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HomeMy WebLinkAboutMiscellaneous - 1831 GREAT POND ROAD 4/30/2018Date .................. . q TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that S I . . . .................. has permission for gas installation 6,010 7i ..... ... ............................... in the buildings of .......... *'*******'**'*.'*"***"*"**"* ....................... at ..ar&vl . ... . o ndover, Mass. Fe .... Lic. No.-F:�% .............................. GAS 1 sp cT;o Check # 09961 m y 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 Wbe in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. //V� PLUMBER/GASFITTERNAME: STCPR EN C. GALINSKY LICENSE# 103ylS SIGNATURE COMPANYNAME: GALI 3- o' PLUE+'iti10C ADDRESS: P.6- WX 1701 CITY: 9 AVE -P -H i Li. STATE: rn - A - ZIP: 01231 FAX: q*79 - 5.11—z4131 TEL: 979-33y— 170 CELL: �+q — 6bA— 590q EMAIL: WV 'W . mr`p1U''Mbe ��yl MASTER [ JOURNEYMAN ❑ LP INSTALLER ❑ CORPORATION / 31 q& PARTNERSHIP ❑ # LLC ❑ # —i MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK GOWNER TYPE OR PRINT CLEARLY CITY: pMAn nDATE: PERMIT # JOBSITE ADDRESS: 3 Gee �� 'f ! OWNER'S NAME: !JL f J (10 ADDRESS: TEL FAX: OCCUPANCY TYPE: COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL'® NEW: ❑ RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES ❑ NO ❑ APPLIANCESZ FLOOR— Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCK MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER INSURANCE COVERAGE I have a current liabilqy insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES NO ❑ If you have checked YES, please indicate the type of coverage by checking the appropriate box below. LIABILITY INSURANCE POLICY [ OTHER TYPE INDEMNITY ❑ BOND ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. s' CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE.OF OWNER OR AGENT y 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 Wbe in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. //V� PLUMBER/GASFITTERNAME: STCPR EN C. GALINSKY LICENSE# 103ylS SIGNATURE COMPANYNAME: GALI 3- o' PLUE+'iti10C ADDRESS: P.6- WX 1701 CITY: 9 AVE -P -H i Li. STATE: rn - A - ZIP: 01231 FAX: q*79 - 5.11—z4131 TEL: 979-33y— 170 CELL: �+q — 6bA— 590q EMAIL: WV 'W . mr`p1U''Mbe ��yl MASTER [ JOURNEYMAN ❑ LP INSTALLER ❑ CORPORATION / 31 q& PARTNERSHIP ❑ # LLC ❑ # O C x G� a b M C) H O z z O H M cn m � m z m N y, 0 H Ci C~/J D I-d O a C+ Ln C7 Z m r%j m L m > z V W � m (� z _ H 0 c C ElCD o z r ❑o K � - � 'rJ Y r e b - 0 z z o H o at 0 0 Q- J —, e� DATE: LOCATION: OWNERS NAME: GENERATOR kw A.o�r- /06�' 21�-7 11 1� NO INSTALLATION OR GROUND DISTURBANCE BEFORE APPROVALS* CONTRACTOR: -CA PHONE NUMBER: ELECTRICAL RESIDENTIAL gas COMMERCIAL TEMPORARY LOCATION OF GENERATOR:,J�h��1 *ZONING DISTRICT: �. *PLANNING APPROVAL (IF IN WATERSHED) *CONSERVATION APPROVAL ' L_ x B- 92 X096 dt3,° 9.37J,9997M, 9P6CYGY d.Y .4Jd:'¢/LPXCB .8Y 9JYd CP7N✓dSPU,d990X 80/(//yyyypy W99N9X 9X6 .8119'?dR sltFS dSP6 90 $G .1P6lLOLd'9 Bk 13528 Pg285 #18493 L G L' \ \l SPECIAL PERMIT PLAN GREAT POND ROAD N °qu°ro�seu" NORTH ANDOVER, MA. LAI 6N°MNpj Nu+cueRRsnNn p1N�� fSCOGI°�yDYSCIUiO NORiH ANOQVER, Mq 01&5 PROFE5510N��(NGINEER58 UNO SORVEyORg n i CS' CHR/ST/ANSEN & SERGI INC. °w eKa uEamtwssnatc°mNan n.sreana�,o °wcanarsavm RC R I T E XTU R E JOEL RM GAGNON, AIBD residential designer RESIDENTIAL DESIGN jg@architextureRD.com 06.20.14 North Andover Building Department 1600 Osgood Street North Andover, MA 01845 Building Inspector: To the best of my knowledge 1831 Great Pond Road has been constructed and completed per the plans drawn by Architexture Residential Design. Minor changes were made during construction that had no bearing on site or structural plans. Civil and structural engineering are the responsibility of others contracted for those services. Sincerely, Joel RM Gagnon owner/designer 80 Merrimack Street, Suite 17 • Haverhill, MA 01830 978.374.1497 www.architextureRD.com Date .... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ..... ......................................................................................................... has permission to perform ......... ...... 1-7 4/1� ......... .... ... ... .......................... .......................................... wiring in the building of.... SJ� ............................................................... . ............ .... ........ ... Fee,/ ......................... Lic. N6 ... ..... ..... ar ELE cAL INsPECroR Check ,4 921109 7� .3 Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. Occupancy and Fee Checked [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 NK OR TYPE ALL INFORMATION) Date: ' City or Town of: NORTH ANDOVER To the In pector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) -I_31g4 T /Do -i rs r Owner or Tenant � � Lt� -_ ,�. Telephone No. Owner's Address tnM&7- Is this permit in conjunction with a building permit? Yes Z No ❑ (Check Appropriate Box) j Purpose of Building Alegi+ Utility Authorization No./ _% % ILt 7 - Existing Service Amps / Volts Overhead Undgrd ❑ No. of Meters _ New Service P 0 g Amps iaG /..2tVolts Overhead Undgrd ❑ No. of Meters / Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: 0 f,- N . i.q] nra— fn1/nwina tnh)n may he waived by the Inspector 01 Wires. No. of Recessed Luminaires R-6 Wi No. of Cel Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA ,Ivo. of Luminaires a - "ing Above In- Swimming Pool rnd `. ❑ rnd. ❑ o. o mergency ig Ing Battery Units No. of Receptacle Outlets 0 No. of Oil Burners �' FIRE ALARMS • No. of Zones , No. of Detection and No. of Switches No. of Gas Burners Initiating Devices f No. of Ranges / Total No. of Air Cond. Tons No. of Alerting Devices / Heat Pump Number Tons _..... KW No. of Self -Contained No. of Waste Disposers P Totals: Detection/AlertinLy Devices No. of Dishwashers , Space/Area Heating KW Municipal Other Local ❑ ❑ Connection No. of Dryers / Heating Appliances KW Security Systems:Y No. of Devices or E uivalent No. of Water KW No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent Telecommunications Wiring: No. Hydromassage Bathtubs No. of Motors Total HP No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of res. 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: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under the pains andpenalties of perjury, that the information o his applicatio is true and complete. FIRM NAME:. t % �� `� LIC. NO.:=� Licensee: p ` �d,, 4 Signature ( LIC. NO.:,--? VV �-- (If applicable, enter "exem t ' zn the license numberline.) Bus. Tel. No.:DK &4C-6 Address: 1�M Ya- 'eiJ "W-11 Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires De artmq' f 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) Elowner Elowner's agent. Owner/Agent SignaturTelephone No. PERMIT FEE: $ r S rk ❑ 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 be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shallbelimited 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 autoinatic 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 , Pass Failed EN Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE SPECTION: Pass ENK, Failed Re- Inspection Required ($.) ❑ Inspectors Co ents: . Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass 0 Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass Failed Re- Inspection Required ($.) ❑`t Inspectors Comments: Inspectors Signature. Date: FINAL, INSPECTION: Pass n Failed Re- Inspection Required ($.),❑ InRectors Comments: �^ Inspectors Signature: ate: DEB WEINHOLD ... TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 ,Y www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/Organization/Individual): ,'-,\`e<) 4)( `) Address:61 City/State/Zip: C64 Phone #: y 7s- Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I /6mployees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. I ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, §1(4), and we have no insu-, mce required.] t IN employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. El Electrical repairs or additions 11. F1 Plumbing repairs or additions 12. ❑ Roof repairs 13. ❑ Other Any applicant that checks box #1 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. contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. am an employer that isproviding workers' compensation insurance for my employees. Below is thepolicy andjob site !formation. , isurance Company olicy # or Self -ins. Lic. #: )b Site Address: Expiration Date: City/State/Zip:, .ttach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). ailure to sbcure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ne up to .,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine I up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of ivestigations of the DIA for insurance coverage verification. do hereby certify under the pains and penalties of perjury that the information provided above is trite and correct. ignature: Date: Official itse only. Do not write in this area, to be completed by city or town official. City or Town: Issuing Authority (circle one): 1. Board of Health 2. Building Department 3 6. Other Permit/License # City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector Contact Person: Phone 1' Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current V 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 Ir year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-7274900 ext 406 or. 1.877-MASSAFE Fax # 617-727-7749 evised 5-26-05 umnu tnaee anv/rlia 10118 Date TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that .. '' (d a- v-t 4-i - has permission to perform ..L w t--kv VVV plumbing in the buildings of ... �. . `� !. `� . . . ...... . . ... . at ..$. 3. ..C. .... .{ 4.