no MAP NO:I ��=PARCEL�ZONING DISTRICT: Historic District ye no Machine.Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Buildingne family ❑Addition ❑Two or more family ❑ Industrial ❑Alt9ral ion No. of units: ❑ Commercial epair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well 0 Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer DESCRIPT ON OF ORK TO BE PERFORM pIdentific tion Please Type r Print Clearly) OWNER: Name: jl old rr �J���'`' S� � Phone: Address: le CONTRACTOR Name: �h � goc-la, 4 hone: � V Address: Supervisor's Construction License: ��? 6 7Z K 77 Exp. Date: Home Improvement License: 16 Exp. Date: ARCHIT ECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BOLDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Ci Total Project Cost: $ FEE: $� Lam' ---- IaO Check No.: 3 19 4/p Receipt No.: vim . NOTE: Persons contracting with unregistered contractors do not have access to the guaran f nd 7Ea:ture of_Agent%Owner w Signature.of contractor j Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ /x Building Department The fol,)wing is--a-list of the required forms to be filled out for the appropriate.permit to be obtained. Roofivig, Siding, Interior Rehabilitation Permits ❑` Building Permit Application ❑ Workers Comp Affidavit o Photo Copy Of H.I.C. And/Or C.S.L. Licenses o Copy of Contract ❑ Floor Plan Or Proposed Interior Work o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks o Building Permit Application ❑ Certified Surveyed Plot Plan o Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o Mass check Energy Compliance Report (If Applicable) o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) o Building Permit pp A lication o Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o Copy of Contract o Mass check Energy Compliance Report o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the apn,,al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submAted with the building application Doc: Doc.Bui?ding Permit Revised 2012 J Plans Submitted ❑ PlansWaived-11 Certified Plot Plan ❑ Stamped Plans ❑ -TYPE:OF-.SEWED AGE DiSPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑. . Swimming Pools ❑ f Well ❑ Tobacco.-Sales ❑ Food Packaging/Sales ❑ Private(septic tank, etc.. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM f DATE REJECTED: DATE.APPROVED j PLANNING & DEVELOPMENT- ❑ ❑ COMMENTS .CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS i Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments I � I Conservation Decision: i Comments Water& Sewer Connection/Si nature& Date Connection/Signature Driveway Permit f DPW Tow; Engineer: Signature: Located 384 Osgood Street FIRE DIEP,4RT �ei�T Temp Dumpster on site yes no Located at 124 Mair Street-. Fire Department signature/date` \l COMMENT'S I -Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions._ .Total land area, sq. ft.: III ELECTRICAL: Movement of Meter location mast orf service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166.Section 21A-F and G min.$100-w00.fine i NOTES and DATA — For department use l i I ® Notified for pickup - Date 1 � E 71111 £ Doe.Building Permit Revised 2010 F i NORTH ANDOVER BUILDING DEPARTMENT Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit • at: ?