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HomeMy WebLinkAboutMiscellaneous - 15 HEPATICA DRIVE 4/30/2018 BUILDN" G FILE �Pe 'oL i Registry ID: 007460373 Rating Number: ABA5303-123 AL Certified Energy Rater: Steve Weglarz Rating Date: 5-19-2014 15 Hepatica Or Rating Ordered For. Key Lime,Inc-Ben Osgood North Andover,MA01845 I"ate fir Estimated Annual Energy Cost Confirmed 5 Stars Plus Use MMBtu Cost Percent Confirmed Heating 124.8 $4165 67% Uniform Energy Rating System Energy Efficient Cooling 0.0 $0 0% Hot Water 23.3 $765 12% 1 Star 11]%11111s t2 Stars 2 Stars Plus 3 Stars 3 Stars Plus —4St- : 4 Stars Plus 5 Stars 5 Stars Plus Lights/Appliances 25.2 $1252 20% 500-401 400-301 300-251 250-201 1200-151 150-101 100-91 90-86 8571 70 or Less Photovoltaics -0.0 $-0 -0% HERS Index: 53 Service Charges $0 0% Generallnformation Total 173.3 $6182 100% Conditioned Area: 3357 sq,ft HouseType: Single-family detached -�- Conditioned Volume: 29248 cubic it Foundation: More than one type - -- -__ Bedrooms: 3 This home meets or exceeds the minimum - criteria for all of the following: Mechanical Systems Features-- 9: _- re a n, - - .1 - --- 2009 International Energy Conservation Code Heating: Air conditioner, air distribution,Propane,96.1 AFUE. IECC Air Sealing Mandatory Requirement-Infiltration<7AC Cooling: Air conditioner,Electric,13.0 SEER. Water Heating: Conventional,Propane,0.67 EF,50.0 Gal. 2009 IECC Duct Leakage Mandatory Requirement* Duct Leakage to Outside: 30.00 CFM25. 2014 MA Residential New Construction-Tier 1* Ventilation System: Exhaust Only:69 dm,9.0 watts. MA Base Code HERS Rating Performance requirement* Programmable Thermostat: Heating:Yes Cooling:Yes Buliding Shell Features Ceiling Flat: R-40.0 Slab: R-0.0 Edge,R-0.0 Under Sealed Attic: NA Exposed Floor. R30.0 *Compliance with criteria forthis program is Vaulted Ceiling: NA Window Type: U-Value:0.300,SHGC:0.290 determined by the rater. Above Grade Walls: R-21.0 infiltration Rate: Htg:944 CIg:944 CFM50 Foundation Wails: R-0.0 Method: Blowerdoortest Lights and Appliance Features Percent Interior Lighting: 91.00 Range/Oven Fuel: Propane Advanced Building Analysis,LLC Percent Garage Lighting: 100.00 Clothes Dryer Fuel: Electric 2 Woodlawn St. Refrigerator(kWhtyr): 569.00 Clothes Dryer EF: 3.01 Amesbury,MA 01913 Dishwasher Energy Factor. 0.78 Ceiling Fan(cfm/Watt): 0.00 www.advancedbuildinganalysis.com The Home Energy Rating Standard Disclosure for this home is available from the rating provider. REM/Rate-Residential Energy Analysis and Rating Software v14A.1 This information does not constitute any warranty of energy cost or savings. ©19852014 Architectural Energy Corporation,Boulder,Colorado. Certif En gy Rat 2009 IECC Certificate 15 Hepatica Dr,North Andover,MA 01845 Building Envelope Insulation T T� Ceiling: R-40.0 Above Grade Walls: R-21.0 Foundation Walls: R-0.0 Exposed Floor: R-30.0 Slab: R-0.0 Edge,R-0.0 Under Infiltration: Htg:944 Clg:944 CFM50 Duct: R-6.0 Duct Leakage to Outside: 30.00 CFM @ 25 Pascals Window Data U-Factor SHGC Window: 0.300 0.290 Mechanical Equipment T T HEAT: Fuel-fired air distribution,Propane,96.1 AFUE. COOL: Air conditioner,Electric,13.0 SEER. DHW: Conventional,Propane,0.67 EF,50.0 Gal. Builder or Design Professional Signature REWRate-Residential Energy Analysis and Rating Software 04.4.1 RESNET HOME ENERGY RATING Standard Disclosure For home located at: 15 Hepatica Dr City: North Andover State: MA 1. The Rater or the Rater's employer is receiving a fee for providing the rating on this home. 2. In addition to the rating,the Rater or Rater's employer has also provided the following consulting services for this home: ❑ A. Mechanical system design ❑ B. Moisture control or indoor air quality consulting C. Performance testing and/or commissioning other than required for the rating itself ❑ D. Training for sales or construction personnel E. Other(specify below) 3. ❑ The Rater or Rater's employer is: A. The seller of this home or their agent ❑ B. The mortgagor for some portion of the financed payments on this home C. An employee,contractor or consultant of the electric and/or natural gas