�h ....... ,North Andover, Mass. Fee .... Lic. No. PLUMBING INSPECTOR Check # 4 -7 '11-- P TYPE OR PRINT CLEARLY 6-0 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY _ ° L�, MA DATE PERMIT # W I I b JOBSITE ADDRESS OWNER'S NAME �G ► UTc3 OWNER ADDRESS _ TEL �--FAX— OCCUPANCY TYPE COMMERCIAL EDUCATIONAL NEW: V RENOVATION: REPLACEMENT: 01 FIXTURES 7 FLOOR- BSM BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/ AREA DRAIN INTERCEPTOR (INTEf KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING RESIDENTIAL PLANS SUBMITTED: YES Q NOF INSURANCE COVERAGE: I have a current -liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YESF- ,NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [] OTHER TYPE OF INDEMNITY ® BOND 0 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 Q AGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in ompliance wit Pe inent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME LS�PE�►-( �E1 s--1 n S I LICENSE # ® SIG RE 1911 ME m CORPORATION 01#=PARTNERSHIP0#�LLC D COMPANY NAME 6 (r ADDRESS (' c� 2� CITY I +E4-kTlj� STATE 1� ZIP L �3 % TEL FAX CELL EMAIL rj o o z (nEl W 6i w Date ..... f ..:...Z Z.'* TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that .. .. °.':y....6.�+��.!-Y S� has permission for gas installation ...1 .. ....1 :..............:........... in the buildings of ............. .L. ` ` v ......................................................................................... at ...... ......1......... North Andover; Mass. Y Fee .J. �:�..... Lic. No. t. �.3..... �......:. ..................:............. GASINSPECTOR Check # ew? ?- 8832 -Y� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY —Jn,\ b-lkr-'< II MA DATE rC-LZ 7��PERMIT# L JOBSITE ADDRESS 6 1f;.(A-A OWNER'S NAME GOWNER ADDRESS �- - - _ TESL� FAX -------!1 TYPE OR OCCUPANCY TYPE COMMERCIAL E] EDUCATIONALRESIDENTIAL PRINT CLEARLY NEW: M RENOVATION: I REPLACEMENT: 0 PLANS SUBMITTED: YESF-11 NO APPLIANCES 7 FLOORS- BSM 1 2 3 1 4 5 6 7 8 9 10 11 :1a 13 14 BOILER BOOSTER CONVERSION BURNER -__- 1— --I __j I ---- COOK STOVE L. ,. DIRECT VENT HEATER DRYER FIREPLACE �_ ----� -- _ FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS I . - - = h�1. -_ _ I ,------- r_.MAKEUP MAKEUPAIR UNIT-- OVEW POOL H EATER a - R"'M / SPACE HEATER RO F TOP UNIT - TEST v_f I - _ ::.( _— _! L_.-_ _.._ _ 1( --{ !� _! I! ._ { _-_ I UNIT HEATER -_ _ __ L s_ . _.. --_ UNVENTED ROOM HEATER I ' ' 1—j WATER HEATER OTHER INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES NO [j] 1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY Ej BOND 0 OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER [ AGENT SIGNATURE OF OWNER OR AGENT 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 ith all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. J PLUM BER-GASF ITTER NAME � r2 � E . -1 t _-..-J LICENSE # ' SIGNATURE MP tj�' MGF [ f� JP -11 JGF LPGI E] CORPORATION [] # - PARTNERSHIPS_ !#= LLCJ(# COMPANY NAME: �f��.._ LrcLUv/ ADDRESS _._. I _ ---7--.___-____.-....__..._� CITY - ._._... _. ._�%_) STATE ZIP L d 3 TEL . ! � - - 4 FAX CELL EMAIL _ Ir- ' o z tit W a W W r' �p Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ 6359000.00 m $ - $ 7,620.00 Plumbing Fee $ 952.50 Gas Fee 100 comm. $ 100.00; Electrical Fee $ 952.50 Total fees collected $ 9,625.00 1831 Great Pond Road 111-14 on 8/1/13 New Single Family Home 325 Date............ N�RTM TOWN OF NORTH ANDOVER PERMIT FOR MECHANICAL INSTALLATION s i�-' .."..!: 7'A� This certifies that ! ` O .. tfi .. has permission for mechanical installaticnl.+.�".^���? �, iti . �.. . ... . in the buildings /aof� t .. . . ! ... � !�" ............... . at North Andover, Mass. Feepro ✓ . Lic. No��?.3!.... ..................... GAS INSPECTOR j� WHITE: Applicant CANARY: Building Dept. PINK: Treasurer Y IL -AV 2—(�, \-Z -, HEATING SERVICE DATE: 07/03/13 555 Woburn St, Tewksbury, MA 01876 Phone 978-851-4403 Fax 978-851-0398 Website www.franksheating.com TO MJC Development Corp. 1831 Great Pond Rd 87 Lafayette Rd Unit 4 North Andover, MA Hampton Falls, NH 03844 603-926-1200 THE FURNISHING FABRICATION AND INSTALLATION OF THREE GAS SYSTEMS AN—D AIR CONDITIONING UNITS SERVING THE FIRST, SECOND, AND BASEMENT FLOORS WITH THE TOTAL OF 4 ZONES USING AMERICAN STANDARD EQUIPMENT AS FOLLOWS: 9 FAMILY/ENT/MUD/KITCHEN ON 1ST FLOOR/BASEMENT * ONE AMERICAN STANDARD 95% EFFICIENT SINGLE STAGE FURNACE MODEL#AUH1D120 * ONE AMERICAN STANDARD 13 SEER CONDENSER MODEL#4A7A3060A1000A * ONE AMERICAN STANDARD 5 TON MODEL#4TXCD061 LEFT HALF OF FIRST FLOOR * O11E AMERICAN STANDARD 95% EFFICIENT SINGLE STAGE FURNACE MODEL#AUH1B040 * ONE AMERICAN STANDARD 13 SEER CONDENSER MODEL'#4A7A3024A1000A * ONE AMERICAN STANDARD 2 TON MODEL#4TXCB025 LOUIS AREA * ONE AMERICAN STANDARD 95% EFFICIENT SINGLE STAGE FURNACE MODEL#AUH1B040 * ONE AMERICAN STANDARD 13 SEER CONDENSER MODEL404A7A3018A1000A * ONE AMERICAN STANDARD 2 TON MODEL#2TXCB025 ;`,yt, !