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Home My WebLink AboutMiscellaneous - 20 METHUEN AVENUE 4/30/2018'Dew k4a4 s Date ... ...... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that 4 .......... .. has permission for gas installation .. .............. e- ... ................................................ inthe buildings of ................................................................................................................... at I... . ... L ... ........................... . North Andover, Mass. Fee .:�.C* ........... Lic. No. 3. ........................................................................... . -,Y ..... .... ..... GASINSOECTOR Check# / 17; -Ir - 01 2 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY: NORTH ANDOVER MA. DATE: 04/18/2014 PERMIT # JOBSITE ADDRESS: 1d 20 METHUEN AVENUE OWNER'S NAME: A.J. SONS, INC GOWNER ADDRESS: TEL: 978-649-2600 FAX: TYPE OR OCCUPANCY TYPE: COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL 2T PRINT CLEARLY / NEW: l 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 0 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 Wwth all Per inent provisions of the Massachusetts Uniform State Plumbing Code, and Chapter 142 of the General Lam. PLU MBER/GAS FITTER NAME;�� ,' 2 �7��S t� LICENSE ## / SIGNATURE COMPANY NAME: OSTERMAN PROPANE LLC ADDRESS: 321A Merrimack St CITY: Methuen STATE: MA ZIP: 01844 FAX: 978-738-0118 TEL: 800-368-9956 CELL: EMAIL: INFOO_OSTERMANGAS.COM MASTER 0 JOURNEYMAN ❑ LP INSTALLER [i4LORPORATION ❑# PARTNERSHIP ❑# LLC ❑ #45-326-3311 It ACoRV® CERTIFICATE OF LIABILITY INSURANCE 6/26/2013 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 W. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED RESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WANED, 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 Cutler Segerstrom Insurance Agency License #0495772 1030 Greenley Rd. Sonora CA 95370 CONTACT Angela Bacon PHONE (209) 532-6951 IFAXC N.I. (209)532-1997 E -M LArr.ss;angelab@cutseg.com INSURERS AFFORDING COVERAGE NAIC9 INSURERAA3 en Specialty INSURED Osterman Propane, LLC P.O. BOX 29 LQhitinsville MA 01588 INSURER B :AIG INSURER C: INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER -Osterman 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. ?LTR TYPE OF INSURANCE ADDL WIL POLICY NUMBER POLICY EFF POLICYEXP LIMITS A -lum- GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE ❑% OCCUR EAM00113 5/30/2013 6/30/2014 EACH OCCURRENCE $ 2,000,000 To DAMMI ES(E cc D 2,000,000 PREMISES Ea occurrence $ MED EXP (Any one person) $ 100,000 PERSONAL BADV INJURY $ 2,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY PRO LOC PRODUCTS - COMP/OP AGG $ 2,000,000 $ B AUTOMOBILE LIABILITY X ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS HIRED AUTOS NON -OWNED AUTOS 4954068 6/30/2013 6/30/2014 COMBINED SINGLE LIMIT Ea accident 2,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ Per accident UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED I I RETENTION $ $ WORKERS COMPENSATIONWC AND EMPLOYERS' LIABILITY Y I N ANY PROPRIETORIPARTNER/EXECUTIVE OFFICERIMEMBER EXCLUDED? (Mandatory in NH) Ifyes, describe under DESCRIPTION OF OPERATIONS below NIA STATU- OTH- EL EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE $ E.L. DISEASE - POLICY LIMIT 1 $ I -F DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) vim" r Town of North Andover 146 Main Street North Andover, MA 01842 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 Pete Kleinert/ANGELA�I[ AL,UKU LO tLUTUIUD) V 1988-2010 ACORD CORPORATION. All rights reserved. INS025 (201005).01 The ACORD name and logo are registered marks of ACORD J 14 �`� ��CERTIFICATE OF LIABILITY INSURANCE DATE/Y 06/26/226/2 0133 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 1-630-773-3800 Arthur J. Gallagher Risk Management Services, Inc. CONT CT Allison Spadaro PHCNNo Ext: 630-285-4456 MAC No: 630-285-4006 TWO Pierce Place E-MAIL all].SOn spadaro@ajg.com ADDRESS: P jg.com INSURERS AFFORDING COVERAGE NAIC# Itasca , IL 60143-3141 INSURERA: INSURANCE CO OF THE STATE OF PA 19429 Mary Beaver INSURED Osterman Propane, LLC INSURER B: INSURER C: INSURER D: 6120 S. Yale Ave. Ste 805 Tulsa, OK 74136 INSURER E: INSURER F: l WVCRNI a l_r'.K IIFI(.{i 1 r NI IWJMFW 3Y%1»43 OG11101l Kl I.II RAMOO. 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 LTR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF MMIDDIYYYY POLICY EXP MM/DD/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ -TO COMMERCIAL GENERAL LIABILITY DAMAGE RENTEDPREMISES Ea occurrence $ MED EXP (Any one person) $ CLAIMS -MADE 7 OCCUR PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ POLICY PRO - T LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident BODILY INJURY (Per person) $ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ NON -OWNED HIRED AUTOS AUTOS PROPERTY DAMAGE Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ RDED EXCESS LAB CLAIMS -MADE AGGREGATE $ I I RETENTION $ $ A A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE79331530 OFFICER/MEMBER EXCLUDED? N❑ N / A 1588377506/30/1 06/30/1 06/30/14 06/30/14 X WCSTATU- OTH- TO ER E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 (Mandatory in NH) If yes, describe under E.L. DISEASE - POLICY LIMIT $ 1, 000, 000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) 978-688-9542 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Attn: Mary 146 Main St AUTHORIZED REPRESENTATIVE North Andover, MA 01845 I USA U IUtI1t$-ZU1U ACOKU CORPORATION. All rights reserved. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD ankurita 34415543 AG VSETTS; ; RVERSLCDILICENSE- END OAF 9a END 4d RMNEA t � x S0925676* y. DOB q; --11:1'5:1960 r Aft3 T is kE •m-,-' rOT UR ONE 1i4MI E A 9 8 ARBOR CT LYNN,MA'01902.1110 �--� r5 DD 11.1S•20131tav02.162009 LICENSE ANG GASFiTTEI?S. ISSUES THE A L?IGAS 7o STAL:LEi1? CENSE MXCr{aa~L� A BRYSON SR B ARBOR CT LYNN MA 01902- ,�. q3,:, � <I 1.i 0 � a .. 05/01/,14 • r, ��c34a9 a' ! The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, AjA 02111 ' �•�� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Qstprman Pronanp LLC Address: One Memorial Square City/State/Zip: Whitinsville, MA 01588 Phone #: 508-234-1573 Are you an employer? Check the appropriate box: 1. ® I am a employer with 775 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. LJ 3.❑ I am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] I am a homeowner doing all work myself. [No workers' comp. insurance required.] " listed on the attached sheet. r These sub -contractors have workers' comp. insurance. 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition" 10. ❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.® Other_LP-Gas Instals and *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. f 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. Iam an employer that isproviding workers' compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name:_ Insurance Co of the State of PA Policy # or Self -ins. Lie. #: 15883775 Expiration Date: 06/30/2014 Job Site Address: All Locations in: �� i1f�3��c�'�f City/State/Zip: INA a,, c. s-e-//—,C- Attach `CAttach 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 hereby Vrtiff,--t-i7ihfertliepaiiisaiidpeiiafts ofperjury that the information provided above is true and correct. r�Si ature: Date: July 1, 2013 Phone #: 508-234-1573 Official use only. Do not write in this area, to be completer) 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 #: Date. 1...�.� ......... I TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that .....0h�...........2e ............................... has permission to perform ......... ... Q..-,-?..... .... . . plumbing in the buildings of .... � '``r S .................................................................. at ... D.. ........................... . tJ....... , .................... North Andover, Mass. Fee......�.�..�....... Lic. No. ��`�.�....... ............................................................... PLUMBING INSPECTOR Check # 3 3 1� - ° 12 e.,63 N W r rtA IAA . 11 A _n ,N, 0 r., V I v I Z7, KA LaJ I VIL, Im t MASSACHUSETTS UNIFORM APPLICA ION FOR A PERMIT TO PERFORM PLUMB114G WORK -I ,J ' CITY _ t� —_ __jj MA DATE I f ( PERMIT# JOBSITE ADDREW cel d it OWNER'S NAME a POWNER ADDRESS TEL I _ FAX TYPE OR OCCUPANCY TYPE COMMERCIAL ® EDUCATIONAL Q RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: ® REPLACEMENT: Q PLANS SUBMITTED: YES ® NO�]I FIXTURES Z FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE 1 �.