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Home My WebLink AboutMiscellaneous - 15 HOLBROOK ROAD 4/30/2018 15 HOLBROOK ROAD 210/021.0-0041-0000.0 I I 1 Date... ......................... CF &ORTh,h r ?' TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that has Permission for gas installation in the buildings o .........AUI�.PRI.... ...................................................... at........ ....................... North Andover, Mass. Fee.6 .... Lic. No. ............. H ...................................................... 6 GAS INSPECMR Check#9635q 9195 •' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY North Andover MA DATE3/24/2014 PERMIT# l JOBSITE ADDRESS 15 Holbrook St OWNER'S NAME 1�t2 OWNER ADDRESS Same TE 11FAX TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL® RESIDENTIAL[j PRINT CLEARLY NEW: RENOVATION: REPLACEMENT:E] PLANS SUBMITTED: YES® NDE] APPLIANCES Z FLOORS- BSM 1 2 3 4 5 6 7 8 9 1 10 11 1 12 1 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER Re lace Gas Meter x and Pi inq as Needed INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 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 El 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 applicat4beinance with all Pertinent provision e Massachusetts State Plumbing Code and Chapter 142 of the General Laws. muoPLUMBER-GASFITTER NAMELICENSE# SI ATURE MP[D MGF® JP® JGF LPGI CORPORATION[D# 3285C ®# LLC # COMPANY NAME: RH White Construction Co ADDRESS 41 Central St CITY Auburn STATE=ZIP 01501 TEL (508 832-3295 FAX 508-926-4347 CELL 508 832-4614 JEMAILI JMarino@RHWhite.com ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# J !�" PLAN REVIEW NOTES f i -- �: - EALTH OF MAS opk'w RIUUP _ z . I�1fBERS AND �YAS{�IT'J'E-RS._.;:;_.: L 1=CkTSED AS'A.. ►TSR - _=-fSSUESTHS'f1BQVE'LIGENSEI`O -M•A-R.I N Q -3'IFARII'NGTQN ST __ .•= � .: w c l R MA 0 io i�V'` - :_:=. '.- 05/01/14 _G;O�l1M NWEAL1-F6 OF iU�ASSl C`t=# J:$RV S `.-;* PLU1tilf$ERS AND GASP[ITERS .y t' - _: LI'C NSED AS A JOURNEYWAN`�l.f fSSUES THE ABOVE LICENSE TO MARINO MFi4RRI`NGTON ., W : R - _ MA 016'0.4=:3:.x09;=° . ; 05101114 _-'_- i I • 04/03/2014 14:04 5088326751 RH WHITE CONSTRUCT PAGE 02/02 DATE(MMIDDNYYYI s CERTIFICATE OF LIABILITY INSURANCE page 1 oQ 08/29/2013 THIS CERTIFICATE IS ISSUED ASA 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 notconferrights to the certificate holder In lieu of such endorsement(s). PRODUCER CONTACT NAMF- 97flliq o£ Massachusetts, Inc. PHONE FAX C/o 26 Cottury Blvd. NO,-EXT). 877-945-7378 _NO)• 868-4y�-2378 P. 0. Box 305191 -MAIL Nashville, TN 37230-5191 D.DRFSZ C4 JLr i£icatg�pC�w•illis.GOIIl INSURER(S)AFFORDING COVERAGE NAIOR INSURED INSURERA: The ChArtOr Oak fire Insurance Company 25615-001 R. X- White Construction Company, Inc. INSURERS:TravolAro Property Casualty Company of Am 25674-009 41 Cantral, Street INSURERC:National Union Piro) Insuranca Company OE 19445-001 P. 0. Box 257 Auburn, MA 01501 INSURERD;TrAvelers indemnity Company 25658-DO1 INSURER E; INSURER F; COVERAGES CERTIFICATE NUMBER:20287680 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OP INSURANCE DD SUB POLICY NUMBER POLICY EFF POLICY EXP A GENERAL LIABLIMITS VTC2000 97789948-13 9/1/2013 9/1/2014 EACH OCCURRENCE :F 2,000,000 X COMMERCIAL GENERAL LIABILITY DAM TO RENTED - PRE� B(Eeoeewan�f _R 300,000 CLAIMS-MADEal OCCUR MED EXP(Any one person ° 10 000 J PERSONAL&ADV INJURY S 2 000,0 OO GENERAL AGGREGATE S 4,QQQ 000 GEN•LAGGREGATELIRITOAPPLIESPER; PRODUCTS-COMPIOPAOr. Is 4,_q_0 0,000 POLICY LOC B AUTOMOBILE LIABILITY VTJCAP 977K955A-13 9/1/2013 9/1/2014 N $ .4 iocdeDt$INGLEI.IMIT $ 2,000,000 X ANY AUTO BODILY INJURY(Perpeison) S AUTOS NED SCHEDULED BODILY INJURY(Peraccltlon!) $ X HIREDAUTOS X NON-OWNED AUT08 $ X Co Defl X Coll Ded $ C UMBRELLALIA6 X OCCUR BE87661.40 /1/2013 9/1/2014 EACH OCCURRENCE $ 5-OOO,000 ::C EXCESS LIAR CLAIMS-MADE AOOREGATE $ 9__,000,000 OED I $ RETENTIONS 10,000 S D WORKERS COMPENSATION VTRRUB 820SA185-13 9/1/203.3 0 AND EMPLOYER8'LIABILI7Y YY//NN 9/1/2014 X TOr{yW D ANYPROPRIETORIPARTNERIFXECUTIVEn