�dXyi THIS INCLUDES THREE APRILAIRE 1410 HIGH EFFIECENT AIR CLEANERS, DRAINS TO SUITABLE SITES, FOUR PROGRAMMABLE THERMOSTATS. THE MAIN SUPPLY AND RETURN DISTRIBUTION TRUNK WILL BE GALVANIZED STEEL, INSULATED WITH,2" AND 3" FSK INSULATION.'' ALL BRANCH RUNS WILL BE A COMBINATION OF INSULATED FLEX AND GALVANIZED STEEL CONNECTED TO CEILING AND FLOOR MOUNTED BOOTS. ALSO A CONTAINMENT PAN WITH FLOAT SWITCH WILL BE INSTALLED, WHICH WILL SHUT THE UNIT DOWN IN THE EVENT THE DRAIN BECOMES,PLUGGED. COMPLETE LESS PIPING AND WIRING. THE INSTALLATION IS WARRANTEED BY FRANK'S HEATING FOR ONE YEAR. THE EQUIPMENT IS.WARRANTEED BY THE MANUFACTURER THRU FRANK'S HEATING x. Commonwealth ®f Massachusetts Sheet Metal Permit Date: � d 13 Estimated Job Cost: Plans Submitted: YES NO Business License # Gi Permit # Permit Fee: $�� I Plans Reviewed: YES _ Applicant License # Ali Business IISnformaation: Property Owner / Job Location Information: Name: f � 3 C I C 06A f aAK f'6 Name: M S L vw t, Street: Street: `6 City/Town: City/Town: Telephone:(9l �SSS l 4 `( U 3 Cil � Telephone: l Photo I.D. required / Copy off Photo I.D. attached: YES Building Type: NO Residential: 1-2 family '� Multi -family Condo / Townhouses Commercial: Office Retail Industrial Educational Institutional Building Cubic Footage: under 35,000 cu. ft. 9/ 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: IAC.. 6",� tV,- w 4ft- w llzt w V-, IAC.. 6",� tV,- w 4ft- w llzt w V-, INSURANCE COVERAGE: I have a current liability insurance policy or its equivalent which meets the requirements of M.G.L. Ch. 112 Yes �o ❑ 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 boxU, 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. Date Date Type of License: Progress Inspections Comments Final Inspection By ❑ Master ❑ Master -Restricted Title City/Town ourneyperson Permit # ❑Journeyperson-Restricted Fee $ ❑ Inspector Signature of Permit Approval Comments Signature of Licensee License Number: 37 3 Check at www.mass.gov/dpi 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 joumoyperson-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) 61Duct 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: } _ _ Seie�:aie rer , mints instal 16d) Ehrli6t required on equipment and . Duct penetrations in fire'ratQ--ivali:, and floors sealed Metal roofing systems installed watertight using proper materials and fasteners Flexible duct nuns installed 6'-0" maximum length Ductwork installed using proper hanger spacing, hanger stock, threaded rod and angle iron Ductwork / plenum connections sealed 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) M Sheet Metal Residential Guidelines / Insnection 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 "D" Duct work sized per manual 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 V 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) -COMMONWEALTH OF MASSACHU47, off y SETTS= r =SHEET METAL WORKERS �-. ASA JOURNEYPER-SON-UNRESTRICTED x G ,SSUES TME 45V. CENSE TO • E TIMDTHY R PALMER [[+ i yi--*moi.-oa.-.�'.s.s.a'T.� A1 • . 4 a da^^*' � y +�- �,,.nw..m--+- �.: 11'2 yLOW-EtL 1 AVE`` �. `-HAVERHIIL' SMA -01832-3710. -, =�d: 3731 09128/14 .257754 _` Loa 4 Entire Short Form e House HEATING SERVICE Franks Heating Service 555 Woburn St, Tewksbury, MA 01876 Phone: 978-851-4403 Fax: 978-851-0398 ro�ectnfoll�matioln� 1831 great pond rd norht andover ma Job: Date: Jul 01, 2013 By: HEATING EQUIPMENT Make n/a Trade n/a Htg Clg Infiltration Outside db (°F) 1 88 Method Simplified Inside db (°F) 70 75 Construction quality Tight Design TD (°F) 69 13 Fireplaces 1 (Tight) Daily range - M Inside humidity (%) 30 50 Moisture difference (gr/Ib) 28 28 HEATING EQUIPMENT Make n/a Trade n/a Model n/a AHRI ref. n/a Efficiency n/a Htg load Heating input 0 Btuh Heating output 0 Btuh Temperature rise 0 OF Actual air flow 0 cfm Air flow factor 0 cfm/Btuh Static pressure 0 in H2O Space thermostat n/a 2029 COOLING EQUIPMENT Make n/a Trade n/a Cond n/a Coil n/a AHRI ref. n/a Efficiency n/a Htg load Sensible cooling 0 Btuh Latent cooling 0 Btuh Total cooling 0 Btuh Actual air flow 0 cfm Air flow factor 0 cfm/Btuh Static pressure 0 in H2O Load sensible heat ratio 0 2029 ROOM NAME Area Htg load Clg load Htg AVF Clg AVF (ft2) (Btuh) .(Btuh) (cfm) (cfm) 2ND FLOOR d 699 13086 7086 309 309 FIRST/BASE d 3319. 48548 40641 2029 2029 SOUTH END d 1207 21796 14514 630 630 Entire House d 5224 83431 62241 2968 2968 Other equip loads 18930 3566 Equip. @ 1.00 RSM 65807 Latent cooling I I I 3616 TOTAI S r))^ , 0236 1 69423 2968 2968 Calculations approved by ACCA to meet all requirements of Manual J 8th Ed. • wri htsoft� 2013 -Dec -02 07:33:05 . " � Right -Suite® Universal 2012 12.1.07 RSU10062 ACCA ... Project\1 831 great pond rd norht andover ma.rup Calc = MJ8 Front Door faces: N Page 1 j' Load Short Form ..�- 09 2ND FLOOR HEATING SERVICE Franks Heating Service Job: Date: Jul 01, 2013 By: 555 Woburn St, Tewksbury, MA 01876 Phone: 978-851-4403 Fax: 978-851-0398 Pro ect'Informat"" Wi �«q 1831 great pond rd norht andover ma Make Trade Model AHRI ref Efficiency Heating input Heating output Temperature rise Actual air flow Air flow factor Static pressure Space thermostat 80 AFUE 0 MBtuh 0 Btuh 0 OF 309 cfm 0.024 cfm/Btuh 0 in H2O Make Trade Cond Coil AHRI ref Efficiency Sensible cooling Latent cooling Total cooling Actual air flow Air flow factor Static pressure Load sensible heat ratio 0 SEER Area 0 Btuh 0 Btuh 0 Btuh 309 cfm 0.044 cfm/Btuh 0 in H2O 0.90 3763 ROOM NAME Area Htg load Clg load Htg AVF Clg AVF (ft2) (Btuh) (Btuh)(cfm) (cfm) LOTUS PLAY 328 6155 3763 145 164 LOUIS BED 171 2679 1559 63 68 L WIC 65 852 188 1 20 8 LOUIS BATH 135 3400 1577 80 69 2ND FLOOR d 699 13086 7086 309 309 Other equip loads 1973 372 Equip. @ 1.00 RSM 7458 Latent cooling 821 TnTAI S acaa cncn nnln wvv oc r oUy .SUy . Calculations approved by ACCA to meet all requirements of Manual J 8th Ed. �wri htsoft' 2013 -Dec -02 07.33:05 9 .Right -Suite® Universal 2012 12.1.07 RSU10082 ACCK ...Project\1831 great pond rd norht andover ma.rup Calc = MJ8 Front Door faces: N Page 2 F' ;' Load Short Form Job: r�.