__ f _. L __ -_ ► _ _,___ _-___� __,__-I ,-____,f _ _.., f -- DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OILISAND SYSTEM —A f ____f _..._J _..I _—I ______j _ _1 _ _ ; __.•� f _ I __ DEDICATED GREASE SYSTEM ._-_.. -.-_ J ._.._.I I DEDICATED GRAY WATER SYSTEM i.. _I _ _ _._. I DEDICATED WATER RECYCLE SYSTEM I ______1 DISHWASHER f __ _.._I _..__ ___._ f _ f .__� ._—•__J _ __I ._.._..w_1 ._-.__1 _.__I ___.__ f __.._ _1.__...-__-I DRINKING FOUNTAIN I ....___j _-.-_-! -J== _...._.. I __.__� .__-__1 .-_--_-�-._--.- I _•- -_- .__..._I �_[ ....____! FOOD DISPOSER FLOOR/ AREA DRAIN _l ___j L__ - .._._ iINTERCEPTOR INTERCEPTOR(INTERIOR) KITCHEN SINK I _ . _1 LAVATORY ROOF DRAIN ._ SHOWER STALL I � I _-_ J d 1 _.._1 ._.___. _ i f _._.1 SERVICE / MOP SINK f __. _I _[ f _-1 1 � .._._.A _.__ I .___� ..._. _ f .-_ _.f ... _._ _._� f f TOILET _i _i f __. f _ � ._^j _____I �- URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING ~__ .�.... _. ._ _ __ � ___..._f _.�.1 _._._._f _.._____f ..____� .. (___._I .__--_._._f _.._. _._I-_••__-.� .._ I _..___._f __..._..! I INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES ' _I NO MJ IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ` OTHER TYPE OF INDEMNITY Q BOND 0 OWNER'S INSURANCE WAIVER: I a 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 1QI SIGNATURE OF OWNER OR AGENT hereby certify that all the details information I have of and 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. PLUMBER'S NAME L LIC E # 1 I SIGNATOR iVIP4xJP Q CORPORATION (PARTNERSHIP Q# LLC U� T COMPANY NAME � _��DDRESS CITY ` STATE'- ! ZIP TEL FAX�% ��ELL ��MAIL o rl z N ❑ a Iii w LL Date ais.. H .................... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION Thiscertifies that .................................................................................................................... has permission for gas . stallation in the buildings of .......... A .... Z.4.1 . S .. ........................................................................... at.J,C) ....... ....... X.4- ............. North Andover, Mass. Fee...I:? Lic. No. .. . ......................................................... GASINSPECTOR Check # Oe 16 t4 vert:. t u ! 2� i 13 DRYER i l . _ I_c �1 L. _ I FIREPLACE FRYOLATOR FURNACE -- -I GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN - - - --- - - [ POOL HEATER _ ROOM / SPACE HEATER ROOFTOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATERI ( j -"- OTHER r I INSURANCE COVERAGE 41 have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL. Ch. 142 YES NO tl IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY �a 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. SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER 0I 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 with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. m PLUM BER-GASFITTER NAME �(}� �►' f 1F�%�1LICENSE # / _� SIGN URE MP 0,MGF Ej1 JP JGF LPGI ® CORPORATION'V# PARTNERSHIP E #= LLC ®# COMPANY NAME:1-53 _LIADDRESS,=R CITY _ STATEZIP �A_—TEL FAX - CEL L. - EMAIL , 1 \% - f N �c _ ► - MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK - C CITY % _in�/f JMA DATE PERMIT# JOBSITE ADDRESS s OWNER'S NAME OWNER ADDRESS TEL— --IFAX TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL ( EDUCATIONAL RESIDENTIAL CLEARLY NEW: RENOVATION: El REPLACEMENT: PLANS SUBMITTED: YES F---Jj N00 APPLIANCES 1 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 1 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER i l . _ I_c �1 L. _ I FIREPLACE FRYOLATOR FURNACE -- -I GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN - - - --- - - [ POOL HEATER _ ROOM / SPACE HEATER ROOFTOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATERI ( j -"- OTHER r I INSURANCE COVERAGE 41 have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL. Ch. 142 YES NO tl IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY �a 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. SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER 0I 