�/1'� S r his that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c11, S150A. - Also, note Permits are required under Fire Prevention laws Chapter 148 Section 1 OA. The debris will be disposed of in: (Location of Facili Signature of Permit Applicant Dat D) ep-�, h19s �5SOe- ;-74 .4 l Page No. of Pages 1 i UNITED ROOFING CONTRACTORS 5 Brentwood Ave. SALEM, MASS. 01970 Phone 745-8313 PROPOSAL SU MITTED TO PHONE DATE STREET JOB NAME CITY, STATE AND ZIP CODE JOB LOCATION ARCHITECT DATE OF P NS JOB PHONE j We hereby submit specifications and estimates for: X�, At 17 lc� eVe/ J / J IVP propOff hereby to furnish material and labor — complete in accordance with above specifications, for the sum of: lv dollars($ /Z Payment to be made as follow!r: le,e—Le All material is guaranteed to be as specified. All work to be completed in a workmanlike manner according to standard practices.Any alteration or deviation from above specifica- Authorized tions involving extra costs will be executed only upon written orders,and will become an Signature extra charge over and above the estimate.All agreements contingent upon strikes,accidents or delays beyond our control.Owner to carry fire,tornado and other necessary insurance. Note:This proposal may be Our workers are fully covered by Workmen's Compensation Insurance. withdrawn by us if not accepted within days. ,ArrPptanre of proposal—The above prices, specifications ' and conditions are satisfactory and arehereb accepted. You are authorized Signatu to do the work as specified.Paymen will be ade as outlined above. Signature Date of Acceptance: lcx The Commonwealth of Massachusetts - Department oflndustriglAccidents Office of Investigations 600 Washington Street Boston,MA.02111 U9 www.massgov/ilia Workers' Compensation Insurance Affidavit: Builders/Contractors!Electricians/Plumbers Applicant Information Please Print Le ibl Name(Businessiorganizationllndividual): C xf- C c)/ ' '7 L Address: 31 City/State/Zip: xXO, Phone#• 2 L/ 5 . . A=employer ployer?Check the appropriate box: Type of project(required): 1. with4. F1 am a general contractor and I 6. El Now construction e)x employees(full and/or rt-timhave liiredthe sub-coi&actors 2.❑ I am a soleproprietor orpartner- listed on the attached sheet. 7• 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 10.❑Electrical repairs or additions required.] officers have exercised their 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 wehave no 12,[]Roofrepairs insurance .re uiredemployees.[No workers' required.] 13.0 Other comp.insurance required.] 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they aie doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is fhe,pollcy and job site information. L� Insurance Company Name:- Policy#or Self-ins.Lic.#: V `—;�� 9 S-7 7 d / _ ExpirationDate: Z, ZG Job Site Address: /!, ��U�� y/ �� �— City/State/Zip:f1/G Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to.$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA.for insurance coverage verification. I do hereby certlounder 17ae�pains an a Ities ofperjury that the information provided aZ-� is it a and correct. - Signature: ` `'/ Date: 9 Phone#• ?A 11 3-3 0 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 - - -Phnil P V. Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract ofhire,• express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occut of the pan 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 ofits political subdivisions shall enter into any contract for the performance ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapter have beenpresented 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),addres (es)and phone numbers)along with their certificates)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. De advised that this affidavit maybe submitted to the Department of Industrial Accidents for confnmation 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 Iine. 