�. Date: Jul 01, 2013 FIRST/BASE By: HEATING SERVICE Franks Heating Service 555 Woburn St, Tewksbury, MA 01876 Phone: 978-851-4403 Fax: 978-851-0398 For: 1831 great pond rd norht andover ma HEATING EQUIPMENT { Make Trade Model AHRI ref Efficiency Heating input Heating output Temperature rise Actual air flow Air flow factor Static pressure Space thermostat 80 AFUE 0 MBtuh 0 Btuh 0 Htg Cig Infiltration Outside db (°F) 1 88 Method Simplified Inside db (°F) 70 75 Construction quality Tight Design TD (°F) 69 13 Fireplaces 1 (Tight) Daily range - M Inside humidity (%) 30 50 Moisture difference (gr/Ib) 28 28 HEATING EQUIPMENT { Make Trade Model AHRI ref Efficiency Heating input Heating output Temperature rise Actual air flow Air flow factor Static pressure Space thermostat 80 AFUE 0 MBtuh 0 Btuh 0 OF 2029 cfm 0.042 cfm/Btuh 0 in H2O COOLING EQUIPMENT Make Trade Cond Coil. AHRI ref Efficiency Sensible cooling Latent cooling Total cooling Actual air flow Air flow factor Static pressure Load sensible heat ratio 0 SEER Area (ft2) 0 Btuh 0 Btuh 0 Btuh 2029 cfm 0.050 cfm/Btuh 0 in H2O 0.89 2416 ROOM NAME Area (ft2) Htg load (Btuh) Clg load (Btuh) Htg AVF (cfm) Clg AVF (cfm) 3/4 bath 126 1073 384 45 19 b bed 379 4939 2416 206 121 hall 276 2301 265 96 13 thea5526 314 3187 231 159 ENT 314 11575 9198 I 484 I 459 LIV 8042KIT I 15562 336 08 3607 _4685 I I 196 24155 I PANT 8176 I 1868 74 93 PWD 47 887 I 692 37 I 35 LAU 45 1235 1199 52 60 MUD 292 I 3408 I 786 I 142 I 39 GYM OAR 11n4 nnn Calculations approved by ACCA to meet all requirements of Manual J 8th Ed. .1111 .,,tL wrightsoft`° Right -Suite® Universal 2012 12.1.07 RSU10062 2013 -Dec -02 07:33:05 Page 3 fiCC10 ... Project\1 831 great pond rd norht andover ma.rup Calc = MAFront Door faces: N FIRST/BASE d 3319 48548 40641 2029 2029. Other equip loads 12825 2416 Equip. @ 1.00 RSM 43058 Latent cooling 5305 TnTAI q 3319 6137 4 48363 2029 2029 Calculations approved by ACCA to meet all requirements of Manual J 8th Ed. wrightsoft`° Right -Suite® Universal 2012 12.1.07 RSU10062 2013 -Dec -02 07:33:05 Page 4 ACCK ...Project\1831 great pond rd norht andover ma.rup Calc = M.18 Front Door faces: N Load Short Form t✓ SOUTH END HEATING SERVICE Franks Heating Service 555 Woburn St, Tewksbury, MA 01876 Phone: 978-851-4403 Fax: 978-851-0398 For: 1831 great pond rd norht andover ma Job: Date: Jul 01, 2013 By: HEATING EQUIPMENT Make Trade Model AHRI ref Efficiency Heating input Heating output Temperature rise Actual air flow Air flow factor Static pressure Space thermostat 80 AFUE 0 MBtuh 0 Btuh Htg Clg Infiltration Outside db (°F) 1 88 Method Simplified Inside db (°F) 70 75 Construction quality Tight Design TD (°F) 69 13 Fireplaces 1 (Tight) Daily range - M Inside humidity (%) 30 50 Moisture difference (gr/Ib) 28 28 HEATING EQUIPMENT Make Trade Model AHRI ref Efficiency Heating input Heating output Temperature rise Actual air flow Air flow factor Static pressure Space thermostat 80 AFUE 0 MBtuh 0 Btuh 0 OF 630 cfm 0.029 cfm/Btuh 0 in H2O COOLING EQUIPMENT Make Trade Cond Coil AHRI ref Efficiency Sensible cooling Latent cooling Total cooling Actual air flow Air flow factor Static pressure Load sensible heat ratio 0 SEER Area 0 Btuh 0 Btuh 0 Btuh 630 cfm 0.043 cfm/Btuh 0 in H2O 0.87 8187 .ROOM NAME Area Htg load Clg load Htg AVF Clg AVF (ft2) (Btuh) (Btuh) . (cfm) (cfm) MAS 436 11778 8187 341 356 M BATH 140 1771 1288 51 56 GUEST 171 4385 2862 1 127 1 124 TOI 19 453 370 13 16 DRESS 166 1878 I 1047 I I 54 I 45 BATH 88 1531 760 44 33 HALL2 186 0 0 0 0 SOUTH END d 1207 21796 14514 630 630 Other equip loads 4131 778 Equip. @ 1.00 RSM I I 15292 Latent cooling I I 2207 TOTALS l')m 47AA^ Calculations approved by ACCA to meet all requirements of Manual i 8th Ed. t wri htsoft� 2013 -Dec -02 07:33:05 9 Right -Suite® Universal 2012 12.1.07 RSU10062 ACCK ...Project\1831 great pond rd norht andover ma.rup Calc = MJ8 Front Door faces: N Page 5 'M S J Q) tj EE O E�- 1kj-Fu.(o tjj, > I" co -U). (01 z -2 0) 04 C L m ill A .0 ji, �,C)o A 00, 0 x LL Ir Lb .0 jLr) 0 do - am CD O N o co S Q) EE O E�- ------------------ CL N m C) E O m of 0 co Oco N U) O N aOo �� c cl N Y '0 CI) T r N co o a F cl� co N 4 co J . z � a Co rn j (\_ N •� (eco CO 5 O Qj LL n m CD LO W N LO - �; \ N 00 cz ~ rn LL O S . O E J �U .00 L G O L � O � O a d a� m c� M W LU J E p 0 y� j J r �o x an DATE (MM/OLVYYYY) �--� CERTIFICATE OF LIABILITY INSURANCE 0627/1013 _THIS CERTIFICATE IS ISSUED ASA MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER, IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the policy(los) must be endorsed, If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement an this certificate does not confer rights to the certificate holder PRODUCER FEDERATED MUTUAL INSURANCE COMPANY HOME OFFICE: P.O. BOX 328 OWATONNA, MN 55060 INSURER A: FEDERATED MUTUAL INSURANCE COMPANY _ 13935 INSURED. 