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Home My WebLink AboutMiscellaneous - 2 Royal Crest 2- BUILDING BUIlDlNG FILE 10/12/2017 *Gas Permit#21157-ViewPoint Cloud 21157 `Gas Permit—Replacement of Existing Fixtures/Appliances(Commercial of Residential) Q Permit Issued TIMELINE OSubmission received Aug 18,2016 at 1:16pm OPermit Issuance Issued Aug 22,2016 at 2:21pm OGas Permit Review Completed Aug 19, 2016 at 8:06am OPermit Fee Paid Aug 22,2016 at 2:22pm *Gas Permit#21157 Replacement of Existing Fixtures/Appliances(Commercial of Residential) https://northandoverma.viewpointcloud.com/#/records/21157 1/6 10/12/2017 *Gas Permit#21157-ViewPoint Cloud V �� . - 0. no, Applicant � Location robert maccormack ` 1 ROYAL CREST DRIVE , NORTH ANDOVER, MA 1. 978-600-1655 Owner @ rgoguen@maccoen... AIMCO/TTA MS 235(View Owner Information) 0 Attachments PDF -OTT7FX1001F_Thu_Aug_18_2016_17:16: Uploaded by robert maccormack on Aug 18,2016 1:17 PM Primary Contractor Search for your Gas Fitter License using the search bar below. Either the Firm's Name or licensee#is required. Firm's(Business)Name Plumber-Gasfitter Name(Licsensee)* License#* Type of Business License Type* License Expiration Date` License Active License Status Robert M Maccormack 9863 Master Plumber 04/30/2018 O Active Mailing Address* Preferred Telephone#:* Fax# Email Alternate Phone# 17 BRIDGE ST STE 203, BILLERICA MA 018211000 9786001655 I hereby certify that all of the details and information i have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. G Project Info https:Hnorthandoverma.viewpointcloud.com/#/records/21157 2/6 10/12/2017 'Gas Permit#21157-ViewPoint Cloud LJ Is this Permit in conjunction with a Building Permit(select yes or no)° No Occupancy Type(NOTE:For any residential building larger than two family please select Commercial)' Commercial/Industrial/Educational Total#Units' Type of WorkDescription of Work to be Performed' Plans Submitted Are you installing a generator° 12 Replacement replaced gas burner in building 2 O No Date Work is to Start(inspections to be requested in accordance tiwh MEC Rule 10,and upon completion) 08/18/2016 Fixtures/Appliances Fill in all proposed fixtures/appliances,their location,and how many are to be installed. If the item is not found it may be listed under"miscellaneous fixtures/appliances" below. If it is not in that section enter the item under'other"within this section. Total Number of Fixtures/Appliances Please add up the total number of fixtures and enter it below Total#of Appliances/Fixtures Miscellaneous Fixtures/Appliances Please complete all that apply Gas Meter and Near Meter Piping Remodeling of Gas Piping-Commercial Remodeling of Gas Piping-Residential Swimming Pool Heater Temporary Heater L.P.Gas Installation Permit ❑ ❑ ❑ ❑ https://northandoverma.viewpointcloud.com/#/records/21157 3/6 10/12/2017 *Gas Permit#21157-ViewPoint Cloud #,Of Residential New/Replacement of Water Heater(s) #Of Commercial New/Replacement of Water Heater(s) #of Residential Furnace or Gas Boiler Replacement and Conversion Burner #Of Commercial Furnace or Gas Boiler Replacement and Conversion Burner 1 Test Total Number of Roof Top Heaters O Total Number of Roof Top Air Conditioners Direct Vent Heater/Fireplace Insurance I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142.If NO is selected a copy of the signed Owner's Insurance Waiver must be attached to this application. Yes If yes,indicate the type of coverage' If'other',specify Liability Insurance Policy https://northandoverma.viewpointcloud.com/#/records/21157 4/6 10/12/2017 `Gas Permit#21157-ViewPoint Cloud 11 AY Worker's Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers To be filed with the permitting authority Are you an employer?Select the appropriate type.Any applicant that selects#1 must also fill out the section below showing their workers'compensation policy information. 1. 1 am an employer with employees(full and/or part-time) Type of Project' Plumbing Repairs or Additions I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Failure to secure coverage as required under MG>c.152,25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Insurance Company Name(Attach a copy of workers'compensation policy declaration page showing the policy number and expiration date) amguard insurance co. Policy#or Self-Ins.License#' Expiration Date" mawc695220 10/11/2016 Workers' Compensation Affidavit Signature I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.' G hftps://northandoverma.viewpointcloud.com/#/records/21157 5/6 Date....�...................�................... a-.dc 01* NORT/y ��"" '•�tiao� TOWN OF NORTH ANDOVER c PERMIT FOR WIRING This certifies that ............................. ('..... "...... :. has permission to per A ................................................ ................................................ wiring in the building of. ....................... ATi'— ! " `x ` Q �..�^:ti. ....� r;North Andover,Mass. at ............................ Fee...05.::.........Lic.No. �Gly.. ...��......AECTRCAL �RINSPECTOR (� •.••.. Qheck# GAJ V 6 Commonwealth of Massachusetts Official Use Only • , Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07j (leave blank) O'M APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASEPPMT.ININKORTYPE ALL)NFORMATION) Date: A0_,V3_L ((o , I q 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) 15() Q O U CL I CCe_S 4- b 2 Owner or Tenant Ar m t C O tel®r?