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HomeMy WebLinkAboutMiscellaneous - 202 SUTTON STREET 4/30/2018moi" Locationaw, -5�4vv,) No. 1� —2cA? Datel2fl Check #,:�z t I L ) .1 1 , U TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $- TOTAL $ I �io Building lnspe�t& W O 0 2 Z ct Q F- W O Z z LL r Z o� O (n ODER **4 r• W -60 ;,f * LO O N � 00 Q N L � 2 m N E W r LL � O H 0 W U W N 0 d F -- a) N _0 -C � � c a(ni0� u).2 E co _ a) rn = re O C E CO O O N 4-- c O O � U � 00 0- Ca U) — 00 O N L N p E O - C O U) m cn U N O N N � vj > O) O *k (nC O N Q 4= N U OZ5 V> (n N m O N Q N C O N U� Rf M N -0 N 'j O O Qom+ > C c = O O O 4- c N :,_, Q O N c 0 0 O OZ C N 0 .- U O Q3:0 O ca F- > !^ 04 .� N �3 L oo ° Qr.�C70_ § bA 0) cd� ,a) y 0 0 N N O 0 �A a; o ° O 0 Cn N U U U ++ bA on U C cd C1 .SG Cd - V ~� � O N E to bA 0) cd� ,a) y 0 0 N N O 0 �A a; o ° O 0 Cn N U U 11, Q 0 bA on Y 4° to OD N o O Q. 0 ° o Cd C,3 to °o ° 3 0 N cd ,a u 11, Q 0 f�• -� » - � w\ k « a Z6 k ) a§ \ �� >» \\ . z@ 0 t/ \:ri Cc t: §) I cx) / o u cm k . ^ ^ .' a © }:E 20• LU a2 ^I LU N« .... K< f £ LL. -t5 §% `Z/ /(L m _ - /�\ zo (§ � . � as §s R E |! S � x\� k�! bLU 2 � k«! 8!& �] �» §K . CD z �§. a.w 'w $ )�§ �° 2 §� 8 LU k §b kLu / -,o a \ ~ §^8 k) co . . ` « ^ �� ]\ X // / t =2 ' . .. & z« . 2 0=3 . :. o E—o / 0 U) U) X06 LO ///o C14 %�� . Q Maaaachussetts - Department of Public Safety Board of Building Rogulationss and Standards Construction Supervisor T License; CS -071652 ? �y� 6, ! RICHARD AHAR�VEY 1.65 TYLER ST T�'1 METHUEN MA 018441 yy Expiration Commissioner 03/10/2016 The Commonwealth of Massachusetts Department of IndustrialAccidents m Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual). Harvey Signs Address 30 Osgood St ".. In aL...,.-. RAA AAAA l,1tV/JlittG/G1U•'""LI '"'^"'VTT rnone F. �Y- Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4 4. ❑ I am a general contractor and I employees (full and/or part-time).' have hired the subcontractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. employees and have workers' [No workers' comp. insurance required. 5• ❑ 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required. t comp. insurance.$ 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. 2071 Type of project (required) 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions I1.❑ Plumbing repairs or additions I2.0 Roof repairs 13.❑■ Other Signs *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name. National Grange Policy # or Self -ins. Lic. #: WC17786Q Expiration Date 9-30-16 Job Site Address: 20,; s',, Y7` ill. A -,vow z u,4 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 required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to 51,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to 5250.00 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. I do hereby certifyr thepains andpenalties ofperjury that the information provided above is true and correct e : 9787942071 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 #: Nick Milley From: Debbie Mathias <dmathias@lbmrealty.com> Sent: Friday, December 18, 2015 1:08 PM To: 'nick' Cc: amy@amyfournier.com; amatses@charlesconstructioncompany.com Subject: RE: 200 Sutton - Miami Fitness.pdf - Hancom PDF Viewer The black and white sign is perfect. We approve of the submission, dated 12/18/15. Should have your overtime number this afternoon. Thank you. debbie From: nick [mailto:nick(obmiamifitnessandlifestyle.coml Sent: Friday, December 18, 2015 11:45 AM To: Debbie Mathias; Amy Fournier Subject: 200 Sutton - Miami Fitness.pdf - Hancom PDF Viewer deb, does this work for you? pls let me know so Harvey sign can get to bldg inspector today thx, nick Sent from my Samsung Galaxy Tab©4 k ': !-- tr�.." A : NA 1 A LLQ. 1 397 Date ,ORT#1 TOWN OF NORTH ANDOVER PERMIT FOR MECHANICAL INSTALLATION yo* All .......... This certifies that . Rte has permission for mechanical installation 4i� . ............ in the buildings of ................ at ........ North Andover, Mass, Fee. Lic. No.. . ........ �N ZeCTOR GAS WHITE: Applicant CANARY: Building Dept. PINK: Treasurer % Commonwealth of Massachusetts Sheet Metal Permit Date: ✓l / a o�� Estimated Job Cost: $3 Plans Submitted: YES V/ NO Business License # ,_// Business Information: Name: Street: c?