360 541 7 INsuRER B: ^ HILLIS CORP 555 WOBURN ST INSURER c: TEWKSBURY, MA 01876 INSURER D: INSURER, r: _ INSURER P: COVERAGES CERTIFICATE Nt1MPFR- 6 nGvlclnru kii iwacn. n 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. VNI TYPE OF INSURANCE AD o POLICY NUMBER M JC�YE'FPOLI 'Y 'XP LIMIT'S GENERAL LIABILITY EACI-I OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE ��qq ��CNTED $100,000 CLAIMS -MADE FX OCCUR _PJ3EMLSES�En.eccun'enaa)—. _ HIED EXP (Any one person) A N N 9385795 06/30/2013 06/30/2014 PERSONAL& ADV INJURY $1,000,000 GENERALAGGREGA'rE $21000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG_ $2,000,000 X POLICY LAG- - LOC _ AUTOMOBILE LIABILITY (�``QMBINED SINGLE LIMIT 1P 9MLL�ul1 X ANY AUTO ?BODILY INJURY (Per person) A AUTOS AUTOEDULED N N 9385794 06/30/2013 06/30/20'14 BODILY INJURY (Per arrldenl) HIRED AUTOS NON -OWNED UT AUTOS P�20PERTY DAMAGE -- �LI�Llflllll X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $3,000,000 A EXCESS LIAB CLAIMS -MADE N N 9385706 06/30/2013 06130/20'14 AGGREGATE $3,000,000 DEO RETENTIONWORKERS WW TTpp��JJ 1'Q�1?LIMITS 0A, AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE C.L. EACH ACCIDENT OFFICER/MEMBER EXCLUDED? NIA _ (Mandalory In NH) E.L. DISEASE - EA EMPLOYEE If yes, describe under DESCRIPTION OF OPERATIONS below El DISEASE - POLICY LIMIT i IUIX Vr VrLfRA I i Viva I LUI,A I IUNa I VtNILLt5 (AR80 AUUND 1U1, Addlllonol Ramarks Schedule, II more space le requlred) f CERTIFICATE HOLDER CANCELLATION 00 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, AUTI-IORIZED RE -PRESENTATIVE - ©1988.2010 ACORD CORPORATION. All rights reserved, ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD Client#: 53676 HILLISFRAN2 ACORD. CERTIFICATE OF LIABILITY INSURANCE DATE(MM10D/YYYY) ACORD. 7/01/2013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. ------------ I NT: If the certificate holder Is an ADDITIONAL INSURED, the pol(Cy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may regUlre an endorsement. A statement on this certificate does not confer rights to the certificate holder in IiOU of such ondorsement(s). PRODUCER NO TACT y HUB International New England PHONE--" J78 � g 5100 G57 299 Ballardvale St E-MAIL MAI --flfiG-h75-7959 - '- ADpl;ess;- nee.certificatesihubinternational.coni Wilmington, MA 01887 - - — ....-----------...._... ....... --- ----- - ___— __INSURER(SIAFFORDINGCOVERAOC NAIC11 978 657-5100 - -- __...-.-. _._._.. _ _ ..... INSURER A_ Independence Casualty Ins Co------- INSURL"D INSURER e Hillis Corp -- — ---------... --- -- - _._.... -- ----- INSIIRER_C DBA ...._ _....._. ............ ......._......_ .,...............__......_......_.... . _.._....__._-._.___....._..-- ..INSURER D_. _.._...._ Frank's Heating Service 555 Woburn St - ----- IrlsuaER e Tewksbury, MA 01876 -' -------------------------------- -- -... .._.... INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED -10 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 ADULSU6R-........_..----...__.__..............__..POLICYEI'F P01_ICYEXf'.___.--._-__.---- .... _...... —.___TYPE OFINSURANCE WVR___ ...POLICY MUMRGR LIMITS .. ..._. IMM/DD/YYYY),.tMMIDO/YYYY).._. GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL. GENERAL_ LIABILITY DAMAGEq RENTED Ph _M 5C CLAIMS-MADE I .I OCCUR MLD t XP (Any one person) $ PERSONAL & ADV INJURY $ GENERAI.AGCREGATG $ GEN'L AGGREGATI: LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG ._...-:- -- ............... _. ......POLICY1' .L....I.JE(;Rn"C....,.I_.._LLOG _...__.._................__........._...------___-------..__. ___-------. _..—...-...__._.._.. _--..---._....-$----...._..._ AUTOMOBILE LIABILITY COMBINED SINGLE LIMfr ANY AUTO BODILY INJURY (Per person) $ _...__...._:.......... ALL OWNED SCHEDULED BODII.Y INJURY (Per acclrlenl) $ ._. AUTOS AUTOS .._ NON-OWNED........E.............._...._.-----------_..----...... ..... AUTOS PROI LRl"Y DAMAGE $ HIRED AUTOS (F,q( ttpcidant) .- $ UMBRELLA LIAe _ OCCUR EACH OCCURRENCE $ - - EXCESS LIAe _^ . 1,CLAIMS-MADE. AGGREGA E $ DED_.L.._LRETEN TION $ WORKERS COMPENSATION WC STATU- 0111 A VVC1001'13'100 0613012013 06130/201 AND EMPLOYERS' LIABILI TYY/N _..__T.lZRY11MITS_.I—_ILR _.._. ANY PROPRIE-1 OR/PAR "rNCR/EXECUTIVE --- El__EACIiACCIDENT______ $SOO,000 OFFICER/MEMBER EXCLUDED? N NIA - --- (Mandato -'" N In NH ) E.L. DISEASE - EA EMPLOYEE $5 000 If yes, describe Under -D[SCR.IPfIONOFOPfRA"fIONSbelow..__._..__E,L.-DISEASE-POLICYLIMIT $5081000„ DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Scherlydo, If more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF TIME ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE 'THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH TIME POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 1950-2010 ACORD CORPORATION. All rights reserved ACORD 25 (2010105) 1 of 1 The ACORD name and logo are registorod marls of ACORD #59512901M949216 DKO04 Date/.. ................... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION r Xz�_Z This certifies that-., i�� has permission for gas installation .!'....:.. ...(,...�. . ......c .. ..