utility serving this home 4. The Rater or Rater's employer is a supplier or installer of products,which may include: Installed in this home by: OR Is in the business of: HVAC systems ❑ Rater ❑Employer Rater Employer Thermal insulation systems ❑ Rater Employer Rater Employer Air sealing of envelope or duct systems Rater Employer ❑ Rater ❑ Employer Windows or window shading systems El Employer Employer ❑ Rater ❑ Employer Energy efficient appliances ❑ Rater ❑ Employer ❑ Rater ❑ Employer Construction(builder,developer,construction ❑ Rater ❑ Employer ❑ Rater ❑ Employer contractor,etc.) Other(specify below): ❑ Rater ❑ Employer ❑ Rater ❑ Employer I attest that the above information is true and correct to the best of my knowledge. As a Rater or Rating Provider I abide by the rating quality control provisions of the Mortgage Industry National Home Energy Rating Standard as set forth by the Residential Energy Services Network(RESNET). The national rating quality control provisions of the rating standard are contained in Chapter One 4.C.8 of the standard and are posted at http://www.natresnet.org/accred/Standards.pdf. This home may have been verified under the provisions of Chapter Six,Section 603,'Technical Requirements for Sampling"of the Standard. Steve Weglarz 1225336 Rater's Printed Name Certification# May 30,2014 Rater nature Date RESNET Form 0300-2 I Date.....f..Z...-.....7... �` r10RTh TOWN OF NORTH ANDOVER c�: -�: • °off PERMIT FOR WIRING c This certifies that ............. has permission to perform ....................... ! ..... vs. ....................................... wiring in the building of............ .��-/1—/. .............................................................. a �/ at ......1..�..Wi.-,� n). ....................................................� torthAndover,Mass. Fee.S..Z "..Lic.No. .2. I blT................... ..... ELECTRICAL INSPECTOR Check# 2058 Commonwealth of Massachusetts Official Use Only ! PermitNo. a Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT INMK OR TYPE ALL INFORMATION) Date: "s-)— j ?o 13 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)_ is Ht,&AS, N(• Owner or Tenant Re fyiN�, (jC r4� Telephone No. Owner's Address % �` j Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps [1� / Volts Overhead ❑ Undgrd No.of Meters. New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: , �U -�� �,, NaV t/ I cll►f D��b(S Completion of thefollowing table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No,of Total Transformers KVA No.of Luminaire Outlets No,of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above F1 In- ❑ o,of Emergency.Lighting rnd.. gmd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No, of Zones. No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons g No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: """"""""'" " ............. Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: p Heaters Signs Ballasts No,of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: � No.of Devices or E uivalent OTHER: �.. e, 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: 11-1"?_ 13.—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 coverage is in 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 ofperjury,that the information on this application is true and complete. FIRM NAME: . c LIC.NO.: Licensee: Signature LTC.NO.: a 1 afapplicable,enter "exempt"in the Z' en number line.) n� Bus.Tel.No.: �Ac(L 7130. Address: `a. (A\)v- {'c r- / i 0 3 Alt.Tel.No.: 006=3-71— 11f � *Per M.G.L c. 147,s.57161,security work requires Department of Public Safety"S"License: Lic.No. CPI 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. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance-with the provisions of M.G.L.c. 143,§3L,the p permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166,§32,an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the J notification of completion of the work as required in M.G.L.c.143,§3L. Permits shall be limited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses conceming the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012. ❑ Rule 8—Permit/Date Closed: ***Note:Reapply for new permit❑ ❑Permit Extension Act—Permit/Date Closed: Trench Inspection Pass R Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICR INSPECTION: Pass Failed Re-Inspection Required($.) ❑ . Inspectors Com n : Inspectors Signature: U Date: PARTIAL ROUGH INSPECTION: Pass n Failed M Re-Inspection Required($.) ❑ Inspectors Comments: Inspecto s Signature: Date: ROUGH PECTION: N Pass IN Failed Re-Inspection Required($.) ❑ Inspectors Comm Inspectors Sig tures U Date: FINAL INSPECTI Pass Failed Re-Inspection Required($.) ❑ Inspectors Comments: _I Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com tt , The Commonwealth of Massachusetts - Department of Industrigl Accidents Office of Investigations quo 600 Washington Street Boston,MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le>sibly Name(Business/Organization/Individual): 1!a 161 'Cc (k 3ZIC •- Address: `)-\ �\y 4A Nie City/State/Zip: 54-, 4,rj M�_ 19kb`)q 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. P .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.t 7• ❑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. 0 We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3111 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.]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. I-Homeowners who submit this affidavit indicating they aie doing all work and then hire outside contractors must submit a new affidavit indicating such. TContractors that 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:. PAo�_Jr\f Veli-le,, Kre Tv-,S. evic Policy#or Self-ins.Lie.#: C,L- a6 IS Ta Expiration Date: r Job Site Address: &2k c, (��( VC. City/State/Zip: /v� /I�crcYe✓ ��N� O!�t��� J` 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 4 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 DTA for insurance coverage verification. Ido hereby certify under the pains andpenalties of perjury that the information provided above is true and corrdct. t Signature: 8)i, Date: 17-7 13 Phone#: q)k-3 7 4- U G a 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 CIerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - - Contact Person: Phone#: r q Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced-acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of , insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit 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(ifnecessary)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 homeowner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to bum 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 offavestfgaliions 600 Washington Street Boston,MA,0.2111 Tel.#617-727-4900 at 406 or 1-877rMA.SS.A.FB Revised 5-26-05 Fay,#617-727-7749 -727-7749 www.mass,govfdxa w I 1:: OMMONWE4LTH OF MS1C'HSETTS<': `'" 13 Of 'EV ECTR I C I AN HE FOLLOW I`N: I�CENS ;€=;; JOURNEYMPrN<<ELEC� RiCI, rr Q I _-5R:j:A A WRISLEY,':: U w E. • '` V i� A YA T� H "` 6 4403 o > ;< IA 01835- 1620<1: .M I Date.O�N .. OAT$, TOWN OF NORTH ANDOVER 0 PERMIT FOR PLUMBING This certifies that........ ........}.^.° ...y - ..........e.. ..................... has permission to perform........R .....Out................................................. plumbing in the buildings of....P.q at.....�5�.... ................................. ...........4 ffh Andover, Mass. Fee 525.11...Lic. No. 103.Y.k.. ......... PLUMBING INSPECTOR Check# 1\7W Date....l.!....................�.................. .a 4 �RTh 7 q 03 9 TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION �$$�cHuss k This certifies that .....C� - ................. has permission for gas installation . .... in the buildings of....! / f.;Q $ �rtn� ......................................: �.... at....4..55....�.A,.% -)CA.............................................. North Andover,Mass. FeeV.19!�w .. Lic. No. 103.