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HomeMy WebLinkAboutMiscellaneous - 16 COMMONWEALTH AVENUE 4/30/2018 16 COMMONWEALTH AVENUE / 210/002.0-0019-0000.0 I J U Date.. . .. .�i 1,4—.i, HOR7M TOWN OF NORTH ANDOVER pF 4r Sao ,ti0 PERMIT FOR MECHANICAL INSTALLATION t • s i � ,SSACNus This certifies that . . . t. . . .. . . . . . . .. . .. . . . . . . . . . . . . . .`. . . . . . . . . has permission for mechanical installation . . . . . . . . . . . . . . . . . . . . . . . . in the buildings of . . . .. . . . .. .... . . ... .. . . . . , at . . . . . . . . . . . .. North Andover, Mass. Fee. . ./. !:. . . Lic. No.. . .. . . . :. . t GAS INSPECTOR WHITE:Applicant CANARY: Building Dept. PINK:Treasurer Commonwealth of Massachusetts Sheet Metal Permit Datef S Permit# Estimated Job Cost: I Od Permit Fee: $ 01a -O? Plans Submitted: YES NO Plans Reviewed: YES NO Business License# Applicant License# o?'J,21 Business Information: Property Owner/Job Location Information: Name: /"/ovy7�t,N i2 t�y:rCa� Name: 7o_5-&_p# Ca�A ld0 Street: G S24 Street: /6 Covo~& ea A�!/� City/Town: `��.ti�t �' 0fy'o City/Town: Allot.& AnalUf veR 97�- ��S- 21.700� Telephone: 92Z- Telephone: � ya3 %9�y Photo I.D. required/Copy of Photo I.D. attached: YES NO Building Type: ,-©4 Residential: 1-2 family ✓ Multi-family Condo/Townhouses Commercial: Office Retail Industrial Educational Institutional Building Cubic Footage: under 35,000 cu. ft. over 35,000 cu. ft. Sheet metal work to be completed: New Work: Renovation: HVAC Metal Roofmg Kitchen-Exhaust System Chimney/Vents I Provide brief description of work to be done: c/G r q AZ /Alulw l� %S 2/ ic.0 __ F IR F INSURANCE COVERAGE: I 1 have a current liability insurance policy or its equivalent which meets the requirements of M.G.L.Ch.112 Yes❑ No❑ If you have checked Yes, 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 112 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 Owner's Agent By checking this box[],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 sheet metal work and installations performed under the permit issued for this application will be in compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws. Progress Inspections Date Comments Final Inspection Date Comments Type of License: By ❑ Master Title ; ❑ Master-Restricted City/Town ❑Journeyperson Signature of Licensee Permit# ❑Journeyperson-Restricted License Number: r�1t)- Fee$ Check at www.mass.gov/dpl Inspector Signature of Permit Approval i OrAMoNWEALTFi. �F • :SHE ETou ox ME; ' IS$UES TgLWORKERS : :: MASTE ALLOWING L I CENSE R UNREST fi08ERT R,I'C TED., j ZENGI LOWSK I „ r 22 CUNNt'NGHAM STS 21, MA 0,1887-1330 .:... I,. 04 28 16 - -__ 24262 Sheet Metal Commercial Guidelines/Life Safety/Critical Systems Inspection Checklist Yes No N/A, Set of stamped engineering documents and detailed description of mechanical system to be installed has been provided All workers performing sheet metal work onsite has valid Massachusetts sheet metal license All sheet metal work being performed with proper joumeyperson-to-apprentice ratios Fire dampers with access door properly installed and checked for operation Smoke and combination fire/smoke dampers with access doors properly installed- actuator checked for proper operation(May also be verified by fire department during fire alarm testing) Duct smoke detectors with access doors properly located (May also be