+gin-. in the buildings of .............................. .....P� Q� c.,-" ................................... cE?...... : C .............. North Andover, Mass. Fee,.33f).-�".... Lic. No..711 .......... L., ................ GAS INSPECTOR Check # w . 8913 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK b CITY I NORTH ANDOVER MA DATE OCT. 11, 2013 PERMIT #CA 0 1 111 lT JOBSITE ADDRESS 11831 GREAT POND RD. OWNER'S NAME I MJC DEVELOPMENT GOWNER ADDRESS MJC DEVELOPMENT TEC 395-6441 FAX TYPE T OCCUPANCY TYPE COMMERCIALEDUCATIONAL PRINT ® CLEARLY NEW: 0 RENOVATION:E] REPLACEMENT: RESIDENTIAL® PLANS SUBMITTED: YES® NDE] I APPLIANCES Z FLOORS- I BSM 1 1 1 2 1 3 1 4 1 5 1 6 1 7 1 8 1 9 1 10 1 11 1 12 1 13 1 14 1 BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF'T'OP UNIT UNIT HEATER UNVENTED ROOM HEATER ALLAN UNDERGROUND INSURANCE COVERAGE have a current' liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES E] NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY E] OTHER TYPE INDEMNITY [—] BOND OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ® AGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are a and accurate to the b?011' my owledge and that all plumbing work and installations performed under the permit issued for this application will beN mpl nce with all P lentio o the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME I JOHN MARSHALL LICENSE #17781—- 778 SIGNATURE MP ® MGF JP ® JGF LPGI 0 CORPORATION �# PARTNERSHIP# LLC []# COMPANY NAME: EASTERN PROPANE GAS ADDRESS 1131 WATER ST. CITY I DANVERS STATE MA ZIP 01923 TEL 1 800 322 6628 FAX CELL EMAIL 16 I27 �Pccc) 1�,� yn�ca.,t, The Commonwealth of MassachusettsI ' mi Mi Department of Industrial Accidents Office of Investigations _ I Congress Street, Suite 100 Boston, ALL 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit:.Builders/Contractors/Electricians/Plumbers. Applicant-Infor-n -ation . __ __:��.___-_.�P-lease=PrintLegibly Name (Business/Organization/Individual): EASTERN PROPANE & OIL 131 WATER STREET Address: . _ DANVERS. MA. 01923. 978 750-6500 . Clty/State%Zip: Phone *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. lContractors 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: ENERGI - Policy # or Self -ins. Lica#: EWGCD000080613. Expiration Date: 03/15/2014: Job Site Address: 3I C-, pa f ?� ) :-City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). 6t �yS 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 copyy of -this statement maybe forwarded to the Office of..., Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. 978-750-6500 Official use only. Do not write in this area, to be completed by cit), 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 Are you. an employers Check the appropriate box 7. ✓ I am a erri to r w ., 45 .:. ❑ . e. ith ..4 p y 4.: I am a general contractor and I .. e. ,. employees (full and/or'parf=time) * have hired the subcontractors 2:0 I am a sole proprietor' or partner- • li"sted.on the:.attached sheet::, ship and have no employees These.sub-contractors.hay.e: working forr ee'in 'anycapacity employees .and have workers', .: [No workers' comp `insurance comp. insurance t required:] 5. We are' a corporation and' its*:. 3' harri a homeowner doing all work officers have. exercised their ::... myself. [No workers' comp. right of exemption per MGL insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' coma. insurance reauired.l *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. lContractors 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: ENERGI - Policy # or Self -ins. Lica#: EWGCD000080613. Expiration Date: 03/15/2014: Job Site Address: 3I C-, pa f ?� ) :-City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). 6t �yS 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 copyy of -this statement maybe forwarded to the Office of..., Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. 978-750-6500 Official use only. Do not write in this area, to be completed by cit), 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 'r4 NHd771.96 ACC)RL® ;CERTIFICATE .p.F-LIABILITY INSURANCE DAT3/14/DD,YYYY) 3/14/2013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A' CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED, REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions. of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the .certificate holder in lieu.of such endorsement(s). _ ._ PRODUCER. .... .__..........—.-_.-.,,.:_.,. ...: .._ ... : (BOO) Commercial Lines — BOO 990-7465 Wells Fargo Special Risks, Inc. 230.Comlilerce Way.; Suite 230 Portsmouth; NH _03801 _CONTAc-T--.—_ NAME: Dnnrra r725h2rna15.. - PHONE i FAX - 855-529-7684 c No 603-559-1361 A/C No E-MAIL ADDRESS donna.desharnais@wellsfargo.com INSURER(S).AFFORDINGCoVERAGE I NAIL 'HDI Ge Ica Insurance Company. 41343 wsuRER a - rling Amer INSURED -..... - - - Eastern Propane Gas, Inc. P. - - 28 -Industrial Way ...., - .Rochester, N H .03867. :. INSURER B :_.._ - - INSURER C INSURER D: . E.: .INSURER. 