�,�..... ............. ........................................... �., � GAS 11�5PECTOR M Check# ; ? ' S ebb !L�' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY MA. DATE PERMIT i JOBSITE ADDRESS I tj edOWNER'S NAME ato't 1(41 POWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE: COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW:Al RENOVATION:❑ REPLACEMENT:F] PLANS SUBMITTED: YES❑ NO ❑ FIXTURES Z FLOOR- BSMT 1 2 3 4 5 6 1 8 9 10 11 12 13 14 BATHTUB Z CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYS DEDICATED GAS/OIL/SAND SYS DEDICATED GREASE SYS DEDICATD GRAY WATER SYS DEDICATED WATER RECYCLE SYS DRINKING FOUNTAIN DISHWASHER J FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK 1 LAVATORY Ll ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET 2 URINAL WASHING MACHINE CONNECTION + 1 WATER HEATER ALL TYPES WATER PIPING i OTHER INSURANCE COVERAGE: ,-,r I have a current liabilityinsurance policy or its substantial equivalent which,meets the requirements of MGL Ch. 142. Yes L� No❑ IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY E�( 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 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 Cha fer 2 o the General Laws. PLUMBER NAME - STEP0150 C. GAUNS10 SIGNATURE LIC#{ 11 03 R S MP[' JP❑ CORPORATION X# 19 b PARTNERSHIP ❑# LLC ❑# COMPANYNAME 6AL0SK( PLi)MOJ fb i- RVATIOG ADDRESS: P.0• GGY, 1,701 CITY HAVERFtt i- STATE IYI.IA. ZIP OIB3 EMAIL VYvww. mEpIVmbe>r�C�iOl . Cowl TEL g7$-37q- 17,4 3 CELL 5015-50q-51014 FAX q7$-SoZ!-1f 131 I ,\ 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 NO`PES MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY: 1j.CJ` % ( �rz+.,J MA. DATE:\•1 PERMIT# JOBSITE ADDRESS:_ OWNER'S NAME: SqLA GOWNER ADDRESS: TEL FAX: TYPE OR OCCUPANCY TYPE: COMMERCIAL❑ EDUCATIONAL ❑ PRINT RESIDENTIAL ] CLEARLY NEW:1 7 RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ APPLIANCES? FLOOR— Bsmt 1 2 1 3 1 4 1 5 6 1 7 1 8 1 9 1 10 1 11 1 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER ` LABORATORY COCK e MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER INSURANCE COVERAGE 1 have a current liabili insurance 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. LIABILITY INSURANCE POLICY g 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 E]SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application w4be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUM BER/GAS FITTER NAME, STEPHEN C. GALZNSKY LICENSE# 103y$ V SI NATURE COMPANYNAME: &ALW:3k11 PLVrA j0(. t µr_*?-ItJ& ADDRESS: P.0- t'.0X 1701 CITY: !<IAVi:RNiLi. STATE: M.A. ZIP: O)$31 FAX: 979- 5ll-4131 TEL: 978-37y- 17y3 CELL: 5'0S- 6tA— 59081 EMAIL: W.w.w. +e+'1i" ft mbe 01rn MASTER( JOURNEYMAN❑ LP INSTALLER❑ CORPORATION/# �1 iib PARTNERSHIP 0# LLC # ROUGH GAS INSPE TION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES �-2 Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES Date.. d: .l X.............. NonTM TOWN OF NORTH ANDOVER oar°•. •, .� °on * PERMIT FOR WIRING d This certifies that S ........................................... ................................................... has permission to kp /,rte. .ti� . wiring in the building of..............:. ...... .......................... .................. ..................................... . at /. P C 1¢ ............... ......................... .........................:, orth Andover,Mass. ...... ��� Fee Lic.No. .............. ..................... ELE&mcAL INSPECTOR Check# 3e Common wealth of Massachusetts Official Use Only ti Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07) (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 N (PLEASEPRINTWINKORTYPE-4LLBWORMATION) Date: 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 Y ty V < Inc i n�, Telephone No. ' OI( --'),C6– %'l Q Owner's Address Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building �, , Utility Authorization No. < - Existing Service Amps / Volts Overhead ❑ Undgrd❑ No.of Meters C� New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion of the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires 10 No.of Ce& Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators RVA _- No.of Luminaires Swimming Pool Above ❑ In- Elo.o mergency Lighting rnd. rnd. Battery Units A No.of Receptacle Outlets J() No.of Oil Burners FIRE ALARMS No. of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices Total No.of Ranges No.of Air Cond. Tons No.of Alerting Devices �.. No.of Waste Disposers Heat Pump INgmber Tons KW No.of Self-Contained ,7p ................._................................. + _ Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No,of Motors Total HP Telecommunications Wiring: OTHER: No.of Devices or Equivalent " S Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: `a >0 (When required by municipal policy.) `n Work to Start: `S- Inspections to be requested in accordance with MEC Rule 10,and upon completion. 2 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 T undersigned certifies that such co erage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and p Malties of perjury,that the information on this application is true and complete. — FIRM NAME: . LTC.NO.: ' C l Licensee: rNs\c Signature a G� � LTC.NO.: ff applicable,enter "exempt"in t e license Lumber ling) Bus.Tel.No.• q7A''S1 0 Address: \ . arc. MA. 0 ktW, Alt.Tel.No.: 516-17 �- *Per M.G.L c. 147,s.5M ,security work requires Department of Public Safety"S"License: Lic.No. � OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent. Owner/Agent PERMIT FEE.$ Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance-with the provisions of M.G.L.c. 143,§3L,the lk permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166, §32,an ` r electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L.c.143,§3L. Permits shall.be limited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real properly.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012. ❑ Rule 8—Permit/Date Closed: ***Note:Reapply for new permit ❑ ❑Permit Extension Act—Permit/Date Closed: Trench Inspection Pass M Failed ❑' Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass M Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: . Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass M Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTIO . Pass Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INCTION: Passw" Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: lel.- ,c S� q Date: 3 DEB WEINHOLD ... TOWN OF MERRI AC,MA. .......dweinhold@townofinerrimac.com The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Uf 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: 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. F1 Now 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.1 7. ❑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 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.[No workers' comp. c. 152,§1(4),and we have no 12.❑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. T Homeowners who submit this affidavit indicating theya're doing all work and then hire outside contractors must submit anew 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 olic information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy anal job site information. Insurance Company Name:. Policy#or Self-ins.Lic.M 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 certo under the pains and penalties of perjury that the information provided above is true and correct SigLiature: 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 ane): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - - Contact Person: Phone#: t 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 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 Commonwealth of Mossachme-tts Department ofIndustrial Accidents Office ofInvestigatiom 600 Washington Street Roston,MA,02111 Tel,#617-727-4900 ext 406 or 1-877,7MA.SS.AFE Revised 5-26-05 Fax#617-727;7749 ��w.l�ass,g4vldla Al :COMMONWEWH OF MASSACHUSETTS. QOARD'QF 4 . ISSUES' EL1rCTR I Cl ANS ' THE FOLLOWING LICENSE AS REC';i:!::? T.El2ED MASTER ELECTRICIAN EY ELECTRIC INC �21 "HYATT AVE E3RApFORD „ MA :01835=8221'' 20 31 18o.;p : 163.1 Date.1512 .�3........- A �NOR7�y, TOWN OF NORTH ANDOVER PERMIT FOR WIRING sg�►cHug� This certifies that tM�N I � . ............................................................................................................................ has permission to perform �R v I,�A "' .............................. ... .................................................................. wiring in the building of................... „ L.tyn J!