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HomeMy WebLinkAboutMiscellaneous - 148 MAIN STREET 4/30/2018 (24) I D 7 E Date.� �?3� ff . TOWN OF NORTH ANDOVER - PERMIT FOR PLUMBING 41 ,SSACMUSE� / This certifies that . . . )oA. . . ./e4z� 4- . . . has permission to perf rm . .ko . . . '? . . . . .j plumbingin the buildings of . . . . . .' '��. . . . . . . . . . . . . . . . . . . . at . .� . . . . . . ,✓.� . . . . . .�. . . . . . :.. . . . . . . . . . No h Andove ass. FJ 30 QO.Lic. No. 7 f PLUMBING INSPECTOR Check # MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING City/Town:�UOf �U r MA. Date: Permit# Building Location:_I y� /'It;r ft1 ,ST C � f Owners Name: 1 / Type of Occupancy: Commercial❑ Educational ❑ Industrial(] Institutional❑ Residential( ' New: Alteration: Renovation: Replacement: Plans Submitted: Yes No FIXTURES DEDICATED Z SYSTEMS Z W V W N to �1 d W a rc Z Z ID Z L W %" ~ '� t; `� O d LUQ W Q Q 11}} W 4 1� �r C J {y Q SUB BSMT. BASEMENT -7-FLOOR FLOOR FLOOR 4 FLOOR 5 FLOOR 6 FLOOR 7 FLOOR 8 FLOOR Check One Only Certificate# Installing//Company Name: J O n dhaa^ Address C� G w,Cl('a C k -V,if, ❑Corporation lCity/Town: �F State: \\ C��Cti3I ❑Partnership Business Tel 200 -90.�� '"'��O �/ Fax: ❑Firm/Company Name of Licensed Plumber: 3-C) C3 L-1 INSURANCE COVERAGE: I have a current liabilityinsurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142 Yes❑ No❑ If you have checked Yes. please indicate the type of coverage by checking the appropriate box below. A liability insurance policy- Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. Check One Only Signature of Owner or Owners Agent Owner ❑ Agent ❑ I hereby certify that all of the details and information 1 have submitted(or entered)regarding this appCcabon 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. By Type of License: rtle C3 Plumber ure o I sed Plumber City/Tovm aster APPROVED OFFICE USE ONLY) Journeyman Licen umber l 3� OP ID: MF CERTIFICATE OF LIABILITY INSURANCE DAT04/05DIYYYY) 04/05/11 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 603-432-2577 CONTACT NAME: Whittemore Insurance 603 432-4700 PHONE FAX 501 Mammoth Road WC,No.Extl: AIC N.Y. Londonderry, NH 03053 E-MAIL ADDRESS: PRODUCER CUSTOMER 10#:LEONJO2 INSURER(S)AFFORDING COVER14 AGE _-_NAIC# INSURED John Leonard _INSURER A:NGM Insurance Compal _ 788 — 6 Tamarack Lane INSURER B: Amherst, NH 03031 INSURERC: -- --- -----— -- — - t —-- — INSURER D 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 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 TYPE OF INSURANCE ADDL SUB POLICY EFF POLICY EXP LTR POLICY NUMBER MMIDDIYYYY MM/DD/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X�COMMERCIAL GENERAL LIABILITY MP005706 05/16/11 05/16/12 PREMISES(Ea occurrAMAGE TO ence) $ 50,000 i CLAIMS-MADE OCCURMED EXP(Any one persons) $- -_ 5,000 — i PERSONAL 8 ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000__ POLICY PRO JE LOC $ I AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 A ~ (Ea accident) ANY AUTO i 81005706 09/12/10 09/12/11 —I --- --- F-7 BODILY INJURY(Per person) $ � ALL OWNED AUTOS —}----- -.- -J j BODILY INJURY(Per accident) $ X I SCHEDULED AUTOS PROPERTY DAMAGE $ X HIRED AUTOS (Per accident) X I NON-OWNED AUTOS I —' $ UMBRELLA LIAB OCCUR EACH OCCURRENCE _ $ EXCESS LIAB CLAIMS-MADE AGGREGATE i .� DEDUCTIBLE f RETENTION $ —_� - $ WORKERS COMPENSATION — WC STATU- OTH- AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE YIN T I T OFFICER/MEMBER EXCLUDED? NIA E.L.EACH ACCIDENT $ (Mandatory in nd E.L.DISEASE-EA EMPLOYEE $ I If yes,describe aunder _ DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) Plumbing and heating COMMONWEALTH OF MASSACHUSETT PLUMBERS AND GASFITTERS CANCELLATION LICENSED AS A MASTER PLUMBER JOHN A LEONARD TOWNBUR ISSUES THE ABOVE LICENSE TO: SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. v 6 TAMARACK LN ,UTHORIZED REPRESENTATIVE � AMHERST NH 03031-2261 z`-'��- 1- ©1988-2009 ACORD CORPORATION. All rights reserved. 13248 05/01/12 795817 i tame and logo are registered marks of ACORD ��np � �°� � �