_44- A N Doit<_v, C, Telephone No. Owner's Address u i IoLl J Is this permit in conjunction with a building permit? Yes ❑ No S7 (Check Appropriate Box) Purpose of Building 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: C�f C-K �I eC� t c ('CSnn�C-E-oc�c `S i 8at5@ 6,_,rc. e-lie tit i C, c g e e r r,a o S t Cr co i k b(ec�k e r S Ft°e®i n k -fih-e o Completion of thefollowing table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Cell:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA AboveIn- o,o mergency Lighting No.of Luminaires Swimming Pool rnd. ❑ rnd. ❑ Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS I No. of Zones No.of Switches No.of Gas Burgers No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: �"' '"I "'** * "' 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 RW No.of No.of Data Wiring: Heaters t Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent__ OTHER: estimated Value of Electrical Work: s 0 Attach additional detail if desired,or as required by the Inspector of Wires. i 3Q(� (When required by municipal policy.) Work to Start:8 t a le i 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 roof 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 certify,under the pains�and penaltiers/of erjury,that the information on this application is true and complete. FIRM NAME: DA.X11 e.I P, V l l g_ LIC.NO.: A I 5,7q q Licensee:"Dwi e-I P=, yl A.,ad e— Signature VMLc LIC.NO.:31650 E (If applicab e enter "exempt"in the license number line.) Bus.Tel.No.- Address: ® D R I C W03 Vn m e3a Ll 5 / Alt.Tel.No.:�508- Go_ *Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent. Own nt PERMIT FEE: $ �—� Signaturetura Telephone No. The Commonwealth of Massachusetts - Department of lndustrial Accidents Office of Investigations 600 Washington Street Boston,MA.02111 www.mass gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lep-ib Name(Business/Organization/fndividual): L ��` Q 1' y1 ,Q � (V7"L).L, Address: Lct ta cc-,`�. City/State/Zip: )C.t✓Ll'G1C(-W) Phone#: Are you an employer?Check the appropriate bog: Type of project(required): 1.❑ I am a employer with 1+ 4. ❑ I am a general contractor and I ' . 6. F1 Now construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. �• ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. E]Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its 10.E]Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL I L❑Plumbing repairs or additions myself. [No workers'comp. c. 152,§I(4),and we have no 12.0Roofrepairs insurance required.]i 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. T-Homeowners who submit this affidavit indicating they ere doing all work and then hire outside contractors must submit anew affidavit indicating such. tContractors that checkthis box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. r» Insurance Company Name:- V11 q��,�v r C Policy#or Self-ins.Lic.#: C.0 `JG�(Q`��J CA) at ExpirationDate: �� f Job Site Address: 50 City/State/Zip: 14,�l1,�()6lyCye MA 01 g 4 S 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. Ido liereb cert&under the pains andpenalties ofperjury that the information provided above is true and correct. - Signature: `� Date: t q(a g' 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 CIerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - - Contact Person: Phone#: COMMONWEALTH O-F MASSACHUSETTS ' = BOAC�I�Ofi ELECTRICIANS ISSUES THE F0LtLOWING LICENSE AS .A t RED[STERED MASTER ELECTRICIAN : uw DANItL P VITAL-E Iz 190 DALE. ST I .I Z WALTHAM „MA 02451-377 15799 a 4'7/31/16 35001 . COMMONUVEALTH,OF MASSACHUSETTS • • • • BOARD1 .. , 'C* 'A ISSUES THE FOLLOWING :L I'GENSE ASJOURNEYMANELECTRICIAN DAN;aEL P VITALE � a 190 DALE 'ST Z WALTHAM MA 02451 3773 31850`'E 07/31./16 35002 C ° lt<,ao aS�c�pU CERTIFICATE OF LIABILITY INSURANCE DATEIllk.� F ACORO 14 THISoCERTIFICATE 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 CONTACT NAME: LESLIE HANNON James O'Connell Insurance AgenP"°NE (978) 667-6150 FAA/X No; (978) 667-0587 572 Boston Rd ADDRESS: JIMINS@OCONNELLINS.COM Unit 7 INSURER(S) AFFORDING COVERAGE NAIC# Billerica, MA 01821 INSURER A:Merchants INSURED INSURER B:A.I.M. Insurance DANIEL P VITALE ELECTRIC INSURERC: 190 DALE ST INSU RERD: WALTHAM, MA 02451 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR AWL SUBR POLICY EFF POUCY EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS A GENERAL LIABILITY BOP9098053 9/12/14 9/12/15 EACH OCCURRENCE $ 1,000,000 X COMMERCIALGENERAL LIABILITY DAMAGE TO RENTED EREMISES(Ea ocu e $ 500,000 CLAIMS-MADE Fx_1 OCCUR MED EXP(Anyone person) $ 15,000 PERSONAL&ADV INJURY $ 11000,000 GENERAL AGGREGATE $ 2,000,000 GEN'LAGGREGATE LIMITAPPLIES PER PRODUCTS-COMP/OPAGG $ 2,000,000 JE X POLICYFI CT PRO LOC $ AUTOMOBILE LIABILITY COMB INED SINGL E L IM TT Ea accident $ ANYAUTO BODILY INJURY(Per person) $ ALLOWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERLY DAMAGE $ HIREDAUTOS AUTOS Peraccident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ B WORKERS COMPENSATION WCC5006538012009 10/11/13 10/11/14 X IWC STATU- OTH- AND EMPLOYERS'LIABILITYI. ANY PROPRIETOR/PARTNER/EXECUTIVE Y� NIA E.L.EACH ACCIDENT $ 100,000 OFFICE RIME MBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yyes describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICYLIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Rerrerks Schedule,if more space is regui red) ELECTRICAL WORK CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN TOWN OF NORTH ANDOVER MA ACCORDANCE WITH THE POLICY PROVISIONS. 120 MAIN ST NORTH ANDOVER, MA 01845 AUTHORIZED REPRESENTATIVE o LESLIE HANNON ©1988-2010 A ORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD Phone: Fax: E-Mail: