HomeMy WebLinkAboutMiscellaneous - 20 HOLBROOK ROAD 4/30/2018Date ... .........
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that ......... (?W "Ae_�MS-Ivz�v— . CA ,,
.
has permission for gas installationV"'J�
.. ....................................
inthe buildings of ........ ..................................................................
at ......... Z.0 .....
.... ... North Andover, Mass.,
Fee .W..�..... Lic. No......
... .... ............. .......................................................
GASINSPECMR
Check #
9196
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY I North Andover MA DATE 3/24/2014 J PERMIT #
JOBSITE ADDRESS 20 Holbrook St OWNER'S NAME
GOWNER ADDRESS I Same TEq Cf Z X333 FAX 771
TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL ® RESIDENTIALE
PRINT
CLEARLY NEW: ❑ RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES N0[:]
APPLIANCES 1 FLOORS BSM 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 COCKS
MAKEUP AIR UNIT
`OVEN
POOL HEATER
ROOM / SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER
Replace Gas Meter x
7an—d—Piping as Needed
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES NO
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ED OTHER TYPE INDEMNITY E] 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 ED
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 compliance with all Pertinent provi&n.of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUM BER-GASFITTER NAME I Joseph Marino LICENSE # 8736 SIGNATURE
MP MGF ® JP ® JGF ® LPGI CORPORATION # 3285C PARtISHIP FE -711# LLC 0#
COMPANY NAME:j RH White Construction Co ADDRESS 41 Central St
CITY I Auburn STATE MA ZIPI 01501 TEL (508) 832 3295
FAX 508-926 4347 CELL 508 832-4614 EMAIL JMarino@RHWhite.com
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04/03/2014 14:04 5088326751 RH WHITE CONSTRUCT PAGE 02/02
A RO• O
CERTIFICATE OF LIABILITY INSURANCE rage 1 of z 08/29/2013
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 poliey(ies)must be endorsed. If SUDROGATION IS WAIVED, subJeot 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),
williq of Massachunotts, Inc. PHONE FAX
c/o 26 CE+ritury sive. N0_QW- 877-945-7378 _No>: 888-467
N1 o. sox 305191 oDRR&s cex'tiPicate_9@w•iIIis.com
Na4lhville, TN 37230-5191
INBURERA: The Ch4krtAr Oak Fi:rO Insurance Company 25615-001
R. X. White Construction Company, Inc. INSURERS:Traval,grs Property Casualty CO%>pany of Am 25674-061
41 Casntr*l, Street INSURER C: National Union Piro Insurancm Company of 19445-001
P. 0. Box 257
Auburn, MA 01501 INSURER0,Tromelers Indmmnity Company 25659-DO1
COVERAGES CERTIFICATE NUMBER: 20287680 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN I$SUED 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. LIMI7S SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR I
1YpEQFINBURANCE DD' SUB POLICY NUMBER POLICYEFF POLICY EXP
LIMITS
A GENERAL LIABILITY VTC2000 977X9948-13 9/1/2013 '9/1/2014 EACMOCCURRENCE F_ 2,000,000
X COMMERCIAL GENERAL LIABII.ITY ppqqMMq T%ENTF,D
PREU _8_(Eeoceubncrl R 300,000
CLAIMS-MADE�OCCUR MEDEXP(Anyone anon $ 1Q 000
J
PERSONAL &ADV INJURY S 2 000, 000
GENERAL AGGREGATE $ 4, 000 QOO
GEN'LAGGREGATfrLIIMITOAPPLIESPER; PRODUCTS-COMP/OPAGG $ �OOO OOO
POLICY LOC
B AUTOMOBILE LIABILITY VTJCAP 977R955A-13 9/1/2013 9/1/2014 $
OaIiINEDClent,SINGLF-LIMIT $ 2000,000
X ALICNENY AUTO BODILY INJURY(Per person)
S
ALI.OWNED SCHEDULED
AUT08 AUT08 BODILY INJURY(Peraccident)
X HII r; AUTOS X NON -OWNED
AUTO$ erftccldent S
AMAC
X Co UP Y
Defl X COIL Ded
Boo $
C UMBRELLALIA6 X OCCUR 830766140 9/1/2013 9/1/2014 EACH OCCURRENCE $ $J 000, 000
EXCESS LIA6 CLAIMS -MADE AGGREGATE 1--5_,000,000
DED I $ IRETENTIONS 10,000 S
D WORKERS EMPLOY RS'Lf ALIT VTRKUB 8205A105-13 9/1/207.3 9/1/2014 X 0
ION
AND EMPL0YER8'LIABILITY YYYYYY//////NNNNNN
n ANY PROPRIETORIPARTNFRlFXECUTIVENN NIA VTC2KUB B203A71A-13 9/1/2013 9/1/a01�4 E.L. EACH ACCIDENT ? 1, )00 000
OFFICER/MEMBER EXCLUDED?
MandafoalnNN) E.L.DISEASE- EAEMPI,OYFE S 1,000,000
u�t�Idin+i�UNW-O URATIONSE?elew E.L,DISEASE- POOCYLIMIT S 11000,000
DESCRIPTION OF OPERATIONS/ LOCATION31 VEHICLES (Attach Acord 701, Addltonp) Remarke 3chedela, If more epees 1& roqulrad)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF TWE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS,
Evidence of Ealsurance AUTHORIZED REPRESENTATIVE
col1:4197604 Tp1:1694012 Cert:20287680 ®1988-2010ACORD CORPORATION. All rights reserved.
ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD
�- .Location
1Vb. Date
� t
4OR71t � �
TOWN OF NORTH ANDOVER
9
Certificate of Occupancy $
w� Building/Frame Permit Fee $ .
ssAG«usEt -F� uii ation rmit Fee $ -
: r t i er Fee $
Sewer Connection Fee $
Water Connection Fee $
a TOTAL $
46
Building Inspector.
N2 -048
Div. Public Works
M.u.
= 4
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- - - .,. .. .... � . .. a .._. - _ - - .. . _..... -- -- - - _ max•-^ ^�"` '�� _ . _
OFFICE OF: oF: _ _ •,�"� ___ `—_TOwn of _�_ : -> _-_ ',;z 1 is[rces
- = AF'Q>✓�s NORTH ANDOVER - rlnndetts
BUILDING Massachusens O t 84s
CONSERVATION 0[v1S[o.t OF
HEALTH -
1°l-e%.NNING PLANNING & COMMUNITY DEVELOPMENT
M
In ac---r.:nncr with the ;r^vts:c _s ,. `'kCL Z -.C- S =». a condiden of Building po it
,tiumbe:s thct �ct is resultine frcrn this work shall be
disnosey it or in a prone: , ... rs.._ -cl- w= -z fZc zs by `IGi. c ili• S
The debris will be disooser' cc in:
TC e lmz- 0J/1JrA,/-)j=/f-
xn c:=::cair•.•)
t::re a[
Aooiicnt
eyCI,(--
Date
N0T_: Demolition permit fra= the To, --a of :North Andover sust be obtained for
this project through the Office of the Building Inspector.
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING v
(Print or Type)
NORTH ANDOVER Mass. Date `
Permit # 4��
l�3uilding location !?J
Owners Name
'dU'.20�1 rte/
Y
• - New 77 Renovation U] Replacement Plans Submitted
(Print or Type)
Installing Company Name
Address v
Check one: Certificate
Corp.
Partner.
E�- irm/Co.
Business Telephone: fo JP 42
Name of Licensed Plumber or Gas Fitter ��,��yrYvizQCrailit�
Insurance Coverage: Indicate the type of insurance coverage by checking the
appropriate box:
Liability insurance policy E!7rOther type of indemnity Q Bond
Insurance Waiver: I, the undersigned, have been made aware that the licensee of
this application does not have any one of the above three insurance coverages.
ignature of owner/agent of property Owner 0. Agent 0
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my
knowledge and flat all plumbing .work and lnsallations performed under' Permit isseed fo: this application will be In complianca with all pertinent
provisions of tho Massachusetts State Cas Code and Chapter 142 of the Genera! Laws.
By TYPE LICENSE:
Plumber
Title Gasfitter Signature of Licensed
City/Town: 7—M
aster Plr Gasfitter
Journeyman
APPROVED (OFFICE USE ONLY) License Number
MEMNON
iINnEMnEM
MIT
OMEN
(Print or Type)
Installing Company Name
Address v
Check one: Certificate
Corp.
Partner.
E�- irm/Co.
Business Telephone: fo JP 42
Name of Licensed Plumber or Gas Fitter ��,��yrYvizQCrailit�
Insurance Coverage: Indicate the type of insurance coverage by checking the
appropriate box:
Liability insurance policy E!7rOther type of indemnity Q Bond
Insurance Waiver: I, the undersigned, have been made aware that the licensee of
this application does not have any one of the above three insurance coverages.
ignature of owner/agent of property Owner 0. Agent 0
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my
knowledge and flat all plumbing .work and lnsallations performed under' Permit isseed fo: this application will be In complianca with all pertinent
provisions of tho Massachusetts State Cas Code and Chapter 142 of the Genera! Laws.
By TYPE LICENSE:
Plumber
Title Gasfitter Signature of Licensed
City/Town: 7—M
aster Plr Gasfitter
Journeyman
APPROVED (OFFICE USE ONLY) License Number
Date ......
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that
C)
has has permission for gas installation f- c-
'
Bin the buildings ofD. - .14 .....................
mat -/ X, L North or ver, Mass.
�t
Fee Lic. /
INSPECTOR
WHITE: Applicant ANARY: Building Ddpt. PINK: Treasurer GOLD: File
Issued to
Address
ya10:261e
Bay State Gas Company
GAS INSTALLATION AUTHORIZATION
�, Date —/���
For Installation of:z5,-�, - ./fie,(GAS
BTU Input AK&2 6
Restrictions
BSG Representative
PERMIT ISSUED _ BY
INSPECTOR
This Portion of Authorization To Be Returned to BSG.
Inspection Has Been Made of the Following Gas Equipment:
❑ Heating System (BTU Input ) ❑ Range
❑ Water Heater ❑ Clothes Dryer
❑ Room Heater
Location
All Work Has Been Done In Accordance With The Massachusetts
State Gas Code And Is Ready For Use.
INSPECTOR
t
BAY STATE GAS COMPANY
ATTN: SALES DEPT.
55 Marston Street
Lawrence, MA 01840
NO POSTAGE
NECESSARY
IF MAILED
IN THE
UNITED STATES
BUSINESS REPLY CARD
FIRST CLASS PERMIT NO. 721 LAWRENCE, MA
POSTAGE WILL BE PAID BY ADDRESSEE
BAY STATE GAS COMPANY
ATTN: SALES DEPT.
55 Marston Street
Lawrence, MA 01840