Loading...
HomeMy WebLinkAboutMiscellaneous - 16 MILLPOND 4/30/2018 16 MILLPOND 210/095.A-0016-0000.0 1 I i I� I i i i I � p I I I I i I Date ............ ...... ............................ 4 TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION mu ....P �� ( P Thiscertifies thatL........................................I................................................................... 4-�I-p- has permission for gas installation ..................... ... ............................. in the buildings of at.....�(,P........ ............................... North Andover, Mass. Fee.3!��......... Lic. No ........ p...... ............................................................... GASINSPECTOR Check# 9716 hr MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK kv — 40 q 1 . 1 CITY MA DATE 1a �- PERMIT# I JOBSITE ADDRESS I OWNER'S NAME IF GOWNER ADDRESS j TE FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL EI RESIDENTIAL PRINT CLEARLY NEW: RENOVATION:El REPLACEMENT: PLANS SUBMITTED: YES 0 NO APPLIANCES-1 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER 9^I CONVERSION BURNER -- COOK STOVE I _ DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE _ �h1 I I Al L _ — _ A - -- r_._ GENERATOR GRILLE INFRARED HEATER ____ _—( __._ �! LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER __-_- - - ROOM/SPACE HEATER (-- ROOF TOP UNIT TEST - UNIT HEATER UNVENTED ROOM HEATER E =Z. �. WATER HEATER ETHER - -- -- -- INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES _ NO [ 1 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLIC I OTHER TYPE INDEMNITY ® BOND O,WNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the iAassachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT [J 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 will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUM BER-GASFITTER NAME {��� ©�__ S' LICENSE#F/<7oll —SIIGGNAT�URE MP 0 MGF 0 JP ® JGF 0 LPGI© CORPORATION #I�!PARTNERSHIP®#E�_ NA��LLC E]# COMPANY NAME: ✓m ew S ! �"• w A, i i? • ADDRESS y E.� G�/0 CITY STATE Ujj�]ZIP TEL 7 l FAX CELLEMAIL U , ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOT Yes No s- THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES �r 4 The Commonwealth of Massachusetts - Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA. 02111 U1F www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): lva ,Z'U- Address: c2 d C r�' City/State/Zip: - e �b Sc Phone Ae you an employer?Check the appropriate bog: Type of project(required): 1 I am a employer with 4. ❑ I am a general contractor and I 6. New construction l * have hired the sub-contractors ❑ employees ees full and/or art-time). p Y ( P Remodeling 2.❑ I am a sole proprietor or partner- listed on the attached sheet.I ❑ g ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. g, ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑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.]i employees.[No workers' 13.❑Other comp.insurance required.] *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. -Homeowners who submit 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 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: c7u ar-e- n Policy#or Self-ins.Lie..9: �+ Expiration Date: L1119Job Site Address: (� / /? City/State/Zip: .w O L_/<f Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one=year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. X do hereby certify under the pains and penalties of perjury that the information provided above is true nd correcI Simature: Date: x Phone#• l 7 ' a e 3� 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#: 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 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 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 CO onwealth ofMassachusetts Department of Industrial Accidents Office of Iavestigatxons 600 Washington Street Boston.,MU 02111 + Tel,#617-727-4900 ext 406 or 1-877,MASSAFB Revised 5-26-05 Fax#617-727-7749 Wvwxnass,goV1dia Division of Professional Licensure:License Search http://Iicense.reg.state.ma.us/public/PubLicenseQ.asp?board—cod .A The Official Website of the Office of Consumer Affairs and Business Regulation(OCABR) Division of Professional Licensure Wss.Gov Mass.Gov Home State Agencies A ZTopics Home>Division of Professional Licensure> ONLINE SERVICES Check a License Check A Professional License Locate a Licensed Professional By the Division of Professional Licensure Online Address Change Contact the Agency LICENSEE Name:EDWARD J. MATHEWS III. REFERENCES& MELROSE,MA RELATED INFO NEW SEARCH Disclaimer Regarding **This Licensee has additional Licenses click here to view them.** Website License Searches Glossary of License Status Codes Licensing Board: PLUMBERS a GASFITTERS License Type: MASTER PLUMBER License Number: 15180 Status: CURRENT Expiration Date: 5/1/2016 Issue Date: 11/28/2006 Exam Date: 11/28/2006 School: This web site disptays disciplinary actions dating back to 1993. This license has had no disciplinary actions taken during this time. The page above has been generated by the Division of Professional Licensure web server on Tuesday,October 21,2014 at 9:37:13 AM. ASSA t1WSETTS - ©2007-2011 Commonwealth of Massachusetts LICENSE o�. s.s 4d NUMBER r f7- - A2 NONE /nS���HycHZZZ l NZ y ofE 7 t§sEitl.IN �$ a= W 3 ri ARD 33.A§HMONT STI `` MELROSE,MA`02178 ` t� �';, � 'S OD 01.26.1011 Rev0)•15-1009 V" ^f, 10/21/9,014 9.37 / 222 Date. .�. AORTN TOWN OF NORTH ANDOVER 3r '� •� OL FO PERMIT FOR MECHANICAL INSTALLATION F s + �s 9...... "'SACHUSES i This certifies that . . . . . j has permission for mechanical installationeN in the bui�lld/i gs of . . . . . . . . . . . . . . . . . . . . . . at . . . . . . . . . . . . . . . . . . . .. North Andover, Mass. Fee. . ,''�r Lic. No.32--T . . . /Z . . . . . . . . . . . . . . . . . . . . . GAS INSPECTOR WHITE:Applicant CANARY:Building Dept. PINK:Treasurer Commonwealth of Massachusetts Sheet Metal Permit Date : ef✓ V Permit# C2_ Estimated Job Cost: Jj tP d Permit Fee: $ (9 d d Plans Submitted: YES NO Plans Reviewed: YES NO Business License# A(l .72 J 7 Applicant License# Business Information: Property Owner/Job Location Information: Name: JFI/ S' I&�¢/,L Name: �PS e--� l c Street: Street: (, t-A City/Town: 0(/drlj l/'Pl; /Gl City/Town: N 6 - A�+ 06�S+- M A Telephone: Jlzy 4G41a X21 Telephone: 7 2 Photo I.D. required/Copy of Photo I.D. attached: YES NO Building Type: Residential: 1-2 family Multi-family Condo/Townhouses Commercial: Retail Industrial Educational Institutional K. Building Cubic Footage: under 35,000 cu. ft. over 35,000 cu. ft. Sheet metal work to be completed: New Work: Renovation: HVAC_& Metal Roofing Kitchen-Exhaust System Chimney/Vents Provide brief description of work to be done: r a> INSURANCE COVERAGE: I have a current liability insurance policy or its equivalent which meets the requirements of M.G.L.Ch.112 Yes No❑ If you have checke Yes _' dicat the type of coverage by checking the appropriate box below: JIIJJJ 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: Fee$ ❑ Check at www.mass.gov/dpi Inspector Signature of Permit Approval 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 journeyperson-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 clea`ances, fire rated enclosures and pressure testing required: res-iaints installer E�rrh&r6"' ired'ori eqd"ment and dr=_:t:�.-r� - _ _ Duct penetrations in fire'rdt&J-it�ali.3 and flo6rs 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-off) _ � S 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-off) BUEND-1 OP ID: JY DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE o7/15�13 CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS-UPON THE CERTIFICATE HOLDER. THIS ERTIFICATE 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. s certificate does not confer rights to the SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate holder in lieu of such endorsements. CONTACT PRODUCER Phone:978 688 8829 NAME: FAX Michaud,Rowe And Ruscak Ins. Fax:978 557 2130 aoNN Ext): AIC No P.O.Box 188 E-MAIL North Andover,MA 01845 ADDRESS: Mark S.Rowe,CIC INSURERS AFFORDING COVERAGE NAIC# INSURER A:Commerce Insurance Company 34754 INSURED Victor Buendia INSURER B:Guard Insurance Group Buendia Sheet Metal INSURER C: 18 Andrew Circle INSURER D' North Andover, MA 01845 INSURER E: 4��: INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ADD SUB POLICY EFF POLICY EXP LIMITS INSR TYPE OF INSURANCE POLICY NUMBER MM/DDIYYYY MM/DD/YYYY 1'000'00 LTR EACH OCCURRENCE $ GENERAL LIABILITY A E T R NTE 50,00 B COMMERCIAL GENERAL LIABILITY BUBP303473 11/20/12 11/20/13 PREMISES Ea occurrence $ CLAIMS-MADE a OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ 1,000,00 X Business Owners 2,000,00 GENERAL AGGREGATE $ PRODUCTS-COMP/OP AGG $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: $ POLICY PRO LOC COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY Ea accident $ 1'000'00 A ANY AUTO BBCM25 03/19/13 03/19/14 BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON OWNED PROPERTY DAMAGE $ Per accident HIRED AUTOS AUTOS $ EACH OCCURRENCE $ UMBRELLA LIABOCCUR AGGREGATE $ EXCESS LIAB CLAIMS-MADE DED RETENTION$ Y U IU OE H- WORKERS COMPENSATION AND EMPLOYERS'LIABILITY Y/N E.L.EACH ACCIDENT $ ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ N/A OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $ (Mandatory In NH) If yes,describe under E.L.DISEASE-POLICY LIMIT $ it DESCRIPTION OF OPERATIONS below PROPERTY 5,00 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space is required) CERTIFICATE HOLDER CANCELLATION NORTH13 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of North Andover ACCORDANCE WITH THE POLICY PROVISIONS. Building Inspector 384 Osgood Street AUTHORIZED REPRESENTATIVE'oI' North Andover, MA 01845 2��/� ��� ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD C }}MIDI t NE-ALTH 4F MASSA 3., _ :• i • - .Rs E M .S M, TAL W��KE T BVl�1"E'N'VY Q_ 18; AN; �K C- R �£ .i �x • i z i .f- 1 ���..., BUEND-1 OP ID:JY DATE ,4co/2L� CERTIFICATE OF LIABILITY INSURANCE 7107/16/1 YYY) 3 "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 Phone:978 688 8829 NAME:CONTACT Michaud,Rowe And Ruscak Ins. Fax:978 557 2130 PHONE FAx P.O.Box 188 A/C No Ext): A/C No): North Andover,MA 01845 ADDRESS: Mark S.Rowe,CIC INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Commerce Insurance Company 34754 INSURED Victor Buendia INSURER B:Guard Insurance Group Buendia Sheet Metal INSURER C: 18 Andrew Circle North Andover, MA 01845 INSURER D INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDLITR TYPE OF INSURANCE INSR IV POLICY NUMBER MM/DD /YYYY MLICY EFF M/DDY Y EXP LTR LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 BUBP303473 11/20/12 11/20/13 PREMISES ETORENTED 50,00 B COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ CLAIMS-MADE FxI OCCUR MED EXP(Any one person) $ X Business Owners PERSONAL&ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,00 POLICY JEC PRO- LOC $ AUTOMOBILE LIABILITY Ea(E, .,der") LIMIT $ 1,000,00 A ANY AUTO BBCM25 03/19/13 03/19/14 BODILY INJURY(Per person) $ ALL OWNEDX SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED FFRETENTION$ $ WORKERS COMPENSATION WC STIMIT CER AND EMPLOYERS'LIABILITY Y/N TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ D? OFFICER/MEMBER EXCLUDEEl N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ PROPERTY 5,00 DESCRIPTION OF OPERATIONS/LOCATIONS/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 North Andover Barber Shop ACCORDANCE WITH THE POLICY PROVISIONS. 569 Chickering Road North Andover, MA 01845 AUTHORIZED REPRESENTATIVE 2�/1 i� �E%ID►�� ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD Date...... ...................... ,&ORT" TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ...... k..;.......�OPAc . ...... . . ........... ............ has permission to perform ......... .......................... ..........;.. ..... ........................ wiring in the building of........WE-- Z ..,-;............................................... at.... M..(.L.0....19dk ..............................................^,North Andover,Mass. Fee.3................. Lic.No. 67G............... ..........I ELECTRICAL INSPECTOR . Check # zq72 V- 9228 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance-with the provisions of M.G.L.c.143,§3L,the 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 he issued to the person,firm or corporation stated on the pemut 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 maybe_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 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. ule 8—Permit/Date Closed ***Note:Reapply for new perm ❑Permit Extension Act—Permit/Date Closed: Commonwealth of Massachusetts Official Use Only .09 Permit No. L 2 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 PRIN K OR TYPE ALL INFORMATION) Date: / /.,g � %l? City o To of: �Aby` .. Igh�Ver To the Inspector of Wires: By this application undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street&Number) /,P(Jr tom. - Owner or Tenant ���j�- tS Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No x BLDG PERMIT # Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No.of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No.of Meters r Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Install low voltage security system at above location r I Completion of the following 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 Swimmin Pool Above ❑ In- 1:1o. o Emergency Lighting g rnd. rnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS I No. of Zones No. of Switches No.of Gas Burners No. of Detection and Initiating Devices g Tons No. of Ranges No. of Air Cond. Total No. of Alerting Devices No. of Waste Disposers Heat Pum J.Nu.m.be.r Tons KW No. of Self-Contained A p Totals Detection/Alerting Devices ste No. of Dishwashers Space/Area Heating KW Local❑ yy Municipal Other No.of Dryers Heating Appliances KW No.of Devices s or Equivalent 1 No.of Water No.of No.of in ; Heaters KW Signs Ballasts No.o eve urvalent Bathtubs No.of Motors Total HP Telecommunications Wiring: No.Hydromassage No.of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: 6qD. ()p (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 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 of perjury,that the information on this application is true and complete. FIRM NAME: Broadview Security LIC. NO.: 7067C Licensee: David Holton Signature p p LL LIC.NO.: SSCO 001352 (If applicable, enter "exempt"in the license nunsber line.) Bus.Tel. No.: 978-657-0443 Address: 155 West Street, Suite 6 Wilmington,MA 01887 Alt.Tel.No.: *Per M.G.L. c.147, s. 57-61,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.