% C/%C�/�/f S✓� City/Town: 4/,j g /V Telephone: �Z61�la zhQ % �jJ-153- Permit # *FZ7 Permit Fee: $ Plans Reviewed: YE-)_ NO Applicant License # Property Owner / Job Location Information: Name: Wz g9 z ���� Street: / City/Town: Telephone: Photo I.D. required / Copy of Photo I.D. attached: YES NO Staff Initial J-1 / M -1 -unrestricted license J-2 / M -2 -restricted to dwellings 3 -stories or less and commercial up to 10,000 sq. ft. / 2 -stories or less Residential: 1-2 family Multi -family Condo / Townhouses Other Commercial: ✓ Office Retail Industrial Educational Institutional Other —Z,, % S�/,l (2 Square Footage: under 10,000 sq. ft. over 10,000 sq. ft. Number of Stories: Sheet metal work to be completed: New Work: Renovation: HVAC V Metal Watershed Roofing Kitchen Exhaust System Metal Chimney / Vents Air Balancing Provide detailed description of work to be done: / G/e /L, t INSURANCE COVERAGE: I have a current liability insurance policy or its equivalent which meets the requirements of M.G.L. Ch. 112 Yes ❑ No ❑ If you have checked Yes, indicate the type of coverage by checking the appropriate box below: A liability insurance policy Q/ Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 112 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only Owner)sn Agent ❑ Signature of Owner or Owner's Agent By checking this box❑, I hereby certify that all of the details and information I have submitted (or entered) regarding this application are true and accurate to the best of my knowledge and that all sheet metal work and installations performed under the permit issued for this application will be in compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws. Date Date By Title City/Town Permit # Fee $ Duct inspection required prior to insulation installation: YES NO Inspector Signature of Permit Approval Pro>:ress Inspections Comments Final Inspection Comments Type of License: ❑ Master ❑ Master -Restricted ❑Journeyperson Signature of Licensee ❑Journeyperson-Restricted License Number: Check at www.mass.aov/dpi REIDM-1 OP ID: JO A� Rte" CERTIFICATE OF LIABILITY INSURANCE 06/16/2015 06116/2015 THIS 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(les) 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 Foster Sullivan Insurance 163 Main St. North Andover, MA 01845 Foster Sullivan Insurance LLC CONTACT John Dussault PHONE 978-686-2266 FAX (PA No Ext : (,X -686-6410 No): 978-686-6410 E-MAIL ADDRESS: certificates@fostersullivangroup.com INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Merchants Mutual Ins. Co. 23329 INSURED REID MECHANICAL CORP., 27 CHARLES ST. _ INSURER B: Merchants Preferred Ins. Co. 12901 -- INSURER C: NORTH ANDOVER, MA 01485 INSURER D: A INSURER E, INSURER F: BOPI085443 COVERAGES CERTIFICATE NUMBER- RFvlclnti NI I11,11i 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 I TYPE OF INSURANCE DDL UBR POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MMIDD/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A COMMERCIAL GENERAL LIABILITY CLAIMS -MADE F-1 OCCUR BOPI085443 05/23/2015 05/23/2016 PREMISES Ea occurrence $ 500,000 MED EXP (Any one person) $ 15,000 X Business Owners PERSONAL&ADV INJURY $ INC GENERAL AGGREGATE $ 2,000,000 GE N'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,000 POLICY PRO-JECT LOC $ -- - - _— AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 Ea accident $ B ANY AUTO MCA1002088 05/23/2015 05/23/2016 BODILY INJURY (Per person) S ALL OWNED X SCHEDULED AUTOS AUTOS BODILY INJURY Per accident $ ( ) X HIRED AUTOS X NON -OWNED AUTOS PROPERTY DAMAGE S PER ACCIDENT X UMBRELLA LAB OCCUR EACH OCCURRENCE $ 2,000,000 A EXCESS LIAB CLAIMS -MADE CUP9147549 05/23/2015 05/23/2016 AGGREGATE $ 2,000,00.0 DED I RETENTION $ $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVEWCA9099504 OFFICER/MEMBER EXCLUDED? ❑ NIA 05/23/2015 05/23/2016 WC STATU- OTH- TORY LIMITSI ER E.L. EACH ACCIDENT $ 500,000 — - -- — — — _ -- (Mandatory in NH) If yes, describe under E -L. DISEASE - EA EMPLOYEE S 500,000 — DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/ LOCATIONS /VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) CERTIFICATE HOLDER rANrFI I ATInN © 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 26 (2010/05) The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN The Town Of No. Andover ACCORDANCE WITH THE POLICY PROVISIONS. North Andover, MA 01845 AUTHORIZED REPRESENTATIVE n ` © 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 26 (2010/05) The ACORD name and logo are registered marks of ACORD Fold, Then Detach Along All Perforations 0 H nn !'