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 with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. m PLUM BER-GASFITTER NAME �(}� �►' f 1F�%�1LICENSE # / _� SIGN URE MP 0,MGF Ej1 JP JGF LPGI ® CORPORATION'V# PARTNERSHIP E #= LLC ®# COMPANY NAME:1-53 _LIADDRESS,=R CITY _ STATEZIP �A_—TEL FAX - CEL L. - EMAIL , 1 \% - f N �c _ ► - 1 The Commonwealth of Massachusetts Department of Industrigl 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 Legibly Name (Business/Organization/Individual):, Address: VO ' l �n U �D City/State/Zip:��P'� � ,'�/� Phone Are you an employer? Check t e appropriate box: LN am a employer with 4. El am a general contractor and I employees (full and/or p -time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. T 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. [J Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions I L ❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other Y -Any applicant that checks box#I must also fill out the section below showing their workers' compensation policy information. T 'Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and 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 Policy # or Self -ins. Lie. #: Expiration Date: J 01 / Job Site Address: 1�b V\C1 "x 1 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 DTA for insurance coverage verification. I do hereby cer}�der the pains and penalties ofperjury that the information provided above is true and correct. Phone #: b I o Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - - Contact Person: Phone #: 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 maybe 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 (ifnecessary) 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 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 MassachvsPtts Depa tment of Zrtdustrial ,Accidents Office of Investigations 600 Wasbington street Boston? M:A. 42111 Tel, # 617-727-4900 ext 406 or 1-877:MASSAFF, Revised 5-26-05 FaY, # 617-727-7749 ww.mass.gov/dia A b ':COMMONWEALTH OF MASSACHUSETTS ji .. , _ :•-�. :. PLUMBERS AND GASFITTERS LICENSED AS A MASTER PLUMBE f ISSUES THE ABOVE LICENSE TO: JOHN E TRICKETT JR 81 MARA LNC GROTO.N MA 01450-1870 1144405/01/14 18773674,772 ' <: •, s-, Ir Fold Ttien Detach Along All Perforations -COMMONWEALTH OF MASSACHUSETTS f PLUMBERS AND GASFITTERS REGISTERED AS A PLUMBING CORP ISSUES THE ABOVE LICENSE TO: JOHN E TRICKETT JR,� JET PLB;i(HTG INC M11444 PO BO -X 99,,81 GROTON MA '10.1450-0998 ,, 2139 05/01/14 187730•:' U r- Date l..4 .1!4 ............. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ................................................................. has permission to perform .....A �. Q ...'.. ......A .................................................................... wiringijQebuilding of. . T... S at ....... . ............. ,North Andover, Mass. Fee.............................. Lic. No. ....................................................................... ELECTRICAL INSPECTOR Check# Commonwealth of Massachusetts Official Use Only Permit No. Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 h (PLEASE PRINT IN NK OR TYPE ALL INFORMATION) Date: 3 Z 4 J City or Town oh NORTH ANDOVER o the Inspector of Wires: By this application the undersigned gives noti a of his or her ' fio o erform the electrical work described below. Location (Street & Number) f n U e n S t— Owner or Tenant /42 f S61 11" t Telephone No. I -:?X (oYq Z (o 00 Owner's Address P 0 00Y ZVI Z�4,15 sham rn �}- \� Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) . Purpose of Building Newt house- Utility Authorization No.—/ S 3 (o (v " 15— Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service 2v0 Amps /Zo / 4y0 Volts Overhead Q Undgrd ❑ No. of Meters 1 Number of Feeders and Ampacity 9. Location and Nature of Proposed Electrical Work: Completion ofthe following table may be waived by the Inspector of Wires. No. of Recessed Luminaires / (v No. of Ceil: Susp. (Paddle) Fans � No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Above ❑ In- Swimming Pool ❑ rnd. gmd. o. omergencyig ting Battery Units No. of Receptacle Outlets 3S7 No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches 70 No. of Gas Burners J No. If testion ting Devices No. of Ranges Tot No. of Air Cond. % Tons Ll No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: Number. Tons ""' " KW ' "' '' " "" No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KW Heaters No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value VElectii al Work: I Z000 (When required by municipal policy.) Work to Start: 25 / Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE C VER A.GE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The r! undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE [`�1✓BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties oferjury, that the information on this application is true and complete. FIRM NAME: • (� �cj rt h P LIC. NO.: 1 e3 72 %i .� Licensee: ()C4,(, ( J loci Y„ Signature ( LTC. NO.: Sa 70 Z 6 /? (Ifapplicable, enter "exempt" in the license number line.) Bus. Tel. No�• GJ?,a 7Slr O�/7 Z Address: S'� 17up /( 5 f'1?e- JroS e /yj /� / A, Alt, Tel No.: � *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. — OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent PERMIT FEE: $ `1 Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the 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 ,g 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 shall.be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012. ❑ Rule 8 — Permit/Date Closed: *** Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection Pass 0 Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INPECTION: Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: . Inspectorl Signature: Date: PARTIAL ROUGH INSPECTION: Pass Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: ( r Inspectors Signature: Date: FINAL INSP ION: Pass ? Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: / 4/ Date: P /y —/ DEB WEINHOLD ... TOWN OF MERRIMAC/MA. .......dweinhold@townofinerrimac.com The Commonwealth of Massachusetts DI Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 UV www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information (� Please Print Legibly Name (Business/Organization/Individual): YJ U ✓rl( T /" 1_e/ , J Address: S-0 19a r S City/State/Zip: Ine 14 6 OZ / 74 Phone #: q 7 F 75� & O Y 7 2 Are you an employer? Check the appropriate box: Type of project (required): L ❑ I am a employer with 4. El am a general contractor and I 6. El New construction ` ployees (full and/or part-time). � have hired the sub -contractors �• E] Remodeling 2. I am a sole proprietor or partner- listed on the attached sheet. ship and'have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 5. ❑ We are a corporation and its 9. ❑ Building addition [No workers' comp. insurance required.] officers have exercised their 10.❑Electrical repairs or additions 3. ❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, § 1(4), and we have no 12. ❑ Roof repairs insurance required.] t employees. [No workers' 13. ❑ Other comp. insurance required.] *Any applicant that checks box 41 must also fill out the section below showing their workers' compensation policy information. T Homeowners who submit this affidavit indicating they ace 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. lam 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. #: Job Site Address: Expiration Date: 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 requireclunder 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. 1 do hereby certi u der thepains andpen�Jties orjury that the information pro vided above is true and correct. Z Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # 2Co // 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 #: 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-contractor(s) 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 maybe 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/liceuse 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 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 CO MPaonwoalth. of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel, # 617-727-4900 ext 406 or 1-877rMASSAFB Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia Fold, Then Detach Along All Perforations ._.. sir.■.......... �.........� :;_ _:.�.. _.._....-......._.