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HomeMy WebLinkAboutMiscellaneous - 162 PINE RIDGE ROAD 4/30/2018 162 PINE RIDGE ROAD 210/065.0-0135-0000.0 I II I Date..:6A ............... A OF NORriy,�O TOWN OF NORTH ANDOVER PERMIT FOR WIRING sSAcau5� This certifies that 4e d-A .................................................................... has permission to perfornkN -�-- wiring in the building of. y .Q„N.� :'�?.47........................................................... at ......`.�� ......... ! _..... .:. .... N h®ndover,Mass. f Fee.... ' '''.........Lic.No }.1.'il i-..'d'........... ................ ELECTRICAL INSPECTOR Check# Comnw wea&o f Mamac4ujetb Official Use Only ' c� Permit No. _ 1?/� aLle�oaatmerct o�3ire�ervicea %W14F 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 IN INK OR TYPE ALL I�N,/FORMATIq n Date: -d 1./-/Lf City or Town of: �o !'/'l P)?d!O tle r To the Inspector of Wires: By this application the undersigned gives notice of his or her intent io to perform the electrical work described below. Location(Street&Number) Z e I c E ©(:::� Owner or Tenant r Li e 17 !d j) p Telephone No. Owner's Address 6 03 9 f e 6,S- Is ,SIs this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building J2e5 )d f m f to . Utility Authorization No. Existing Service Amps / 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: Com letion of the fiollowing table may be waived by the Inspector of Wires. g No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fang No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA AboveIn- o.o Emergency Lighting No.of Luminaires Swimming Pool rnd. ❑ rnd. ❑ Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas BurNo.of Detection and ners Initiating Devices Total No.of Ranges No.of Air Cond. Tons No.of Alerting Devices 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 Kms, Security Systems: No.of.Devices or Equivalent No.of WaterKW No.of No.of Data Wiring: . Heaters Si ns Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: Q (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVE GE: 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 0 BOND ❑ OTHER ❑ (Specify:) A�S A G r v(7p I certify,under thepains andpenalties ofperjury,that the infor tion on this application is true and complete. FIRM NAME: H B $ Ge p h r LIC.NO.: l-:::J 8jr/7 Licensee: SignatureLIC.NO.: (If applicable,enter "exempt"in t e license number line) Bus.Tel.No.:— V Ze-( .,7 Address: Qe M a l fvy 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 amrthe(check one)❑owner ❑owner's agent. Owner/Agent PERMIT FEE. $ Signature Teler�hone No. H IvZ-_C1' IIContact Person: T - _ Phone# - II 0 •fx 1 `,y �.. ..a. S* -r •yfi-,a,.��� ,i t�� ..Y�.� j.. ,k 1.. '`p'+y"'.�..w,; ! � r a+� j ;»: � .F t d a,G•tt' to Y.1'6 2 ,ad:�� �rr � '`4 q �w'F! a r'i ^?'. 1 . r • r i Date.. ... ........ .... ................... ,40RTN TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING CHU This certifies that ......... s ...e ............................................................. ........./...................... has permission to perform ......... ....... ..................................................... ..... . ....... wiring inthe buildi of........... .................................................................................................... at 12. ............ ........ ... ......& ................ ...... orl Andover,Mass. , Fee.,2�........ Lic.No E** C*A L* PECTOR* Check# 12 � is -7 12-Z- 14 Commonwealth of Massachusetts Official Use Only `f Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.l/07] (leaveblank 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 rNMK OR TYPE ALL INFORMATION) Date: City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intentjon to perform the electrical work described below. Location(Street&Number) Owner or Tenant M 10, Telephone No.,!5'0 Ie92/.9S 6 6 Owner's Address Is this permit in conjunction with a building permit? Yes No ❑ (Check Ap ropriate Box) Purpose of Building Utility Authorization No Existing Service Ff Amps 4. 