�D as D Cn m a_ mH �•aHnhH DX.ro ar A9 C> b'�> C axb=_ _ O pp cr brr .. y( ¢H� -0 �Lvr. ��xry C�. rv. Cja'F�EF r'iG ��b �SnoOw��-I_ry zO7x CZH .jympOrrm>O n tl OA �> C 2 ms c �roro y��r5='` an crOmC ��� t �C D KO> �O_A sn z D zm 'LD Z�H Dp.n �n rr,r>+m K 3rXu Tkx a r me [nL Om. 2' HL]rZr m CDydCTF vzb,0 px�ab0� XX • �mx A rO> �a0 ° n� > C�1 w ypr yCs r te' m2 mDr-�F 'x '�� z Ht� wL0a-Z O OHn,-'.cb C]SZ(>.'� 4'c� i2 min off= c n zo �o� m< �vt OF D O Cbno- txnpC5 O �y G`Dn cDr,�_m�i'.2.in Oc ��GNao-LO rn n;Hvvjm .•roro-ly DH D „ag,'m1CC077. h(LR.y> G N"ADZJ, >5o m bOz z€C£a ny 00..a yZOyA A03 tlH moi. [r'2 £C1 Z� nz �rb 00 bD r?Z [r- 9 Z 2r�� yz K oy?� nyC ro nD H H > O CE -.v^ O =¢v vK. F- bfa'. D p° r H �t KAy,H`, z9b X tl9 A 'i?yZ . L O�- C^ mS C� i P OZ03 ro HX n 'nZ � an• >G Yc' mxD ar yea 3� E > o opn� "'� ns z Dyz qq mr 5� � �•L� m �- 3� mti a°v,g F 3 zEn v1 �xq 6H HO A SF CIO ��� 5 003�w w Rr pyo H= S 3 n0 H C rr•O m 0 i McCABE ASSOCIATES HVAC PIAN � 12/10/15 CONSULTING ENGINEERS AND DETAILS arc �` U.M. �VSED: PRDJM Miami Fitness and Lifestyle o P 75 GMHUE ROAD DERRY, HH 03038 Tw: 6oa437 zoos 202 Sutton Street / North Andover / MA 11 15 *11 � Date./.'/;.`-�­/­**.K .. TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ...... 6,,4 ..... P*******--*--'--* ........... ... ... ... has permission to perform c; .. plumbingin the ui in s of ............................................................................................. atcP f .4 ................. *"*"***'**** ....... ..... . ANo h Andover, Mass. -4Lic. No. Fee,41.1 ...................................... SPECTOR Check #,4�4 l` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ' CITY. _11 MA DATE (PERMIT# JOBSITE ADDRESS Cs _� OWNER'S NAME (' POWNER ADDRESS TEL -]FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL EI PRINT CLEARLY NEW: RENOVATION: ® RE ACEMENT: ® PLANS SUBMITTED: YES NOM FIXTURES 1 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM �J ! F _._( � (! =__j ___—J DEDICATED GRAY WATER SYSTEM ( .-._._ ! DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER -- i----__! ! ( ! f ._ -_-J .__ _ l ___--_•_( __.__J FLOOR/ AREA DRAIN } _ _J INTERCEPTOR (INTERIOR) I (---__-! _ ._ .! .__._.! ( _._ .-.--j T_! ...__.__! - ._! I .__.__.i KITCHEN SINK LAVATORY ROOF DRAIN ! J ! __—! J ! _! J ._ _ _._. E _71 _ _._. SHOWER STALL SERVICE / MOP SINK -TOILET ! _ _ URINAL 'WASHING MACHINE CONNECTION WATER HEATER ALL TYPES ! i WATER PIPING OTHER _ _ _ _-_ � ( ! ! . _._...._.� ._._ _ _! I ! -_ _ -__! {------! r- -----( I ___._.1------► ----.J _.-.___i ....._.I INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES , NO �1 IF YOU CHECKED YES, PLEASE INDICA E THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ! OTHER TYPE OF INDEMNITY © BOND Q 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. CHEC ONLY: OWNER A7 IMI SIGNATURE OF OWNER OR AGENT 1 hereby certify that all of the details and information I have submitted or entered regarding this applicatitfn are trLX acc ate of knowledge and that all plumbing work and installations perfo med Lvider the permit issued for this application will a in co pli a ertin t pf on of the Massachusetts State Plultgng fode an Chap r 142 the General Laws. PLUMBER'S NAME �, LICENSE # TURE IMP�IJ JP CO ORATION 1 PARTNERSHIP 0# ; LLC I� � _ COM PAN NAME DDRESS _ f -- CITY t STATE . IP �� TEL FAX ]CELL[__- -- EMAIL �- ------------- - - - - - - -... - --- --- —-------- ..---._._....__ H O H U W R W h O ❑ z o F w o W Cl- Z u LU a I o a W a LUOLU w L in a p o w �- � U ..1 a a Q � LU = w ►- LL. H H •� U W P-4 CIOa P-4 a ' The Commonwealth of Massa. chusetts Department oflndustrialAccidents d 1 Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print LeziblV Name (Business/Organization/Individual): Address: City/State/Zip:, Are you an employer? Check the appropriate box: Phone #: 1.❑ I am a employer with . employees (full and/or part-time).* 2. rJ I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3.0 I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.# 6. Q 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): 7. ❑ New construction 8. Remodeling 9. ❑ Demolition 10 F1 Building addition 11.0 Electrical repairs or additions 12. Fl Plumbing repairs or additions 13.E] Roof repairs 14. F] Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees,' they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees.' Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lie. #: 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 required under MGL 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. I do hereby certify under the pains and penalties ofperjury that the information provided above is true and correct. Signature: Date: 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 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 fhe 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 burn leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia I This certifies that Date../ ......... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION -114 has permission for gas installation ...... . . ......... e. .......................... .... ...... . .. ... ... --0. SS in the buildings of ................. N . .......... Tj ...................................... .... ...... ......... ........... ........... C -r 1A at ................ ........................ . North Andover, Mass. .... .......... ... . . ........... .. ......... . ......... Fee Ap- 5-- (V Lie. No. �e, &.) Check # .2 / 0 VV ...................................... GASINSPECTOR -` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK .1 W CITY MA DATE1.) PERMIT# `V" �'' — . It - - I) 11A JOBSITE ADDRESS �� OWNER'S NAME (- GOWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL [j EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: 14 RENOVATION: El REPLACEMENT: ® PLANS SUBMITTED: YES Q NOQ APPLIANCES 7 F[DORS- BSM' 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE .,.-,.-,- ,i♦ .. _.... ._., _ . _ . _.. _ _ DIRECT VENT HEATER DRYER T ...� J= I FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS�:- MAKEUP AIR UNIT OVEN_ POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT H ATER UNVENTED ROOM HEATER WATER HEATER OTHERS, —{ -- -- _........ . .......... INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YESNO E] 1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW // LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY 0 BOND OWNER'S INSURANCE WAIVER: I am aware that the lic nsee 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 GENT 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 e a a rate t be o knowledge and that all plumbing work and installations performed under the permit issued for this application will be in c pli ce i all rti a ro i ' n of the Massachusetts State Plumbing Cod d hapter 142 oft Gene 1 Laws. PLUMB R-GASFITTER NAME_ 1 C� LICENSE # 6� SIGNATUR MP MGF J ( JGF ( LPGI CORPORATION PAR TNERSHIP0I#= LLC ®#L� COMPANY AME: v ! ADDR SS /J CITY _ STATE ZIP ' TEL FAXI CELL _ EMAIL •` d "� —. �El W CL w w LL •The Commonwealth of Massachusetts Department ofIndustrialAccidents X Congress Street, Suite 100 V. Boston, HA 02114-2017 www mass.gov/dia Workers, Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERWT�TIlVG AUTIiORITY. Name (Business/Orgaiiization/individual): Address: City/State/Zip: Phone Are you an employer? Check the appropriate box: I I am a employer wi� employees (full and/or part-time).* 2. 1 am a sole proprietor or partnership and have no employees Working forme in any capacity. [No workers' comp. insurance required.] 3. 1 am a homeowner doing all work myself. [No workers' comp. insurance required.] t 4. ❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no euipldyees. 5.