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/li.cense 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 CoMmonwalth of l\4_assa.,chusPtts Depafteut offaduAdal.Accidents Office Othwestig-Wom 600 WasWWoll Street . Boston} OZX�1. TQL#617-727-4900 est 406 oz 1-877-MASUFF Revised 5-26-05 Fay,#6X7-727-7749 CERTIFICATE OF LIABILITY INSURANCEDATE(MMlDDIYYYY) T TIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE OLDER. 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 PROQUCER 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 and endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: EASTERN INS GROUP LLC: PHONE FAX 233 WEST CENTRAL,ST (AIC,No,Ext): (A1C,No): NATICr, 10A0I 760 E-MAIL ADDRESS: 22MLW INSURER(S)AFFORDING COVERAGE MAIC# INSURED INSURER A: TRAVELERS PROPERTY CASUALTY COMPANY OF Aiv1HRICA j UNITED R00FING CONTRACTORS LLC INSURER B: E INSURER C: INSURER D: 5 BRENT `0 )D A'ENLfE INSURER E: IN51JRER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY HA THE PO GPES OF 1 S RANCE 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. INSR .r liDD SUB POLICY EFF DATE POLICY EXP DATE LTR TYPE OF INSURANCE L R POLICY NUMBER (M%tDMYYYY) (MmODIYYYY) LIMITS GENERAL LIABILITY ACH OCCURRENCE $ CO:1MERCIAL GENERAL LIABILITY CLAIMS MADE r7 OCCUR. Aia1AGE TO RENTED REMISES(Ea.occurrence) diED EXP;4rry one person) $ GEN'L AGGREGATE LIMIT APPLIES PER ER,SONAL&ADV ITdJURY $ POLIO ..GENERAL AGGREGATE $ `:' �PROJECT ®LOC RODUCTS-COMP OP AGG $ AUTOMOBILE LIABILITY COMBINED SINGLE $ ANY AUTO LIMIT(Ea accident) �- ALL OWNED AUTOS BO c D L INJURY SCHEDULE AUTOS (Per person; HIRED AUTOS BODILY INJURY $ PION-OWNED AUTOS (Per accident) PROPER T Y DAMAGE $ (Per accident] lJ'17.2RE1_LA LIA.B OCCUR. EACH OCCURRENCE $ EXCESS L.4B D CLAIMS-MIA.DEG 4GREGATE $ DEDUC--;BLE RETENTiOIJ $ WORKER'S COMPENSATION AND 1 We STATUTORY Z OTHER w EMPLOYER'S LIABILITY YIN UB-5B957705-13 05!08./2013 05;0812014 LIMITS AN e PROPERITOR/PARTNER;EXECUTIVE 0FFICERPVEMSER EXCLUDED> NIA E.L.EACH ACCIDENT $ 100,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,COG' If yes,describe un.drr DESCRiPTIOrd JF OPERATIONS below E L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONSILOCATIONSIVEHICLESIRESTRICTIONS/SPECIAL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE. CERTIFICATE HOLDER w..,.,,,, CANCELLATION FAIRWEATHER APTS. &PRESERVATION, SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 40R HIGHLAND AVE BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENT4VE t SALENI,1vIA 01970 , ' �. ,t Y� ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD1988-2010 ACORD CORPORA710N. All'rights reserved."'�"� A' R� CERTIFICATE OF LIABILITY INSURANCEDATE(MM,DD,YYYY) _ J 9/11/2013 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). PRODUCER ' CONTACT NAME__. lect Dept. Eastern Insurance Group LLC -Main i,';•_;. PHONE AX x_508 653 8089 233 West Central Street ,ac No Ext:508 651 7700 Natick MA 01760 AAooREss:selectwork_ easterninsurance.com —_ INSURER(S)AFFORDING COVERAGE NAIC q ._,_. LNSURERA:First Mercu Insurance Co _____ INSURED INSURER B: United Roofing Contractors.LLC INSURER C: 5 Brentwood Avenue INSURER D: Salem MA 01970 - INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:1618793599 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 REOUIREMEN T. 