1NsuRER F . .. COVERAGES,:.; CERTIFICATE NUMBER: 5736801,% REVISION NUMBER. See below': ' I '"'THIS ISI& CERTIFY THAT THE POLICIES" O.F INSURANCE'L'ISTED"BELOW `HAVE BEEN -ISSUED T0'THE^INSURED-+NAMED" ABOVE:FOR THE-POLICY'PERI D, INDICATED. "NOTWITHSTANDING ANY REQUIREMENT, TERM OR_.CONDITION.OF`ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT.TO.,WHICH THIS, CERTIFICATE MAYBE ISSUED OR MAY, PERTAIN,' THE INSURANCE AFF..O.RDED BY 'THE' POLICIES'DESCRIBED' HEREIN IS SUBJECT 'T.O;:ALL;THE TERMS, EXCLUSIONS AND CON DITIONS OF SUCH; POLICIES: LIMITS SHOWN`.MAY:HAVE BEEN REDUCED BY PAID CLAIMS. INSR 'LTR ,2.,.'. TYPE OF INSURANCE : _:;..... ..' ADDL SUBR - -- . '` .: f - - •POLICY'NUMBER-'.:-. POLICY EEF MMIDD/YYYYI" POLICY EXP :.. IMM/DD/YYYY " .' .:.. LIMITS ... .. A GENERAL LIABILITY. - X COMMERCIAL GENERAL LIABILITY ., CLAIMS -MADE OCCUR = . ,I. EGGCD000080613 ~ - - 03/15/2013 031151201'4 EACH OCCURRENCE, a i 000.00c DAMAGE TO RENTED 250,000 PREMISES Ea occurrence $ MED EXP (Any one person) $ Excluded PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000.000 .GEN'L AGGREGATE LIMIT APPLIES PER:' POLICY PRO- LOC PRODUCTS - COMP/OP AGG $ 2,000,000 $ A AuromoBlLE uaBIUTY X ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS AUTOS EAGCD000080613 03/15/2013 03/15/2014' COMBINED,SINGLE LIMIT 100,000 (Ea accident $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) S (PerPER n DAMAGE $ - $ "_.......Hi UMBRELLA CIAB EXCESS LIAB, OCCUR CLAIMS -MADE . .... ..._...... ........ ... ....._._:.._:. _. _..._-..... .,.,..- -•. ... EACH OCCURRENCE $ .AGGREGATE $ ;... DED.. RETENTIONS.. $ " .A .WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETORIPARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? � . (Mandatory in NH) .. If yes, describe under DESCRIPTION OF OPERATIONS below �.:. N / A - EWGCDOOD080613 - - ,- 03/15/2013 - I - - 03/15/2014 X WC STATU= OTH-". T R FR E.L. EACH ACCIDENT S 1,000,000 E.L. DISEASE - EA EMPLOYE $ 1,000,000 E.L� DISEASE - POLICY LIMIT S 1,000,000 A Excess Auto EXAGD000080713 3/15/2013 3/1;5/2014: 1,900,o0o excess of $100,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if mores pace is required) Evidence of coverage CERTIFICATE HOLDER CANCELLATION Any city/town in Massachusetts SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE I ne Awru name and logo are registered marks of ACORD Uc 1!Jbb-2U1U ACORD CORPORATION. All rights reserved, ACORD 25 (2010105) f •y Lj rfi -::D r .. 701 cr rn Cn L7 tr mCD D ¢ G L \ �� .-i..J 6.1E L rrn �— J r Corn _ '>:m v _ Date ..... 3 ............ TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that k?. -J ................ ........................................................ ..... ....... . .......... has perniissio n to perform —I(O.A- . . .. ... . ............. 6 ....... JI�U"V wiring in the building of ......................................o ......................................................................... at . ..../ A� ...................................... I .......... ....... J Ad 4�orth Andover, Mass. Fee ..-:!5� . .......... Lic. No4� ................. .......... ................... ELECTRICAL INSPECTOR Check, 11925 4 Commonwealth of Massachusetts Official Use 0 Department of Fire Services Permit No. 1W p BOARD OF FIRE PREVENTION REGULATIONS [Rev. Occupancy and Fee Checked 1/071 leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 0 C t --�5 . 2 D 1 1-3 City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number)'�� Owner or Tenant !�t`1-rLla , g�;-rs Telephone No. Owner's Address Is this permit in conjunction with a building permit? Purpose of Building Existing Service Amps / Volts New Service Amps / Volts Number of Feeders and Ampacity Yes ❑ No Rr (Check Appropriate Box) Utility Authorization No. A�77/699 Overhead ❑ Overhead ❑ Undgrd ❑ No. of Meters Undgrd ❑ No. of Meters Location and Nature of Proposed Electrical Work: Cmmnletinn nftho fnllnwino tnhlo >r,..,, ho —;,-4 h,, il- 1.....,,.,.i,,,.-,rul;--, No. of Recessed Luminaires -' - ----'Cy No. of Ceil: Susp. (Paddle) Fans rr{Ica. No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above11In- ❑ o. o mergency Lighting rnd. rnd. Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of AlertingDevices No. of Waste Disposers Heat Pump Number Tons KW No. of elf -Contained Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating KWLocal ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances K, Security Systems: No. of Devices or E uivalent No. of Water KW Heaters No. of No. of D Data Wiring: Si ns Ballasts No. of Devices or E uivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach addtttonal detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such cover ge is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE [BOND ❑ OTHER ❑ (Specify:) I certify, under the pain and penalties of perjury, that the information o application is true and complete FIRM NAME: LIC. NO.:a �- Licensee: / 1 d �t"����,�� Signature LIC.NO.•�3892— (Ifapplicable, enter "exempt" in t e license number line.) JJJ� Bus. Tel. No.: 6 Address: `moi 14 i!'IG t t7f� L4aJ� �z/�il o Alt. Tel. No.12P 8iS 9/ *Per M.G.L c. 147, s. 57-61, security work requires Depa nt 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 a ent. Owner/Agent Signature Telephone No. PERMIT FEE: $ is w