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: Completion of thefollowing table may be waived by the Inspector of Wires. A. 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 ❑ In- ❑ o.o Emergency Lighting rnd. grnd. 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. TotalTons No,of Alerting Devices " No.of Waste Dis posers Heat Pump Number Tons KW " No.of Self-Contained p 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: Beaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent j. OTHER: 4C LOSe d G �Cea z Foy�J �,X Attach additional detail if desired,or as required b the Inspector of 97res. 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 undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURA=NCE ❑ BOND ❑ OTHER ❑ (Specify:) I certl&,under the pains and penalties ofperjury,that the information on this application is true and complete. FIRM NAME: LIC.NO.: Licensee: t 5Signature LIC.NO.: (If applicable,enter "exem t';in the license number 114e) t Bus.Tel.No. Address: t'1/ ]C ctS Alt.Tel.No.. O I `Per M.G.L c. 147,s.57-61,security work re wires Departmenr ublic Safety"S"License: Lic.No.v OWNER'S INSURANCE WAIVER: I am aware that the Licen e 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 T 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 4� 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 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 Passn? Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed Re-Inspection Required($.)❑ Inspectors Comments: . Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass M Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: R b PASS ^.'.; Fil'ed'0 Re=lnspe'�tion Required($:) El, y Inspectors Comments: Inspectors Signature: Date: FINAL INSPECTION: Pass Failed Re-Inspection Required($.) ❑ Inspectors.CommV14ts: nll 'en le �,. Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com r Y` The Commonwealth of Massachusetts - Department ofIndustrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lealb Name(Business/Organization/Individual): Address:6 ✓h-S l:l4-, City/State/Zip: w 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. El New construction employees(full and/or part-time).* have hired the sub-contractors 2.0 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. ❑ 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.]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 a're doing all work and then hire outside contractors must submit a new affidavit indicating such. 1Contractors 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 formy employees. Below is thepolicy and job site information. Insurance Company Name:. )'�j OJT Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: /l/ A6 4 C C_ 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 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 sof up to$250.0 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of. Investigations of e DIA for' urance coverage verification. I do hereby cer t pain nd penalties ofperjury that the information provid a ove ' true and correct. Si afore: Date: Phone#: 3 / ` C� CL 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.PIumbing Inspector 6.Other - - - Contact Person: Phone#: 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 whoresides 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 ofpublic 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 cant'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 numberAn 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. Anew 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 o£Masgg, v.,sPtts Department of Industrial Accidents Office of Investigations 6.00 Washington.Street Boston,SIA 02111 Tei,#61.7-727,4900 ext 406 or 1-877,7MASSAFE Revised 5-26-05 Fax#617-727-7749 www.tllass,govfdia COMMONWEALTH OF MA$::' SETTS BOARD'OF 1=,LECTR ICIANS ISSUES THE FOLLOWI.IJG .LI'CENS A.S. A REG JOURNEYMAN:;ELECTRI C ( .: JEFFREY J THOMAS f ` ` I J 50 C{,FE�4iGptS CIRCLE TW1(SSURY MA 01876-1134 34154 > 07/31/<t6 181207 I I Date. ...