-. ' atP .. !�-' .,North Andover,,IVlass. - .................................................. Fee � Lic.No. c ! o� 11"''`" aU....... ........... ... .. . ... ............. ELECTRICAL INSPECTOR Check,t 16015 3 Commonwealth of Massachusetts official use only i� Permit No. Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: City or Town of: Mon T11 AN7>0!/-®2 To the Inspector of Wires: By this appli,�clation the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) �/4 �1 Telephone No. q78 8 Owner or Tenant � P /[�3 Owner's Address jS3B 2-PA161/611T"1E- .�% 1�lll?,1 Is this permit in conjunction with a building permit? Yes JK No ❑ (Check Appropriate Box) Purpose of Building� rQ/t-W--Y /L/F Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd- No. of Meters , New Service Amps 120 /2 OVolts �Undgrd No.of Meters 01y16 Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: 1/V 111 -, I N Co- 5 � nth(� Ila6 i Completion o the ollowin table ma be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans r o ota Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ n- ❑ o.o Emergency Lighting rnd. rnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones IV­No.of Switches No.of Gas Burners oTotal . o etect�on an Initiating Devices No.of Ranges No.of Air Cond. Tons No.of Alerting Devices No.of Waste Disposers eatu um er ons o.o e - ontame Totals "" Detection/Ale rting Devices a icipal No.of Dishwashers Space/Area Heating KW Local❑ un Connection 11Other No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water KW o.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent r No. Hydromassage Bathtubs No.of Motors Total HP Telecommunications firing: No.of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. 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 g q undersigned certifies that such coverage is `n g g i force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE a BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: LIC. NO.al 1983 Licensee: Si nature . LIC. N T.O TTS ONTTNO I; O. .28788 (If applicable, enter "exempt"in.the license number line.) t Bus.Tel. No.•9 78_1635 42 0 Address: 1 nnNnvaRT nu wr-grp NV WPUR_Dpr_`1-1 Q85 I Alt.Tel. No.: *Per M.G.L c. 147,s. 57-61,securitywork requires Department of Public Safety "S" License: Lic:No. OWNER'S INSURANCE WAIVER: 1 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 . Signature Telephone No. PERMIT FEE. $ I -- ��� `�f /�, �� �. -to!mm©NWEALTH OF MASSACHUSETTS EJEC7RICIANS �fEG{ TERED MASTER ELECI �A Y- 4 1SSUES THEBOVE LICENSED Y �NTINbEEEDTRI Axl �e D N, --v DR. r - u " U.7: .. 01._ - i - - /31 /13 u ,.1198 A 07 CaMMOA1INEALTH OFYMASSACJl3ETSµ - OR Lei WMIRMCMIEU • • -- - >„ i !' LECTFt;ICI-ANS t A A RfG JC?URNEYMAN EL�CRIrIAN ` ISSUES THE ABOVEFUCENSE 70 1r"DDNdi%4Ni � ' -1�EST 1�•E►+JBI.1'I�Y" MA`'�"/0.195 '1'��g t . s -- Date TOWN OF NORTH ANDOVER PERMIT FOR GAS,INSTALLATION 4. This certifies that ..................C..4 has permission for gas installation ... A.43..... .. ..... k inas of......................t in the build* o- . .. ..... ........... at....f -7 North Andover, Mass. .......... mC.......... ... ..................................e . Fee.:��.6....... Lic. No. .9.3,3......... "..6.................................................... 140 6 GAS INSPECTOR Check# 1012 l mhC4 p MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK s CITY: NORTH ANDOVER MA. DATE: 12/07/2013 PERMIT# 902-6- JOBSITE ADDRESS: 15 HEPATICA DR OWNER'S NAME: KEYLIME INC GOWNER ADDRESS: TEL: 508-3284630 FAX: TYPE OR OCCUPANCY TYPE: COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL "�� PRINT ^ CLEARLY NEW: 9-' RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED:YES ❑NO k41-' �-(= APPLIANCES FLOOR Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOKSTOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCK MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch. 142 YES El 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 ❑ OWNERS 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 permit application is true and accurate to the best of my Knowledge. I certify that all plumbing work and installations performed under the permit issued,will be in compliance with all Pertinent provisions of the Massachusetts Uniform State Plumbing Code,and Chapter 142 of the General Laws. PLUMBER/GASFITTER NAME:/yLP4*r_-5�-! s,J LICENSE# 9-2>3 SIGNATURE COMPANY NAME:OSTERMAN PROPANE LLC ADDRESS: 321A Merrimack St CITY: Methuen STATE: MA ZIP:01844 FAX:978-738-0118 TEL: 800-368-9956 CELL: EMAIL: INFO@OSTERMANGAS.COM MASTER❑JOURNEYMAN ❑LP INSTALLER WeIRPORATION ❑# PARTNERSHIP [-]kLLC Q#d5-326- 1 Ci�c¢_eX VnGISS. 