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. INSR ADDL SUBR I POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSRIWVDI POLICYNUMBEER MMtDD/YVYY MM/DOIVYYY LIMITS A GENERAL LIABILITY Y NJCGL0000027775 /30/2013 30,12014 EACH OCCURRENCE $1;000,000 X I DANW W€�crr D - COt4PAERCIALGENERA�.ABILITY i PREta11SEStEaoccurrence $100,000 FCLA.INIS-MADE OCCUR r" i MED EXP(Any one person) $5,000 PERSONAL&.ADV IFdJURY $1,000,000— _ GENERAL AGGREGATE $2.000,000 GEN'LAGGREGATE LIMIT APPLIES PER: I " PRODUC:TS-COMP/OPAGG $2.000,000 X �PRO- I $ --— — POLICY L.:... LOC AUTOMOBILE LIABILITY i _� i CO) \ I Ea a.ccidern) _ $ _ ANY AUTO BODILY INJURY(Per person) $ u ALL OWNED SCHEDULED BODILY INJURY(Per as idant) $ AUTOS AUTOS HIRED AUTOS 1'1014-OWNED PROPERTY DA.M,AGE $ AUTOS Per acckle".) _ $ UMBRELLA LIAB . OCCUR j EACH OCCURRENCE 1$ EXCESS LIAB CLAIMS-MADE I. AGGREGATE $ AGGREGATE RETENTION$ I $ WORKERS-COMPENSATION '; i (CRY LRvI TS l OER ITH- AND EMPI-6YERS'LIABILITY Y N _ ANY PROPRIETOR/PA.RTNER/EXECUTIVE E.L.EACH AC:CI OFFICERMIEMBER EXCLUDED?-, ` N/A ..... (Mandatory In.NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS l LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space Is required) Roofing Contractors. v... CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Mlchae; Shea-United Roofing Contractors LLC ACCORDANCE WITH THE POLICY PROVISIONS. 31 R Wz.'shington Square Sale';';:MA01976 4056 AUTHORIZED REPRESENTATIVE 4 1 ©1988.2010 ACORD CORPORATION. All rights reserved ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License: CS-071677 --; MICHAEL T SHEA 5 BRENTWOOD ANT SALEM MA 01970 _ Expiration Commissioner 04/01/2014 l Bus �aauctu�aetta �e�e Tpan�im�? L • Regulation I Office of Consumer AffairCONTRACTOR OME IMPROVEMENT Type: egistration: (06854 DBA xpiratio n: . 7128x20;1:4... 1 UNITED ROOFING C. Michael Shea — 5 Brentwood Avenue Undersecretary Salem,MA 01970 Location No. 09- S Date �oRT� TOWN OF NORTH ANDOVER „ Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit FeeShge $ ZSR Sewer Connection Fee $ Water Connection Fee $ TOTAL $ Z-S� uilding Inspector 11/10/94 09:45 25.00 PAID 7724 Div. Public Works PERMIT NO. t(QE;� "S APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. PAGE 1 MAP 4J0. I LOT NO. 2 RECORD OF OWNERSHIP -'DATE BOOK -'PAGE — ZONE SUB DIV. LOT NO. OCATIONNipU--t-�A PURPOSE Cir+oYiiei�liiCsZw np f1v A (7� W%ER'S NAME NO. OF STORIES SIZE %ER'S NA�MEl s-sc�u OWNER'S ADDRESS 11/ �� / �F u� BASEMENT OR SLAB _ ARCHITECT'S NAME T �V SIZE OF FLOOR TIMBERS IST 2ND 3RD UILDER'S NAME / SPAN --- DISTANCE TO NEAREST BUILDING DIMENSIONS OF SILLS DISTANCE FROM STREET " POSTS DISTANCE FROM LOT LINES—SIDES REAR " GIRDERS AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW SIZE OF FOOTING X IS BUILDING ADDITION MATERIAL OF CHIMNEY IS BUILDING ALTERATION _ IS BUILDING ON SOLID OR FILLED LAND ILL BUILDING CONFORM TO REQUIREMENTS OF CODE _ /�S. IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION. IF ANY .G� IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE 3 PROPERTY INFORMATION INSTRUCTIONS LAND COST SEE BOTH SIDES EST. BLDG. COST PAGE I FILL OUT SECTIONS I - 3 EST. BLDG. COST PER SQ. FT. EST. BLDG. COST PER ROOM PAGE 2 FILL OUT SECTIONS I - 12 SEPTIC PERMIT NO. ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR //AT AT LE /� D BOARD OF HEALTH (((/// SI ATURE OF OWNER OR AUTHORIZED AGENT FEES PLANNING BOARD PERMIT GRANTED G�n 19 l" BOARD OF SELECTMEN BUILDING INSPECTOR WHITE: Building Dept. CREAM: Assessors CANARY: Treasurer BUILDING RECORD 1 OCCUPANCY 12 SINGLE FAMILY StoRIES THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM MULTI. FAMILY OFFICES LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA- APARTMENTS RAGES, ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. CONSTRUCTION 2 'FOUNDATION 8 INTERIOR FINISH CONCRETE a I 2 13 CONCRETE BL'K. BRICK OAR STONE HARDW D PIERS PLASTER _ —' 21Y WALL _ UNFIN. 3 BASEMENT 11 AREA FULL FIN. B'M'TAREA _ '/ 1/1 3/, FIN. ATTIC AREA _ N_O B M'T FIRE PLACES _ HEAD ROOM MODERN KITCHEN 4 WALLS I 9 FLOORS CLAPBOARDS - B '1 2 3' DROP SIDING CONCRETE �_ WOOD SHINGLES - 'EARTH ASPHALT SIDING HARDW'D _ ASBESTOS SIDING COMIACN - VERT. SIDING ASPH.TILE - STUCCO ON MASONRY �— STUCCO ON FRAME BRICK ON MASONRY ATTIC STRS. 8 FLOOR _ BRICK ON FRAME CONC. OR CINDER BLK. STONE ON MASONRY WIRING STONE ON FRAME _ SUPERIOR I� POOR ADEQUATE NONE 5 ROOF 10 PLUMBING GABLE HIP BATH (3 FIX.( GAMBRELMANSARD TOILET RM. (2 FIX.) _ FLAT I SHED WATER CLOSET _ ASPHALT SHINGLES LAVATORY WOOD SHINGES KITCHEN SINK _ SLATE NO PLUMBING _ TAR 8 GRAVEL STALL SHOWER _ ROLL ROOFING MODERN FIXTURES _ TILE FLOOR TILE DADO 6 FRAMING I 11 HEATING WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. TIMBER BMS. &COLS. _ STEAM STEEL BMS. & COLS. HOT W'T'R OR VAPOR WOOD RAFTERS _ AIR CONDITIONING RADIANT H'T'G UNIT HEATERS 7 IA. OF ROOMS GAS OIL B'M'T 2nd _ ELECTRIC 1st 13rd NO HEATING FE! 11:17 I•fU: WOOD STOVE INSTALLS HON QHECI�LIST , 3 Permit A building permit is required for the installation of any solid fuel burning appliance. The building permit and installation inspection are limited to the stove installation and-not to the stove construction. Stove Used ..�` A. New B. Typelradianloc �, �a ),-,, SK�=>` Circulating t C. Manufacturer Z-' Lab.No. Name/Model No. '��'� ''k1 Collar size Dimensions/Height 3,,"" /-%'=' �y �''�' Length Width Chimney A. New Existing B. Size(flue area) — C. Other appliances attached to flue(Number and flue size) . D. Prefab(Manufacturer—name and type) E. Masonry/Lined Flue liner ,type 8 manWacmror) Unlined F. Height(refer to diagrams) cap 12 r hurl. I aVErZ IC i tvtlty surf. lot I$"btlN. HEARTH a x --- CHIMNEY HEIGHT Hearth(non-combustible) A. Materials B. Sub-floor construction C. Minimum dimensions(refer to diagram) Clearances and Wail Protection/see stove installation clearances chart) A. Type of wall protection provided B. Clearances(refer to diagrams) I I II r FIREPLACE CORNER WALL410ENTER } r a.r 4 `�.'�. i't •♦i.. ,,�..y,4•it�T`,6 "Mti,� r.,v•a.�a1`:t �,L, e�:::y'..,,:,j..a.;�,_. `: � ..y, r "�'i�':�ui �i+1V^s��. tmii��:.i.�.t�•i�..�,'�? :12i':4a�:1.�s.1.�.3'�Y:.1,'ft�4:.tr.,€i�iitt„t�v1��i8t..�a?:�$•;•;.;m.�igx`J.w:ii:.lw,i.�.sia.a�ieaa:r:,.���'ut.d�',:�aSL•31.aNS�i1rI..�..,r�:.!var.�A;.'.�s�:i1�e,'�Yt: S.t.1�;: yT:} NON , CATALYTIC WOOD INSERT CITArI100N f ` H _ i € F _ p 1 t s f. Til— TiSPPE `�. y � 354 N. Broadway Jct. Rts. 28 & 111 • Salem, NH 03079 TEL. 603-893-0456 FAX 603-898-1697 Wood&Coal Stoves,Zero/Clearance Fireplaces, Gas Logs,Fireplace Grates,Boilers,Furnaces, "tea i= 7` Glass Fireplace Enclosures,Mesh Fireplace Screens,Toolsetl&Gifts, Complete line of Metalbestos Chimneys,Stovepipes 8 Accessories, Wooden Swing Sets&Forts,Installations,Sales&Deliv4ries C L A S VIRGINIA KIMBALL Sales ntroducing the Citation"Classic" non-cataiytic wood insert. A quality work of craftsmanship that complies with todays stringent standards without compromising good looks. Each Citation