verified by fire department during fire alarm testing) Smoke/atrium exhaust systems installed and operation verified (May also be verified by fire department during fire alarm testing) Stair pressurization systems installed(where required)and operation verified(May also be verified by fire department during fire alarm testing) Grease/kitchen hood exhaust system installed with all seams and connections welded airtight with properly located cleanouts.Proper cle Yanoes,fire rated enclosures and pressure testing required. .Soicini:re,, mints installoil=xrliu c;required on equipment and d1=_:. t-. Duct penetrations in fi e'ratc imali:Y and floors sealed Metal roofing systems installed watertight using proper materials and fasteners Flexible-duct runs installed 6'-0"maximum length Ductwork installed using proper hanger spacing,hanger stock,threaded rod and angle iron Ductwork/plenum connections scaled substantially airtight Ductwork insulated by means of external covering or internal lining Volume dampers installed for each supply air branch duct New/clean-properly sized filters installed(final inspection) Testing and Balancing report complete(final sign-oft) ' M Sheet Metal Residential Guidelines/Inspection Checklist Yes No N/A Detailed description and sketch of sheet metal system to be installed has been provided All workers performing sheet metal work onsite has valid Massachusetts sheet metal license All sheet metal work being performed with proper joumeyperson-to- apprentice ratios Equipment sized per heating/cooling load calculations Duct work sized per manual "D"calculations Bath/shower rooms contain mechanical exhaust fan vented outdoors Electric dryer exhaust properly installed maximum total run 35'-0", maximum flexible run 8'-0" Flexible duct runs installed 14'-0"maximum length Volume dampers installed for each supply air branch duct Ductwork installed using proper gauges and hangers Ductwork/plenum connections sealed substantially airtight Ductwork insulated by means of external covering or internal lining New/clean-properly sized filter installed(final inspection) Testing and Balancing report complete(final sign-oft) � • rt w,ri9htsott.. ProjectSummary Dae: Oct 06,2015 Entire House By: Mountain Air Mechanical Project • For: 16 Common Wealth Ave.,North Andover,MA Notes: \Mather: Lawrence Muni.MA US Winter Design Conditions Summer Design Conditions Outside db 9 `F Outside db 88 'F Inside db 72 'F Inside db 73 °F Design TD 63 °F Design TD 15 'F Da i ly ra nge M Relative humidity 50 % Moisture difference 36 gr/Ib Heating Summary Sensible Cooling Equipment Load Sizing Structure 38925 Btu Structure 20226 Btu Ducts 6502 Btu Ducts 2088 Btu CentraIvent(0cfr) 0 Btu C e ntra I ve n t(0 cfm) 0 Btu Humidification 0 Btu Blower 0 Btu Piping 0 Btu Equipment toad 45428 Btu Use manufacturer's data n Rate/swing multiplier 0.93 Infiltration Equipment sensible load 20707 Btu I -!hod Simplified Latent Cooling Equipment Load Sizing Construction quality Average Fireplaces 0 Structure 1870 Btu Ducts 1358 Btu Heating Cooling Central vent(0 cfm) 0 Btu Area(ft') 2186 2186 Equipment latent load 3227 Btu Volume(R') 17488 17488 Fir:har'ges/h011r 0.41 0.21 Equipment total load 23935 Btu 1) Eiuiv..Aw(clm) 120 61 Req.total capacity at 0.70 SH R 2.5 ton Heating Equipment Summary Cooling Equipment Summary Aske nra Make n/a Trade. n/a Trade n/a Model n/a Cond n/a