NIA VTC2KUB B203A71A-13 9/7,/2013 9/1/2014 E.L.EAGHACCIDENT $ 1,000_000 OFFICER/MEMBEREXCLUDED? +��J (Myyenddtory In NN) E.L.DI2EA8E-EA EMPLOYEE S 1,000,000 uiE�ty KillI�UNUdOPURA71ONSbelow E,L,DISEASE.POUCYLIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(Attach Acord 101,Addltonpl Remsrkd Sthedvla,If more epees Is rvqulrgd) 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, AUTHORIZED REPRESENTATIVE 1�'XC�ei1Ce of IntlluzariCe Colli4197604 Tpl:1694012 Cert:20287680 ®1988-2010ACORD CORPORATION.All irights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD 09733 Date TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ti 11 y Vais certifies that `--'1. �._4� . . t1 E has permission to perform . r /. . . . . . . . . . . . . . . . . . . plumbing in the buildings of. 'A . . . . . . . . . . . . . . . . . . . at . . . � ,�� ,.�. r � . . . . . . . . . ,North Andover, ass. Fee . (?. . Lic. No. �I hb PLUMBING INSPECTOR d Check#� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY NORTH ANDOVER MA DATE �Z/��iL PERMIT# JOBSITE ADDRESS /-4— fj�p�Q,�pp� �� OWNER'S NAME,&/,`/-;j Y OWNER ADDRESS SAME TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: RENOVATION:Ej REPLACEMENT: = - PLANS SUBMITTED: YES NO FIXTURES-1 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 FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR INTERIOR KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL S_ RVICE/MOP SINK TOILET UfZINAL VhASHING MACHINE CONNECTION WATER HEATER ALL TYPES i WATER PIPING OTHER INSURANCE COVERAGE: 1 have a current liabilityinsurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES,X11 NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 561 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: OWNER AGENT SIGNATURE OF OWNER OR AGENT i hereby certify that all of the details and information I have submitted or entered regarding this application are 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. e PLUMBER'S NAME THOMAS HALLORAN LICENSE# 24833 SIGNATURE MP E] JP[D CORPORATION E-1# PARTNERSHIP# LLC E# COMPANY NAME HALLORAN PLUMBING ADDRESS 826 DALE ST. VU CITY NORTH ANDOVER STATE MA ZIP 01845 TEL 978-685-9504 lit" FAX 978-208-0840 CELL EMAIL \21 Zso ' �� A�� IJ�7ll��e.� C�►. � ' y . �� • F `, ;; �� (� .� (� ; . __ _ , � _. ., ., } ,. 1 � a _ . . � � a R AL1'�1 OF MASSAC"USE'�CS pOMMONWE e. •• • W.., L • GASF AMBEa ASsp JOURNEYMA ' SED LICEN THE ABOVE LICENSEIO a $sub M NALLDRAN !� I 82'6 DAE ST 1 MA 018(45 � 422 14274] ANDOVER NORTH 05/01/14 . 24833 • • } orations Along Then Detach Along Ail Ped to� The Commonwealth of Massachusetts --- Department of Industrial Accidents Office of Investigations ' 600 Washington Street a - Boston, IVDA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): cJ`f'q--,V Address: 02 City/State/Zip: IV, 4,0VrJoVo;0 AY4' a8'YS- Phone #: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. F-1 I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2 I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. Demolition working for me in any capacity. employees and have workers' 9 comp. insurance.: . [No workers' comp. insurance [] Building addition P• required.] 5. E] We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doingall work officers have exercised their 1 l.❑ Plumbing repairs or additions myself �o workers comP right of exemption on er MGL 12.E] Roof repairs insurance required.]t c. 152,§1(4),and we have no employees. [No workers' 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. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins. Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under thepains andpenalties ofperjury that the information provided above is true and correct. Sig v*� Date Phone#: 2-7 5"' 4U9_.<— Official use only. Do not write in this area, to be completed by city or town officiaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#• Date . TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION Y � This certifies that . . .�kd.\M has permission for gas i stallation . k-- A e1 . . !� �� . . . . . . . . in the buildings of. . 