�. .�. ......................... � pF NpRT�y,h TOWN OF NORTH ANDOVER h p * PERMIT FOR GAS INSTALLATION �� gs4cMus� This certifies that . Q. :.P ...b:..Ut,Q.. .S H.P.(I.... ... has permission for gas47V-,e\0rI & qV,-4D llation ... �:t ....................................... a in the buildings of......... ...................................................................................... lat......... .. ........... North Andover, Mass. Fee... ... Lic. No. ....Wk.?... N�,.........:::................................................. �� GAS INSPECTOR // Check# U4 4 9412. i t s MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITYMA DATE€ l�p /e` PERMIT# JOBSITE ADDRESS!/ OWNER'S NAME? _ OWNER ADDRESS t TEL l�Q .FAX TY EiNT OR OCCUPANCY TYPE COMMERCIAL:­ EDUCATIONAL RESIDENTIAL PR CLEARLY NEW:', „.` RENOVATION = REPLACEMENT;,,.,, PLANS SUBMITTED: YES 1„ NO APPLIANCES 1 FLOORS— BSM 1 2 3 4 5 1 6 1 7 8 9 10 11 12 13 14 BOILER i BOOSTER , CONVERSION BURNER �€ t COOK STOVE DIRECT VENT HEATERS DRYER �} fl b w T m FIREPLACE .. �..,..... '...:_- + W FRYOLATOR ;( 4 FURNACE GENERATOR I �: [ - GRILLE INFRARED HEATER g ( x LABORATORY COCKS MAKEUP AIR UNIT OVEN _ I POOL HEATER QOM/SPACE HEATER �'OF TOP UNIT TEST UNIT HEATER , UNVENTED ROOM HEATER ... P« E4..«. _.... WATER HEATER , C I OTHER } a ` - « II f 2 rvA. INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO _. 11 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ; BOND C1 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 [j AGENT >, z 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 k dge and that all plumbing work and installations performed under the permit issued for this application will be in complia with all Pertinent provision of he Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME Peter G.Viens LICENSE#12116 x SIGNA URE MP MGFJP JGF LPGI w CORPORATION,,# 3631 C PARTNERSHIPS 3#� LLC # M.. ,..u,. PANY NAME:[ Valley Corporation ADDRESS 15 Aegean Drive,Unit#3 CITY ;Methuen STATE MA ZIP01844 ;TEL 978-6890224 FAX!978 689-2206 CELL[ 807 2819EMAILpviens@mvalleycorp com . ,. >_ z - 1 ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES A The Commonwealth of Massachusetts a Department of Industrial Accidents w v Office of Investigations w c l Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/]Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: .' "�c,,� .- City/State/Zip: Phone #: KL AWl ou an employer? Check the appropriate box: Type of project(regluired): ]. am aemployer with� 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. F] 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 g• ❑Demolition workingfor me in an capacity. employees and have workers' y p �'• 9. ❑ Building addition [No workers' comp. insurance comp. insurance.$ required.] 5. ❑ We are a corporation and its I0.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I I.❑ Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL 12.❑ Roof repa insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13.OfOther i comp. insurance required.] v *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: J Policy#or Self-ins. Lic. #: Expiration Date:/ tfJ It ,/Job Site Address: 0o? / Aeo V City/State/Zip:N•E7.lnztle 6 /G59q5 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 herebZce �u der t7pai �sanf nal ies of pew th the infor tion provided above is true and correct. Si ature: �` � 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#: Client#: 79303 MERRIMACKV17 DATE(MM/DD/YYYY) ACORD,. CERTIFICATE OF LIABILITY INSURANCE 6/11/2014 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 '?RESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. r..r,JORTANT: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 CONTACT NAME: HUB International New England PHONE 978 657-5100 AX,No: 866-475-7959 A/C No Ext 299 Ballardvale St ADDRess: nee.certificates@hubinternational.com