51 .�Ol`�r ,t t�►.r Q_ .i,v� , tl AC R® DATE(MMIDDNYYY) `..,� CERTIFICATE OF LIABILITY INSURANCE 6/26/2013 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 OW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED RESENTATIVE 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). PRODUCER NAMEACT Angela Bacon Cutler Segerstrom Insurance Agency PHONE . (209)532-6951 No:(209)532-1997 License #0495772 ELADDREss:angelab@cutseg.com 1030 Greenley Rd. INSURERS AFFORDING COVERAGE NAIC# Sonora CA 95370 INSURERA�i3 en Specialty INSURED INSURER B:AIG Osterman Propane, LLC INSURER C: P.O. BOX 29 INSURERD: INSURER E: Whitinsville MA 01588 INSURER F: COVERAGES CERTIFICATE NUMBER:osterman 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. ILTR ADDL SU POLICY EFF POLICY EXP TYPE OF INSURANCE POUCYNUMBER MILDICA Y MMIDD LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Ea occurrence $ 2,000,000 A CLAIMS-MADE ❑S OCCUR EAMG0113 6/30/2013 6/30/2014 MED EXP(Any one person) $ 100,000 PERS ONAL&ADV INJURY $ 2,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 X POLICY PRO LOC $ AUTOMOBILE LIABILITY EO COMBINED accidenSINGLE LIMIT 2,000,000 #BX ANY AUTO BODILY INJURY(Per person) $ ALLOWNED SCHEDULED954068 6/30/2013 6/30/2014 AUTOS AUTOS BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED NON-OWNED PROPERTY DAMAGE $ OS Per anent UMBRELLA LIAB OCCUR EACH OCCURRENCE $ P EXCESS LIAB CLAIMS-MADE AGGREGATE $ ; DED I I RETENTION$ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY YIN -E ANY PROPRIETORIPARTNER/EXECUTNE OFFICER/MEMBER EXCLUDED? NI A E.L.EACH ACCIDENT $ (Mandatory In NH) EL DISEASE-EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS bel I E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space Is required) 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. Town of North Andover 146 Main Street North Andover, MA 01842 AUTHORIZED REPRESENTATIVE i Pete Kleinert/ANGELA .�e,,#-,[ , ,r,r, r.�7f' ACORD 25(2010105) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025(201005).01 The ACORD name and logo are registered marks of ACORD eco CERTIFICATE OF LIABILITY INSURANCE D06/26IDDIY3 � RANCE 06/26/2013 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 1-630-773-3800 CONTACT Allison Spadaro Arthur J. Gallagher Risk Management Services, Inc. PHONE c o Et: 630-285-4456 aC No: 630-285-4006 Two Pierce Place ADDRIESS : allison spadaro@ajg.com Itasca , IL 60143-3141 INSURERS AFFORDING COVERAGE NAIC# Mary Beaver INSURER A: INSURANCE CO OF THE STATE OF PA 19429 INSURED INSURER B Osterman Propane, LLC INSURER C: 6120 S. Yale Ave. INSURER D: Ste 805 Tulsa, OK 74136 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 3.4415543 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 LTR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP POLICY NUMBER MMIDD/YYYYI (MM/DDIYYYYI LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Ea occurrence $ CLAIMS-MADE FlOCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMITAPPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY PRO J C LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ A WORKERS COMPENSATION 15883775 WC ST/ OTH- ANDEMPLOYERS'LIABILITY Y/N 06/30/1 06/30/14 X TORY LII A ANY PROPRIETOR/PARTNER/EXECUTIVE 7933153006/30/1 06/30/14 E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? N❑ N/A (yes,dorybeund E.L.DISEASE-EA EMPLOYE $ 1,000,000 in NH) If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) 978-688-9542 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Attn: Mary 146 Main St AUTHORIZED REPRESENTATIVE North Andover, MA 01845 USA m ' �. Ps•.r.�, ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD ankurita 34415543