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HomeMy WebLinkAboutMiscellaneous - 20 MAYFLOWER DRIVE 4/30/2018\. r' �-� N Date .... :!K- // - / 2, ........................ .0 TOWN OF NORTH ANDOVER .M inwam PERMIT FOR WIRING This certifies that ............. C6."V7-/ ....... ............. �Vq ........ ................................ has permission to perform�e�? wiring in the building of ........ /< ......... at .............. M.je ... ...... North Andover, Mass. .... b 4- . - I Fee ...Lic. No.11.1.4m .......... . . 2- 4�i;'�Rilc*�'L IiNSPE�*j&R- 25:---r ..... Check # r J ir 10767 f1, Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Use Permit No. Occupancy and Fee Checked tev. 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 INFORMATION) Date: City or Town oh /UC)2T# 14 1\17Da l/tr=t2. 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) ` ©`-' '` 14 %� � �2J> P / _ Owner or Tenant l jr;:- X� //L(�/Telephone Owner's Address 1-5--3)9 rPO N/'/ft ,65 Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) ` Purpose of Building (SNF Y Utility Authorization No.—/()7 o 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: r�� f 0f,2f4 (2-Y. S"Z-77 r'mmnletinn ofthe following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans ° ota Transformers KVA r No. of Luminaire Outlets No. of Hot Tubs Generators KVA of Luminaires Swimming Pool rnd. Above ❑ °"rnd. ❑ cy ighting tEmergNo. o. o Batter Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of /tones No. of Switches No. of Gas Burners Dd o. o Initiating et ng D an Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices Disposers No. of Waste Dis p eat u Totals: P um er ons No.of elf -Contained Detection/Alertin Devices No. of Dishwashers S ace/Area Heating KW P g Local ❑Municipalecti❑ Other Connection No. of Dryers ry Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KW 0.0 No. o Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP TelecommunicationsWiring: No. of Devices or Equivalent OTHER: Attach additional, 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 coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE Rk BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the Information on this application is true and complete. FIRM NAME: LIC. NO.:A1 1983 Licensee: LOUIS (`ONTTNO Signature LIC. NO.:�;2B788 (If applicable, enter "exempt" in the license number line) Bus. Tel. No.:9 7 8 _ 3 6 3 _ g, 4 0 Address: _ _1 nONOvaN DR -r WEST NPJABUF.Y-, MA 039135 Alt. Tel. No.: wo *Per M.G.L c. 147, s. 57-61, security rk requires Department of Public Safety "S" License: Lic: No. OWNER'S INSURANCE WAIVER: l am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, l hereby waive this requirement. 1 am the (check one) ❑ owner ❑ owner's agent. Owner/Agent . Signature Telephone No. PERMIT FEE. $_ ., r s Date. -/,z J -10t ..... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that . A��r..�!(�1., .....ri. ......... has permission for gas installation ...... f VV FIYC-..0!1./y.. ". in the buildings of . XeA. Q.s9.,9 P"� ......... .......... . / at . !.6 T... No ndover, Mass. Fee.... �Lic. No. ai*.%f..3. ...... .......... GA INSPECTOR Check # (/)14,/ 8327 �Ip ` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY�r ®�'�� Y1 . _._,� MA DATE �:�,:.°,,.�... , �•�--- PERMIT # JOBSITE ADDRESS p,WNER'S NAME rfv�®��� GOWNER ADDRESS . TEL��y!`�-�a,��FAX PPE OT OCCUPANCY TYPE COMMERCIAL (�]I EDUCATIONAL ® RESIDENTIALA CLEARLY NEW: CQ RENOVATION: E] REPLACEMENT: PLANS SUBMITTED: YES Q NOW APPLIANCES I FLOORS- 0 Us ' f�lf�lf>�I �I�[�If�i� �It�l11�— 11�—[11�—F�►I BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE (FAA C GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST y UNIT HEATER UNVENTED ROOM HEATER WATER HEATER INSURANCE COVERAGE 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES �]1 NO R I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 4 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 IF -11 AGENT F-1 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 that all plumbing work and installations performed under the permit issued for this application will be in compli, Massachusetts State Plumbing Code and Chapter 142 of the General Laws. all to the best of my PLUMBER-GASFITTERNAlb ME �-?��%�-( LICENSE#���� SIGNA the MP L -z J MGF JP;W JGF [- LPGI CORPORATION _) # =PARTNERSHIP 0#= LLC D# COMPANY NAME: LP7` RESS CITY j=DtA_L.tt2CSTATE ZIP TEL ,f`"�--��� FAXj CELL i EMAIL H °z 0 0-(. H U w W ' z Q y ❑ >- W � ~ w °z ° au LU Q W 5W O> a a LU Q Ilk w w N a o d a a J F., a IL � w x w F-- LL. v� H °z 0 H U C�7 • °a The Commonwealth of Massachusetts Department of IndustrialAccidints Office of Investigations 600 Washington Street Boston, MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2.14I 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. ❑ 1 am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, §1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. E] Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.0 Plumbing repairs or additions 12. ❑ Roof repairs 13. ❑ Other AAny 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. f Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: 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 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 &z4nsM)mce coverage verification. I do hereby the information provided above is true and correct. 31f -Els' Offccial use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: 'i Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or. written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced -acceptable evidence of compliance with the insurance coverage required" Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -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 policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)" A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or' -permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of MassachuSetts Department of Industrial .A,ccidents Office of Investigations 600 Washington Street Boston., MA, 0.2111 Tel, # 617-727-4900 ext 406 or 1-877:MASSAFB Revised 5-26-05 Fax 4 617-727-7749 WwVt mass,90v/Glia r Date..? ................... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION I t % v \. ............ This certifies that . t ..v ..... / .........04 ...... has permission for gas installation . e w'.. �. ........ in the buildings of ..0-.O.. 5PA !t4 V-,.. . . . ............ at ......... Mass. Fee.,O�Lic'. No..1.4�3�t 16" , 00 GAS INSPECTOR Check # '7.s 3q 8262 GOWNER TYPE OR PRINT CLEARLY MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY: b�} �ili,lnJUl.✓ MA. DATE: `7 S /2 PERMIT # JOBSITEADDRESS:_ OWNER'S NAME: SAL-ew" -r ADDRESS: TEL: FAX: OCCUPANCY TYPE: COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL NEW: W RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES ❑ NO ❑ APPLIANCEEBURNER FLOOR- 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCK MAKEUP AIR UNIT , OVEN t POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER j INSURANCE COVERAGE I have a current liabiliq 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. CHECK ONE ONLY: OWNER [IAGENT ❑ 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 ill be in co fiance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER/GASFITTERNAME:_STEPNEN C GALrNSKY LICENSE# 103y6 SIGNATURE COMPANYNAME: CAL1oS3, KY PL0tA1NI ,y6 t J4CKf- J& ADDRESS: P.Q. ROX 1701 CITY: OAVFRH I STATE: !m - A• ZIP: 01231 FAX: 978- 5a1-41SI TEL: 979 - 37H- 17y3 CELL: 501r- 50Q- 590`4 EMAIL: wyy W . m rpi u m bermxo MASTER R JOURNEYMAN ❑ LPINSTALLER ❑ CORPORATION /# 319G PARTNERSHIP ❑ # LLC ❑ # W H O z z 0 H U W a CIO a w _ z z o 140 �- w a ~ Cl) o w o H 0- z U w W = z <w _Z L w o z �T" w ¢ w V a C7 z a ¢ 0 a Q _- F� °- a w L w F 0 z z o N U W w d x 0 0 a • Date. .7 ^ v2 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ..l.�.g..l i'��Y...0V4v%A!'o has permission to perform .. NA—W. . .t!' '......... i ..... plumbing in the buildings of ..0.-& .