AHRlref. n/a Coil n/a AHRI ref. n/a Efficiency n/a Efficiency n/a Heating input Sensible cooling 0 Btu Heating output 0 Btu Latent cooling 0 Btu Temperature rise 0 -F Total cooling 0 Btu Actual airflow 0 cfm Actual airflow 0 cfm Air flow factor 0 cfm/Btu h Air flow factor 0 cfm/Btu h Static pressure 0 in H2O Static pressure 0 in H2O Space thermostat n/a Load sensible heat ratio 0 Calculations approved byACCAto meet all requirements of Manual J 8th Ed. ir. 2015-Oct 0 316-t 2 40 wrighlsO"— Plght-Suttee Universal 2015 15,0.04 RSU06994 P.9.1 ..Ammon Wealth Av e.N.A.ndovel,MA 10-06-2015.rup Calc=MJ6 r tont Door I aces N . wrlghtsoft� Pro ect Summa Job: 1 ry Date: Oct 06,2015 Lower Level BY: Mountain Air Mechanical Project • For: 16 Common Wealth Ase.,North Andover,MA Notes: Design lnfotirnAtio'-n'-'::';;"':';,;' Weather: Lawrence Muni,MA,US Winter Design Conditions Summer Design Conditions Outside db 9 °F Outside db 88 °F Inside db 72 °F Inside db 73 of Design TD 63 of Design TD 15 °F Dailyrange M Relative humidity 50 % Moisture difference 36 gr/Ib Heating Summary Sensible Cooling Equipment Load Sizing Structure 18317 Btu Structure 7861 Btu Ducts 1759 Btu Ducts 614 Btu CentraIven1(0cfm) 0 Btu Ce ntra I ve n t(0 cfm) 0 Btu Humidification 0 Btu Blower 0 Btu In Piping 0 Btu Equipment load 20077 Btu Use manufacturer's data n Rate/swing multiplier 0.93 Infiltration Equipment sensible load 7865 Btu Method Simplified Latent Cooling Equipment Load Sizing Construction quality Average Fireplaces 0 Structure 555 Btu Ducts 481 Btu Heating Cooling Central sent(0 cfm) 0 Btu Area(ft2) 841 841 Equipment latent load 1037 Btu Volume(ft') 6728 6728 Air changes/hour 0.40 0.21 Eq uipm ent total load 8901 Btu Equiv.AVF(cfrn) 45 23 Req.total capacity at 0.70 SHR .0.9 ton Heating Equipment Summary Cooling Equipment Summary Nbke Make Trade Trade fvbdel Cond AHRI ref Coil AHRI ref Efficiency 80 AFUE Efficiency 0 SEER Heating input 0 Btu Sensible cooling 0 Btu Heating output 0 Btu Latent cooling 0 Btu Temperature rise 0 °F Total cooling 0 Btu Actual airflow 446 cfm Actual airflow 446 cfm Air flow factor 0.022 cfm/Btu h Air flow factor 0.053 cfm/Btu h Static pressure 0.50 in H2O Static pressure 0.50 in H2O Space thermostat Load sensible heat ratio 0.89 Calculations approved byACCAto meet all requirements of Manual J 8th Ed. 2015-001-06 16:1240 WTight5oft' Right-Suite®Universal 201515.0.04 RSU06994 Paget ...o mmon Wealth Av e,N.Andover.MA 10-06-2015 rup Calc=MJ8 Front Door f aces N 1 � r wrightsoft" Project Summary Dae: Oct 06,2015 Upper Levels By. Mountain Air Mechanical Project • • For: 16 Common V\balth Ave.,North Andover,MA Notes: Weather: Lawrence Muni,MA,US Winter Design Conditions Summer Design Conditions Outside db 9 °F Outside db 88 °F Inside db 72 'F Inside db 73 °F Design TD 63 °F Design TD 15 °F Da ily ra nge M Relative humidity 50 % Mo istu re di ffere nce 36 gr/Ib Heating Summary Sensible Cooling Equipment Load Sizing Structure 20608 Btu In Structure 12.441 Btu Ducts 4743 Btu Ducts 1481 Btu Centra Ivent(0cfm) 0 Btu Central vent(0cfm) 0 Btu Humidification 0 Btu Blower 0 Btu In Piping 0 Btu Equipment load 25351 Btu Use manufacturer's data n Rate/swing multiplier 0.93 Infiltration Equipment sensible load 12920 Btu In Method Simplified Latent Cooling Equipment Load Sizing Construction quality Average Fireplaces 0 Structure 1314 Btu In Ducts 876 Btu Heating Cooling Central sent(0 cim) 0 Btu Area(ftz) 1345 1345 Equipment latent load 2191 Btu \/oiume(ft) 10760 10760 Airchanges/hour 041 0.21 Eq uipm ent total load 15110 Btu In Equiv.AUF(ctm) 74 38 Req.total capacityat 0.70 SHR 1.5 ton Heating Equipment Summary Cooling Equipment Summary Ma ke Ma ke Trade Trade fvbdel Cond AH RI ref Coil AHRI ref Efficiency 80 AFUE Efficiency 0 SEER Heating input 0 Btu Sensible cooling 0 Btu He ati n g ou tput 0 Btu Latent cooling 0 Btu Temperature rise 0 °F Total cooling 0 Btu Actual airflow 730 cfm Actual airflow 730 cfm Air flow factor 0.029 cfm/Btu h Air flow factor 0.052 cfm/Btu h Static pressure 0.50 in H2O Static pressure 0.50 in H2O Space thermostat Load sensible heat ratio 0.86 Calculations approved byACCAto meet all requirements of Manual J 8th Ed. ' W£Ig�'1t.56'tt:I" Rig ht-Euite®Univ ersa1201515.0.04 RSU06994 2015-Oct-06 1612.40 Page `- ...ommon Wealth Av e.N.Andover,MA_10-06-2015.rup Calc=MJ8 Front Door faces: N i 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 ba 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 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' 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 penmit/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 bum leaves etc.)said person is NOT required to complete this affidavit. The Department's 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 wwwmass.gov/dia The Commonwealth of Massa chusefis ' Department oflndustrialAccidents 1 Congress Street, Suite 100 Boston,PM 02114-2017 www mass.gov/dna Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE PILED WITH THE PERMITTING AUTHORITY. Applicant Information " / Please Print Lezibly Name(Business/Organization/Individual): MoyAI'f�,(�/ 4 Z2 e '�CC.&W21LG Address: Y1 SV City/State/Zip: r�m„yGTanJ /!'IA, t�/ ,� Phone 1.4 /7000 Are you an employer?Check the appropriate box: Type of project(required): 1. ]I am.a employer with 0.. : employees(full and/or part-time).* 7. 0 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.] 9. El Demolition 3.❑I am a homeowner doing all work myself[No workers'comp.insurance required.]t 10 Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole I L❑Electrical repairs or additions proprietors with no employees. 12.E]Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.F1 Roof repairs These sub-contractors have employees and have workers'comp.insurance.$ / 6.FJ We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q Other S�ee� �9e}�t f 152,§1(4),and we have w employees.[No workers'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 submif this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-conlracfors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workerscompensation 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 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. I do Hereby certify un+r the pains and penalties of petjury that the information provided above is true and correct. Sign e: ted+• 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 one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: 10/21/2015 1.3:05 FAX 8038897308 total air 10001/0004 Basement 5" 16x8 16x8 5 r� 8 7" 7. Basement 8 0- 10x8 6x8 %8" r, Job#: Scale ^ 52 Performed for: Mountain Air Mechanical Page 18 CArtmon Wlelth Ace Rqd-.,AVMS Urnversel 2015 Nath Ardor ,er,PAA 75.004 R8U06894 2016-Oct-2113'.2:31 ..e,N,Ardorer.MA_14062015 rup . 