Wilmington,MA 01887 INSURER(S)AFFORDING COVERAGE NAIC# 978 657-5100 INSURER A:Travelers Casualty Insurance Co 19046 INSURED INSURER B: Merrimack Valley Corp etal � INSURER C 15 Agean Dr#3 INSURER D Methuen, MA 01844 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. ADDLTR TYPE OF INSURANCE NSRL WVD POLICY NUMBER MWDD/YYYY Y EFF MM/DDY/YYYY EXP LIMITS A GENERAL LIABILITY X X C01 A653551 T_ IL14 6/13/2014 06/13/2015 EACH OCCURRENCE $1.000.000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Ea occurrence $300000 CLAIMS-MADE a OCCUR MED EXP(Any one person) $5,000 X PD Ded:2,500 PERSONAL 8 ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 _ POLICY X E LOC $ -1UTOMOBILE LIABILITY X X 8102A91436000F14 6/13/2014 06/13/201 Ea acccidentSINGLE LIMIT $1,000,000 X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ X AUTOS AUTOS X NON-OWNED AUTOS PROPERTY DAMAGE HIRED D AUTOS Per accident $ A X UMBRELLA LIABX OCCUR X X ZUPl OP714314NF 6/13/2014 06/13/2015 EACH OCCURRENCE s6.000.000 EXCESS LIAB CLAIMS-MADE AGGREGATE s6,000,000 DED I X RETENTION$10000 $ A WORKERS COMPENSATION X DTAUB1A64521314 6/13/2014 06113/201 X WC TORY LIMIT OTH- AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y/ND N/A E.L.EACH ACCIDENT $110001000 OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $1,00 OOO If yes,describe under E.L.DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS below A Install Floater C01A653551TIL14 6/1312014 06/13/2015 $500,000 Transit Limit $250,000/$500,000 $1,000 deductible DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space is required) Blanket Additional Insured, Blanket Waiver of Subrogation, Per Project Aggregate& Primary/NonContributory wording applies as per written contract; Named Insured includes Matz-Rightway, Berkshire Heating&Air Conditioning and Sanders Heating&Air Conditioning CERTIFICATE HOLDER CANCELLATION Evidence of Coverage SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE g THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD _ w Location No. C-) Date NI"T►, TOWN OF NORTH ANDOVER n Certificate of Occupancy $ '~ Building/Frae�e040K �+sS +cMust "° . Fc�i r t�eSn ermit Fee $ , $ Sewer Connection F Tolled'of Wa I'. � ,e�ll& ee $ TOTAL $ Building Inspector Div. Public Works 1 'PERMIT NO. .APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. liPAGE 1 MAP 4'40- bit b 4) LOT NO. 2 RECORD OF OWNERSHIP jDATE BOOK' iPAGE ZONE I SUB DIV. LOT NO. F LOCATION AAA ,1 PURPOSE OF BUILDING PS S P-1 6 JIV I �'C 7 OWNER'S NAME /'�Ay / S 1�L, L' �� NO. OF STORIES J l' SIZE [- OWNER'S ADDRESS �.^ 'l�G ��` BASEMENT OR SLA —_ ARCHITECT'S NAME ciAP- .A , SIZE OF FLOOR T BERS IST 2ND 3RD BUILDER'S NAME 6K SPAN DISTANCE TO NEAREST BUILDING , , DIMENS12ffi OF SILLS DISTANCE FROM STREET A/ , I POSTS DISTANCE FROM LOT LINES—SIDES /I/ y� REAR " GIRDERS / J , AREA OF LOT FRONTAGEEIGHT OF FOUNDATION THICKNESS A SIZE OF FOOTING X A IS BUILDING NEW IS BUILDING ADDITION r A-ITA w i:..i/ MATERIAL OF CHIMNEY IS BUILDING ALTERATION 1I 1 514 �g4j keit L.ell V- IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO'REQUIREMENTS OF CODE"G/il'�//L S IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION. IF ANY �l c� IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE INSTRUCTIONS 3 PROPERTY INFORMATION ,leAND COST SEE BOTH SIDES EST. BLDG. COST, {)r PAGE 1 FILL OUT SECTIONS 1 - 3 EST. BLDG. COST ER SQ..FT. PAGE 2 FILL OUT SECTIONS 1 - 12 EST. BLDG. COST PER ROOM SEPTIC PERMIT NO. ELECTRIC METERS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR w r DATE FILED o — // �/ \ BOARD OF HEALTH SIGNATURE OF OWNER OR AUTHORIZED AGEN FEE 'Loo PLANNING BOARD PERMIT GRANTED a 19 BOARD OF SELECTMEN BUILDING INSPECTOR BUILDING RECORD 1 OCCUPANCY 12 SINGLE FAMILYSTORIES THIS SECTION MUSTSHOW EXACT DIMENSIONSOFLOT AND DISTANCE FROM MULTI. FAMILY OFFICES LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA- APARTMENTS RAGES. ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. CONSTRUCTION 2 FOUNDATION =I 8 INTERIOR FINISH CONCRETE _ 3 1 2 13 CONCRETE BL K. PINE BRICK OR STONE HARDW D PIERS PLASTER _ DRY WALL UNFIN. 3'• BASEMENT 11 , EA FULL FIN. B M'TAREA _ - '/. '/t 3/1 FIN. ATTIC AREA _ V_O BMT FIRE PLACES _ iEAD ROOM MODERN KITCHEN - 4 WALLS I 9 FLOORS ZLAPBOARDS B 1 2 3 - - DROP SIDING CONCRETE �_ WOOD SHINGLES EARTH ASPHALT SIDING HARDW'D ASBESTOS SIDING COMMON VERT. SIDING ASPH.TILE STUCCO ON MASONRY iTUCCO ON FRAME BRICK ON MASONRY ATTIC STRS. & FLOOR _ 3RICK ON FRAME CONC. OR CINDER BLK. STONE ON MASONRY WIRING STONE ON FRAME _ SUPERIOR I� POOR ADEQUATE NONE 5 ROOF 10 PLUMBING - - �ABLEHIP BATH (3 FIX.) _ AMBREL MANSARD TOILET RM. 12 FIX.) _ :LAT SHED WATER CLOSET - 4SPHALT SHINGLES LAVATORY - NOOD SHINGES KITCHEN SINK _ RATE NO PLUMBING _ (AR & GRAVEL STALL SHOWER _ 2OLL ROOFING MODERN FIXTURES r TILE FLOOR TILE DADO 6 FRAMING I 11 HEATING k HOOD JOIST + `PIPELESS FURNACE M _ FORCED HOT AIR FURN. - 'IMBER BMS. &COLS. STEAM ;TEEL BMS. & COLS. _ HOT W'T'R OR VAPOR NOOD RAFTERS _ AIR CONDITIONING r RADIANT H'T'G 11 UNIT HEATERS 7 NO. OF ROOMS GAS OIL 1'M'T 2nd _ ELECTRIC ' st 13rd I NO HEATING � j r— -AI; � .] Fi� 1'' o it::. - z�-.__—_ _ � NORTfj --.e -- 9 n ry n of. 6 QL 0 19 - — Andov9pper oR p� SS BOARD OF HEALTH PERMIT T L 0� THIS CERTIFIES THAT. �. .11� ..�i�l. .. � ......... .. . . . . .... ......... ® . BUILDING INSPECTOR has permission to ereA A . ... d nngs�oin Rough • ♦ Chimney to be occupied as� ��� �1/ .. ........................ Final provided that the person accepting this permit shall in every respect conform to the terms of the application on file in PLUMBING INSPECTOR this office,and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and Construction of Rough Buildings in the Town of North Andover. Final VIOLATION of the Zoning or Building Regulations Voids this Permit. PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTR TION STARTS Rough Service • Final ....... . . ..... ........ .................. BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Final Display in a Conspicuous Place on the Premises Do Not Remove Burner FIRE DEPT. No Lathing to. Be Done Until Inspected and Approved by Smoke Det. Building Inspector a Town of North Andover BUILDING DEPARTMENT Homeowner License Exemtion ` (Please print) f DATE ;; JOB LOCATION doL R11)G r` �0 T/L= Number ri Street Address Section of town ' "HOMEOWNER" CIN��ceS 2- •�r�f Name �5 ' 173 t/ Home Phone Work Phone 1 PRESENT MAILING ADDRESS 4 Al z> AA.)000�E 2 City Town /l State Zip code - " ; The current exemption for "homeowners" was extended to incl ude owner :occupied dwellings of six units or less and to allow such homeowners t engage an individual for hire who does not possess a license, rovid ed o that the owner acts as supervisor. (State Building Code , Section 10 .,'r.'.. .,DEFINITION OF HOMEOWNER: 9 . 1 . 1) Person(s) who owns a parcel of land on which he/she resides o ` : reside, on which there is , or is intended to be r intends to ing, attached or detached structures accessory toasuch usesand/orfamily farmwell- structures . A person who constructs more than one home in a two- period shall not be considered a homeowner. year shall su .to the Building Official , on a form acceptableuto themeownerBulding Officialbmit ,.. ,;., .that he/she shall be responsible for all such work performed under the ', building permit . ' ,,� (Section 109. 1 . 1) The undersigned "homeowner" assumes responsibility for com lianc . ; State Building Code and other applicable codes , by-laws , rules andwith the - regulations . The undersigned "homeowner" certifies that he/she understands the Tow North Andover Building Department minimum inspection procedures and n of ' ,`,requirements and that he/she will comply with said procedures and requirements . .'HOMEOWNER' S SIGNATURE APPROVAL OF BUILDING OFFICIAL Note : Three family dwellings 35 , 000 cubic feet , or larger, will be required to comply with State Building Code Section 127 . 0, Construction Control .