� �t�. ^'-.. VA4.16JA,.,... . at.. a'Z-c� . V1i1c-ky 64QLJ ..... , No h ndo r Mass. Fee .-:..G�A/7Lic. No. l.( �ll.e .. 20. t'�7.... . PLUMBING INSPECTOR Check x 753 JL\ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY &tk>NVa oI" w 'v' MA. DATE %— `2 PERMIT H JOBSITEADDRESSIh/-j4a1✓�.l OWNER'SNAME OLtO SkjL_j6L ViLcyC�_ POWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE: COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW:Q RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES ❑ NO ❑ FIXTURES -1 FLOOR— BSMT 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB .L. CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYS DEDICATED GAS/OIL/SAND SYS DEDICATED GREASE SYS DEDICATD GRAY WATER SYS DEDICATED WATER RECYCLE SYS DRINKING FOUNTAIN DISHWASHER FOOD DISPOSER FLOOR / AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN f SHOWER STALL I SERVICE / MOP SINK TOILET I 1 URINAL I WASHING MACHINE CONNECTION WATER HEATER ALL TYPES I WATER PIPING I OTHER INSURANCE COVERAGE: ,/ I have a current liabili insurance policy or its substantial equivalent which, meets the requirements of MRGL Ch. 142. Yes No ❑ IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY E? OTHER TYPE OF 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 BOX ONLY: OWNER ❑ AGENT E]Si nature of Owner or Owner's Agent 1 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 Codeand Cha ter 142 oft a General Laws. PLUMBERNAME STEPI C0 L GALINSKY SIGNATURE LIC # t103q S MP [?�' JP ❑ CORPORATION X# 319 b PARTNERSHIP ❑ # LLC ❑ # COMPANY NAME 6AL11J'.SKY PLUi 0JJD 1b ADDRESS: P-0- GGX 1-7011 SITY NoavERk1l,L STATE rOI•A- ZIP 01'931 EMAIL WWW. mrpiymbeftia-po1, C'0^1 rEL (OV- 37y-17Al 3 CELL 508- 60 - 590'1 FAX q7$- 5 -Al - A40 i V t w H 0 z z H U a z a d z w `W (� � � 00 z o m 0 w c z rILLLACID � � w U) w z Q Q 24 w C) Q w LLI w z a. 2 Q r CL w w H O 7 O � U w a z J a. x 0 :x l A Date.. �? — 15- tz OF NORrN qti s o0 o .rte; rm TOWN OF •ANDOVER Fol * # * r #PERMIT FORf gruel Z t This certifies that ....... ' ...eO/vT 4.1,:P� 6 has permission to perform ..... Akw............... wiring in the building of ..../:� �c Y. �—l.Pga... T -x -.e . ......... at . Ze . M. ©ccs E?L , ...bk. _, ...... �? North Andover Mass. (. �....� . .� lee . 1�7- tic. No.. 3 - a ELECTRICAL INSPECTOR Check # $~ZZ 11018 ft I Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Permit No. official Use Onl, I b IS Occupancy and Fee Checked ,ev. 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 INFORMATION) Date: City or Town of: ND RT'# IINPC1 t1E� 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) Ao Owner or Tenant M E -T G Telephone No. 979 .e; 6? 314j Owner's Address � v�19 7W k /Nl to/ (q-jE S7, 41a/P7 4MA-1L4AL Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) )) Purpose of Building 0IYE (=,¢M l LY JfQ V,!; ' Utility Authorization No. ,43 Existing Service Amps New Service = Amps Number of Feeders and Ampacity / Volts Overhead ❑ a�olts Overhead ❑ Undgrdr ❑ No. of Meters Undgrd,ff No. of Meters 01/� Location and Nature of Proposed Electrical Work: W Tl E IV Completion ofthe following table may be waived by the Inspector of Wires. No. of Recessed Luminaires ?j No. of Ceil: Sus Paddle Fans r� p (Paddle) .7 o. o Total Transformers KVA No. of Luminaire Outlets �' No. of Hot Tubs Generators KVA No. of Luminaires SwimmingPool Above ❑ n- ❑ rnd. grnd. o. o Emergency Lighting Battery Units No. of Receptacle Outlets % �, No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners O/Yr o. oDetection an 1 Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Dis osers eat Pump Totals: [Number. ons o. o e - o0ine Detection/Alerting Devices No. of DishwashersSpace/Area j Heating KW Local ❑ MunicipalEl Other Connection No. of Dryers 1 Heating Appliances KW Security ystes: No. of Devimces or Equivalent No. of Water KW Heaters o. Of o. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP "Tra ecommunicationsiring: No. of Devices or E uivalent OTHER: Attach additional 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 coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE a BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties ofperjury, that the information on this application is true and complete. FIRM NAME: LIC. NO.:A1 1 983 Licensee: LOUTS CON TNn Signature LIC. NO.,V � g 7 g g (If applicable, enter "exempt" in the license number line) Bus. Tel. No.:S 7 g-363- ` 4 0 Address: nnNnvnN nu TW._P,STNEW18URY MA -01 98r Alt. Tel. No.;'s'a;Fs 312 `l WC *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. 1 am the (check one) ❑ owner ❑ owner's agent. Owner/Agent . PERMIT FEE. $ Signature Telephone No. Date .. Z. �. !'...... . TOWN OF NORTH ANDOVER A PERMIT FOR GAS INSTALLATION N This certifies thatA9<... YnA,4.. Prb?.!r".4 has permission for gs installation� . # t u... p��.� .dug .0„� in the buildings of ..k..� H !+!” -^ �' .............. . . .... . . at ... 2;-00 .. HqL North Andover, Mass. Fee.. .. Lic. No...tqq 121.... qf:...................... 2 GAS INSPECTOR Check # 1 J1 +'M r a — GOWNER TYPE OR PRINT CLEARLY MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY: N ANDOVER MA. DATE: 9/12/2012 PERMIT # JOBSITE ADDRESS: 20 MAYFLOWER DR OWNER'S NAME: KEYLIME INC ADDRESS: TEL: 978-683-3163 FAX: OCCUPANCY TYPE: COMMERCIAL 0 EDUCATIONAL ❑ RESIDENTIAL ❑ NEW: ❑ RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES ❑ NO ❑ APPLIANCES 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 liability 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 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 permit application is true and accurate to the best of my Knowledge. I certify that all plumbing work and installations performed under the permit issued, will be in compliance with all Pertinent provisions of the Massachusetts Uniform State Plumbing Code, and Chapter 142 of the General Laws. a PLUMBER/GASFITTER NAME:�J/G�i f�C 80010ENSE # 93,3 SIGNATURE COMPANY NAME: OSTERMAN PROPANE LLC ADDRESS: 321A Merrimack St CITY: Methuen STATE: MA ZIP: 01844 FAX: 978.738-0118 TEL: 800-822-1300 #3 CELL: EMAIL: INFO(aASTERMANGAS.COM MASTER ❑ JOURNEYMAN EX -INSTALLER OCORPORATION ❑# PARTNERSHIP E:]#—LLC P]945-326-331 q -zo -kZ �TF�IJL 6� wtC P ..'I ,#�Q � A F « —, �A RD CERTIFICATE OF LIABILITY INSURANCE 06/z8/2012 PRODUCER 209.532.6951 FAX 209.532.1997 Cutl er-Segerstrom Insurance Agency License #0495772 1030 Greenley Rd. Sonora, CA 95370 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC # INSURED Osterman Propane, LLC One Memorial Square P.O. Box 29 Whitinsville, MA 01588 INSURER A: HDI -Gerling America Ins. INSURER B: INSURER C: INSURER D: INSURER E: 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. II TR NSRD' TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS GENERAL LIABILITY EGGCD000043312 06/30/2012 06/30/2013 EACH OCCURRENCE $ 2,000,000 A X COMMERCIAL GENERAL LIABILITY CLAIMS MADE OCCURMED DAMAGE TO RENTED $ 100,000 Pa EXP (Any one person) $ PERSONAL & ADV INJURY $ 11000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY PRO LOC JECT PRODUCTS - COMP/OP AGG $ 2, 000, 000 AUTOMOBILE LIABILITY X ANY AUTO ALL OWNED AUTOS EAGCD000043312 06/30/2012 06/30/2013 COMBINED SINGLE LIMB $ (Ea accident) 2,000,000 A SCHEDULED AUTOS BODILYINJURY $ (Per person) HIRED AUTOS NON -OWNED AUTOS BODILY INJURY $ (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY OCCUR FICLAIMS MADE EACH OCCURRENCE $ AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY TWC STATU- OTH- E.L. EACH ACCIDENT $ ANY PROPRIETOR/PARTNEWEXECUTIVE OFFICER/MEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYE $ If yes, describe under SPECIAL PROVISIONS below OTHER E.L. DISEASE - POLICY LIMIT 1 $ DESCRIPTION OF OPFRAtlnuc i i nr•nrinue i vcuir, ec i c..^, Town of North Andover 146 Main Street North Andover, MA 01842 ACORD 25 (2001/08) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL PtWiilbTd�E SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON TH -INSURER, RER, lSAGJENTS OR REP*RE ENTATVES. SAUTHORIZED REPREENTAT Ej Pete Kleinert ©ACORD CORPORATION 1988