10/24/2015 1.3:06 FAX 6038897308 total atr Z0002/0004 J 1 st Floor 41 cfm'8a;h1 34 cfm 101 cf rObedrooml halIll 101 efm Kitchenl 91 cfm 229 cfm 150 cfm Living rm- Large rm/stairs' 150 cfm 89 cfm Job#: Mountain Air Mechanical scale:1:62 Performed for: passe 2 16 Qmm4n Wealth Ave. R fight-sume u roversv 12015 NOAh AKSW C,VA 16.0.04 RSU06W 20160d-21 13 12.81 ...e.N Answer,M4_i 0-062095 rup 3.0121/2015 13:06 FAX 3038897308 total air 0003/0004 2nd Floor 143 cfm Kitchen2 104 fIrn Sed2 54 cfm haa2 0--288 cfm bath2 �-----262 cfm Living; large 2 158 cfm 124 cfm Job rk: scale:1:62 performed for: Mountain Air Mechanical °arta 3 16 Common VNIM,A+I. Rip-SUMO UrMvsro012015 North At over.UA 15.0.09 RSVM694 2015.Oc1•21 13 1231 ...e.N.Ardwo.WA 10GS2016.rup 10/21/2015 13:07 FAX 6038897308 total air 0004/0004 J 3rd floor wiC2 $" 7 222 Cfm—4 ha113 111 2 222 cfm 116- t4 ` 155 cfm i Bedroom 3 10" 10 ' 8" 155 cfm Job#: Scale:1:62 Porfomed for: Mountain Air Mechanical Pape 4 16 Cormmn Weihh Ave. R gN-Swi&O Uav ersa12015 Nonh MADY a,MA 15.004 RSUCS994 201E-0tf•21 13.12.31 ...t.N.Andover,nni_10.062015.nw Rightfax 112-1 11/3/201 3 59:^ J'73�r i ti FAX 1` v � TO: ZENGILOWSKI ROBERT ►j(;K ���ri ��lNTt��r «int ME�;kir.FJl� Company. Fax: 9786583981 Phone: From: Assigned Risk Workers Comwensat Fax: Phone: E-mail: ��ilr':.71'I= ��/�'Y'/ii'�t1i�r'��lf��l���'��►�;w NOTES: :Brtificate of Insurance 0G 1306 106-30-2016 7his communication,including attachments,is confidential,may he subject to legal privileges,and is intended for the sole use of the addressee.-Any use,duplication,disclosure or dissemination of this communication;other than by the addressee,is prohibited If you have received this communication in error,please notify the sender immediately and delete or destroy this communication and all copies Date and time of transmission: Tuesday, November 03. 2015 3:30:06 PM Number of pages including this cover sheet:02 �. CE�� . �.. .f-A0;:��E � ' �.�iQ;Bi�.,l� f '. v �? � E.,�le fMRyrL-DN,YYYI b/ 1FF+C-E{ :;'l:A{. iii:.SUED AS A MATTER OF INFORMATION ONLY AND CONFERIll S NO RIGHTS UPON THE CERTIF{CAT HOLDER111 IS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATI[VELY AMEND,EXTEND OR ALTER THP r_.nvE(gAOLe AFFORDED gDEO BY THE pOLjCr,i:$BEL01Af, JAMTHIS CERTIFICATE OF INSURANCE DORS:NOT CONSTITUTE A CONTRACT QE`TWEEN THE ISSUING INSURER(3►,Al1T'�(1Rt Fg R RESENTgTIVE THE IMOIORTAN'r:If the certificate holder Is an ADCiTIONIA1,INSljron line terms and Conditions of the poiicv,^,vrtRin npilm. K•r F ..�- .,r'1'aar uv t'gvrS6U- "8U!61RG 3AT{ON 13 WAIVED,subject to r�?r�a1W,4-1na h111� „rn .; 9►'n.p • •, a_ Y and endorsement. A Statement on this cartlficate does not Confer rights to r ,:wtJUvsil CONTACT , A JI .I IJ Vr'./Y,.4V uROUP PHONE ` I PO Rr-�Y lm(l FAX I °A—,i%i,,rur bkh�p "''s., 0'0.x, C.�.•IL ADDRESS: �hJli °a1pi3' �rFJicuiir�t wVlttAfiE rvr u nluJecFIJ INSURER A. TRAV12LflRS INDEI44)xY CONOANT OF AMERICA 2ENGILOWS►(1_R09FC r rNp-a a,nr _.. - FINSA UItFR C: 22 CUNNINGHAM ST URER D: WILMINGTON',MA 018$7 NSURERE; !!A INSURER p: COVERAGES CERTIFICATE NUMBER: TREIST T TNF P ICIE9 DPI URAN E L LO TED NEW ISSUED THE INSURED NAMED ABOVE FOR THE POLICY PI O D INDICATED, NOTWITHSTANDING ANY REQUIREMENT,TRAM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH ftUPECT TO WHICH THIS CERTIFICATE MAY BE ISSURD OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HERVIN IS 9UIIJECT TO ALL THE TERMS,EXCLUSIONS AND CONOITIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, INOR ADO SUp LTR TYPE OF INSURANCEL R POLICY NUMBER P MM%DDIYYYYIE P JMWDMY p`" )E LIMITS GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S CLAIMS MADE [7 OCCUR. DAMAGE TO RENTED $ REMISES(Ea omurrvics) PRODVCTS-COMP.'CPAGG P(Any one person) 3 GEN'L AGGREGATE LIMIT APPLIES PER: NAL a ADV INJURY S POLICY �PROJECT LOC AL AGGREGATE S S AUTOMOBILE LIABILITY ANYAUTO COMBINED SINGLE $ ALL OWN E D AUTOS LIMIT(Ea accidsna BODILY INJURY $ SCHEDULEAUTOS (Per son) 1 1 HIREDAUTOS BODILY INJURY 5 NON-OWNED AUTOS (Per eoolcent) PROPERTY DAMAGE $ �'---` (Per BCCkyant) UMBR EXCESS LIAB LLA LIAB OCCUR EACH OCCURRENCE $ EXCESCLAIMS-MADE EGGREGATE TE UCTI .. }S RETENTION $ —i A WORKER'S COMPQNSATION AND ,NC STATUTORY OTHER EMPLOYER'S LIABILITY Y/N UB-DG130CI1.16 0el3D=15 0613012010 LIMrrS ANY PROPERITOR(PARTNERIEXECUTIVE I [Mandatory M MEMBER EXCLUDE09 © NIA E.L.EACH ACCIDENT $ 100,000 .deav In NM E.L.DISEASE-EA E.MPLUYEE $ 100,000 f y 9,descripp Utld6t DESCRIPTION OF OPERATIONS b how E.L.DISEASE-POLICY UMIT S 500:00D DESCRIPTION OF OPERATTON$fLOCATIONSNEHICLEBIRESTR{CTIONSISPECIAL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFEi 1NG WORKERS CORP COVSKAGE. TKE WORxERS COMPENSATION POLICY DOES NOT PROVIDE COVERAGE FOR LBNOILOWSKI,ROSER.T. CERTIFICATE HOLDER CANCELLATION TOWN OP NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 1600 OSGOOD ST BLDG 20 STB 2035 BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. NORTH ANDOVER,ivlA 01845 AUTHORIZED REPRESENT E ACOR5-15(2010106) The ACORD name and logo are registered marks 91"ACORD1988.2010 ACORD CORPORATION, All rights reserved. CERTIFICATE OF LIABILITY INAURANCE F D—ATEjMM1D—D1M­Y)-j 14-it is—16fiED AS A MATTER OF INFORMATION AND CONFERS NO j!!jjqj'j L' —-------- CER7711CATE DOES NO- AFNIRMATIVELY OR NFn1a1'.Jr1 V A 1642�— %30N THE CEkT',F'!(,,VrL HOLBE;A, IP AUTHORIZEE) rKUUuk;F-R',A",M TWK rEFqTiFi,' 1*1111 q iMI*ORT'A=N"T',-T tt7hr,;""O"erUtlijote—hol.lo�, Ar-017; • :C1 the tema and conditions of the polll ;I.Iky( must be endorsed. If SUBROGATION ItFw-ANW,-subject-to DeqIficate O!f, 11-9y retliuli%,i-j:91100011MOML A statement on this holds ca j.teu of such andomom&nttg). Is oertiftate does not confer rights to the PRODUCER cow Heidi Sansouci Fay Insurance Group - Manchester NE 1989 Elm St (603)641-8111 (603)642-0922 j Manchester NH 03104 INSURER(S)AFFORD1140 COVIERAOR NAIC 0 INSURED a Mutual Casualt 1415 —INBURER Q- ROBERT ZENOILOWSEI D/B/A. MOUNTAIN AIR 22 CtWN11;GHA14 ST INSURER 0: INSURE IWILMINGTON MA INSURER01887-1330 COVERAGE$ jM.URFR r- — CERTIFICATE NUMSERIM4Uaster I THIS IS /16 - REVISION NUMBER: TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED TME POLICY PERIOD ER DOCUMENT WITH RESPECT TO WHICH THIS INDICATED NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR O�'H RED NAMED ABOVE FO 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 AVE BEEN REDUCED IN UpteRAIEM00 10 or E OP INaURANCI BY PAID CLAIMS. L T!RRR D131.BUBM LIABILITY r- M =11 POLIO NUMBPR !!T 7 GENERAL LIABILITY LIPATS COMM RICIAL Gr OCCURRENCE 00"000 A =NEZ� L[A EACH OCCUMRENCE $ L10001000 X COMMERCIAL GENERAL LIASIUry A E ED 100,000 A CLMMG-MADE Ea '-00'0"" OCCUR 0/22/2015 �1/22/2016 MED EIXP(A One so.,j) 6 5 000 5 0()(1 NA L OV I PERSONAL LI 411 11000,000 .2LUONALLAI)VINI I 000'0()o Or-N'L AGGREGATE LIMIT APPLIES PER AI AGGREGATE S 2,00-0,AooO PRODUCTS-COMPIOP POLICY F G $ —2,000,000 AUTOMOBILE LIARILITY I 7mnl:LIMIT ANY AUTO 3 ALL OWNED S SCHEDULED BODILY INJURY{Perpwmon) AUTOS AUTOS HIRED AUTO NOr4.OWNFD BODILY INJURY(P.eracc'denj) Al ITnA 1 murrl I T UANIA'Pr rS",14 L �LLA WASEOCCUR -?%' kK0L1A9 IUCGURRtvyCE^ g. —2AIMS-MADE ' ............ G .— A0(3hWA'1 F �D RMN N S ............. 'VM15v-.-As C"'PENSATI�05 AN":%:%Lt V UABIUry U- DTH- ANY PI,.',P 'i YfN yx T WPARTNER)EXECUITIVE� .-A=7— OFRCFo 'JER EX!,LUDED? N/Al '-�LA�CtArCIDENT DESCRIPTION �PERATIONS ho4— L-- -El.DISEASE-EA RMPI nv=g t E.L.DISEASE-PQUOY LIMIT S M3CRPPT!C!4()r-' 101,Add1l.n.1 Rt-.rk.fth-d.19 fi CtRTI CANCELLATION (978)658-3981 SHOULD ANY or THE ABOVE DESCRIBED POLICIES SE CANCELLED BEFORE TeFTh 0>r THE EXPIRATION DATE THEREOF) NOTICE WILL BE 01!!LrVERED IN North AndQver ACCORDANCE VMTH THE;POLICY PROVISIONs. 1600 09C100d St Bldg 20 t 4 1 2'.3, AUTffQRIZED RIPREMNITATIVP North Andover, MA D184-r, INS025 0 1600-11D COO-0-01tA710N. Ail 6�1"-U revorvil d. The ACIORD name and logo are reg16tei:::! 9 Date...'�'—''_ NOR7M TOWN OF NORTH ANDOVER o p PERMIT FOR WIRING ,SSACMUSE� �--- This certifies that L ` has permission to perform ....4r:4.�Pnb.........R,Epk—z .. ....................... wiring in the building of � /'f -...��..X....................................... ............... .... ..... �(� 11?>� .r T . w at..... ............�?�:�'�!�/.i�..............:.....................�,North Andover,Mass. Fee.... .�..... Lic.No. . 33.r0". ('C,r--, , !t...... .«ERICALINSPECTOR y Check # IUC) U �' L) awr&Aa ff=TjtmrV=ALaArffll Permit No. BOARDOFFJREPRBVF1NlllaIVRBGVLMM5VaM, iN 4a mone O=aFmmy R Fen Checked ��• APPUCAHON FOR PERNIIT TO PERFORM ET, C7 ICAI,WORX ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHOSSTS ELECTRICAL CODE,527 CMB 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Da I Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location(Street&Number) 16 6oi&1vt-oA) to Owner or TenantAi-Te Owner's Address is this permit in conjunction with a building permit: Yes[M No [D (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps I Volta Ovedlead Underground No.of Metas New Service Amps Volta Ovediesd Uriderpound No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work yL No,of tJandtta outku Na of Hot Tubs No.of TME"gen Totd Na of La6lins Piatmaa Swlrturdna Pod' Abovezmond KVA Below ( KVA No.of ReceptacM Outlue Na of W Burma Na of F mtxae-7 IJahtina Buttery Unki No.of Switch Oudeu . No.of ass Barren :4 Na of Ranges No,of Air Coad. Total FIRE ALARMS No.of zx= Tate Na of Dispoub Na of Hod Total oNa of Detecdoo and pump TOM Wdeliag Davina No.of Diehwuhm Spwe Ana Hadoa KW -- Na of Souodin�DimonNo.of Set[Cottwow No.of Drym Hoeft Devices KW L Dal ools m-WWa Devkee Modcipd other No.of Water Heaton KW No.of No.of CoMeodon S Bellai No.Hydro Mmye Tubs No.of Mono Told HP r rYT141 . t2 tLil o v v( L ktsua Qhi2W Piaretbtb:reQitrirnt Larks lhneaatamtLir4�Yhaarael�fcYitdu�rq or*au6�yldt�ci►aitrit y� 0' NO lnaes�rrbdraiaproda bfreomm Y$9EO a edsygq� :�efletypedao by E 13 On O� 0 �� ��� R 10 WbikIDSaR Tt �ni7lneRec}L�d Rail EseQlsbdvalaafl�eti�W�S Sigiedunds�Pk�bofpajlay. J �f� � FMMNAME ( Liw=Na Addkep C/ 407 Bi"711% OWP�WSMJRAl4MWANPRIamawaeihrt Licca lheiaaaixcv�e. � AtThLNa► rdtbetrry ondispeadt vlaitaliregciltrmt a �a'I1°4�byM=hMGaaitlLam (Plc _ o Agent a Telephone No. per.FEB! 7 - J