1 i at . . �5. . �r�!_ ��4. . P—V, . . . ,North Andover, ss. Fee ZO�1 . . . . . Lic. No24A,5� . M,. _.�. . . . . GASINSPECTOR Check# \Z 8520 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK x CITYNORTH ANDOVER MA DATE 11/7% PERMIT# 75 JOBSITE ADDRESS OWNER'S NAME /4� GOWNER ADDRESS SAME TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW:E] RENOVATION: REPLACEMENT:FX; PLANS SUBMITTED: YES NOR APPLIANCES 7 FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER "ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER 1 OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY BOND OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER AGENT SIGNATURE OF OWNER OR AGENT 1 hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. J� �� PLUMBER-GASFITTER NAME THOMAS HALLORAN LICENSE#24833 SIGNATURE MP '` MGF El JP D' JGF Ej LPGI CORPORATION # PARTNERSHIP E3# LLC 0# COMPANY NAME:HALLORAN PLUMBING ADDRESS 826 DALE ST. l ' \ CITY NORTH ANDOVER STATE MA ZIP 01845 TEL 9,5-05l FAX _ CELL EMAIL 1 978 208-0840 �Z�ZCP((-2- ,* �. i I i I I n� � '! f l �,� � � A� � -- -� -- � I I i r i I TH®F M4SSA� d yUS TTs .COMMON ® S onAL os AGAuM PLUMP A A JOURN�YM D SE?o LlG�N5E. <'ISSUE Tti E ABOVE LICEN �a , THOMAS`" NI NALLORAN 826 DA.�E ST 1 O NORTH' ANpOVER MA 4 lc'L701 1 05/01/1 24533 Ali m a • ' Then Detach Along All Pertorations �t The Commonwealth ofMassachusetts -- --R9 - Department of Industrial Accidents Office of Investigations V tE 600 Washington Street - f Boston, IVDA 02111 3; www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual):� /�� Address: aaZG .-r City/State/Zip: /V 4WU40,7,0 IY14 6PFY.5' 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 employees(full and/or part-time).* have hired the sub-contractors 6. F1 New construction 2 I am a sole proprietor or partner- listed on the attached sheet. 7. F1 Remodeling ship and have no employees These sub-contractors have g, E]Demolition working for me in any capacity. employees and have workers' 9 F� Building addition [No workers' comp. insurance comp. insurance.$ required.] 5. We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I LE]Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.]� c. 152,§1(4),and we have no employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I arm.an employer that is providing workers'compensation insurancefor my emplovees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins. Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is trite and correct Signature: ��` �— Date: /Z Phone i Official use only. Do riot write in this area, to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: Dat r t, p ".��':��c TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING # ,SSACMUSE� k YYY ' This certifies that�;'`� . .*�. . . . . . . . . . . . . . . . : . . . . . . has permission to perform.-:---. .. f . . . . . . . . . . . . . . . . . . . plumbing in the buildings of . . . . . . . .`r . . . . . . . ... . . . . . . . . . . . . . . ta,t P. . . -�, - . . . . . . . . . . . .e, North Andover, Mass. " v.7i. . PL NG INSPECTOR Check # MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS Building Location A—&&-colc– Date Owners Name /%C/ / Permit# Type of Occupancy Amount New Renovation ®� Replacement 1:3 Plans Submitted Yes El No FIXTURES o rA 54��1�II' 1A Kja R z1a ROM m FI+ oQ2 41HROM 5TH MOM � 6TH PIAQTZ 7MMUR 1 SIH Hfm (Print or type) J Check one: Certificate Installing Company Name, Corp. Address b& Partner. 14 r x 2 C- Business lelephone ��(ey �) S7 � 'j-7 ® Firm/Co. Name of Licensed Plumber: Insurance Coverage: Indicate the twe of insurance coverage by checking the appropriate boy;: Liability insurance policy Other type of indemnity ❑ Bond F1 Insurance Waiver: I,the undersigned,have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner Agent I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State i Egter 142 of the General Laws. By: iana nrr n- --, N --o------- — --•—••��u a auaawGt Type of Plumbing License Title A /Jz/7/ PPRwnOVED(OFFICE USE ONLY icense um er Master Journeyman ❑ PPR