Classic represents a careful integration of the best in modern design, construction technique and decorative detail. A welcome addition to any home. Out-careful blending of cast iron and steel ensures endurance and countless years of troubiefree performance. The expansive giass paneiied door on each mouei provides an unobstructed view of the crackling fire without maintenance or sacrificing efficiency. The state-of-the-art non-catalytic combustion system and internal heat exchanger coupled with a unique convection air system circulates heated air throughout the room. In addition, reversible flue collars for fireplace installation and a large ashpan with slide-on, carry-out cover for clean convenient ash removal, are standard features. The Citation Classic isn't only functional. Its just about the best looking stove to be introduced in years. Available in porcelain enamel and several painted shades, the Classic wood insert was designed to enhance any living environment. Optional decorative features allow that distinctive touch, a personal signature to what assuredly will be the focal point of any setting. We offer a limited three year warranty, a network of highly qualified Dealers and the assurance of our commitment to customer satisfaction. SPECIFICATIONS MODEL WI45 Non-Catalytic STANDARD FEATURES ` MAX. HEAT OUTPUT 45,000 BTU/HR Large glass door panel Insert panel with brass trim MAX. LENGTH OF BURN Up to 6.5 HRS Large ashpan with cover Convenient front loading AREA HEATED Up to 1200 SQ FT Manual primary air control Factory set secondary air Interchangeable top& rear flue LOG LENGTH 20" Standard painted color • Charcoal RECOMMENDED FUEL Hardwood OPTIONS Solid brass door trim FLUE SIZE Oversized insert panel with brass trim 6" Round Circulating blower with speed control Porcelain enamel finishes • Warm Mahogany Brown REAR FLUE HEIGHT 21.25"To Center • Colonial Blue STOVE WEIGHT 410 LBS Custom painted colors • Goldenfire Brown • Patriot Blue INSERT PANEL SIZE 30" H x 39"W CI F,AR A NCF.S MANTEL 39" MODEL W145NC 18" UNSHIELDED INSERT 711 9 11 U U Z Z a u^ aoa00000a000000000aoaa v A oo ® c� 0 3 3 INSERT J LUJ A C 18, 8" O P:23.75" TO' TO WALL TRIM — O p M r^ FRONT �4 Hearth flush with floor A=26" L i. ►I Raised hearth A= 16" 3" 10" h-1-2.775"" 5.25" U U NOTE Lr) Z Heating capacitu,heat output and other svecifi'cations are hosed an a range from n' minimum to rapid or hot burning times.These should be taken as guidelines 5 only.Variables such as quality of wood,chimney draft,outside temperature, O insulation and even the operator of the appliance are all governing factors in w __jw determining the heating capabilities of any stove.Your Citation Dealer will help O 0 you select the product which best fits your individual needs. 0 0 All solid fuel burning appliances and related accessories must be installed and — operated in accordance with Federal,State,County and Local laws,ordinances D M N and permits as well as manufacturer's instructions.Contact your local building or fire official about restrictions and installation inspection requirements. 7.75" Utilizing NFPA 211 clearances may be reduced up to a maximum of 50%. Citation reserves the right to change,update or improve the product as needed. Stoves colors reproduced here may vary frorn actual color. Installations shown are staged. ARNOLD GREENE TESTED AND APPROVED TO UL 1482 SPECIFICATIONS. ARNOLD GREENEICBOnTL110 CITATION C L A S s I C Manufactured by CITATION MARKETING a Division of F1PPr