❑I am a general contract.o and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.t 6. ❑ We are a corporation and its, officers have exercised their right of exemption per MGL C. 152 81(4) and yve have rio employees. [No workers' comp. insurance required.] �3--3r Type of project (1'ecluired): 7. [1 NdVd6nstru6tion 8. E] Remodeling 9. ❑ Demolition 10 (] Building addition 11.[] Electrical repairs or additions 12T[].Ptunabing repairs or additions 110 Rb6f repairs 14.n Other *Any applicant that check's box#1 must also fill out the section below showing theirworkers' compensationpo"cyinformation ,1 Homeowners who submit•this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such whether or $Contractors that check this box must attached'an additional sheet showing the name of the sub -contractors and state not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. rance for my employees. Below is the policy and job site X am an employer that is information. Insurance Company Nan: Policy # or Self -ins. Lic. compensation ensu ExpirationDate_ % V �/ ' A City/State/Zip: fob Site Address: Attach a copy of the �evoxkers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required as as civil ivier lZpeL c 152, I in the is a form of aS OP al violation WORK ORDER and a fine of up to $250.00 a by a ffib up to $1,500.00 and/or one-year imprisonment, day against the violator. A copy of this state t may e ded to the Office of Investigations of the DIA for insurance coverage verif tcatio X do hereby cer ' un rte ains enald of e ry that the information provided above is true and correct. Date: Si afore: 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 Clerk 4. Electrical inspector 5. Plumbing Inspector 6. Other _ Phone Contact Person Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their ebaployees. 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 receiv&br trustee 6f an individual, partnership, association or other legal entity, employing emplbyees:.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 b6 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 �notproduced -acceptable evidence of compliance with the insurance coverage xequired." Additionally, MGL chapter 152, §25C(1) 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. Anew 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 Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-AIASSAFE Fax # 61.7-727-7749 Revised 02-23-15 www.mass.gov/dia Pate ....... zl� .................. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that bi, 114,—, 14-),e 4 /d— ............................................................. ... . ............................. ............ �as permission to perform .... 77 wiring in the building of. at................ ..................................... ............ ...................... . North And6ver, Mass. Fee.. . .... Lic. N . .............. .. ................................................ ; ................................... ELECTRICAL INSPECTOR Check # /77/ f7 -) -% /,D,04 5�2LI Date .... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies thatb'l�'" . ... ....... ................................... (-.� .. . ........ has permission to perform , * ( 51.1-.x ....... .............................. H 04�' -�,s wiring in the building of ................................................................ at 2o 2- �� ......................................................................................................... . North Andover, Mass. Fee 15. 0 . .. . ....... Lic. No.2.1.1.�..� ............ ELECTRICAL INSPECTOR Check# U V 6Z 2-o 1,i., Commonwealth of Massachusetts Official Use only Permit No. Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leaveblank) ' 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: 11/17/2015 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) 202 Sutton Street Owner or Tenant Miami Fitness Owner's Address Same Telephone No. Is this permit in conjunction with a building permit? Yes 0 No ❑ (Check Appropriate Box) Purpose of Building Fitness Studio Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters NewService Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity '? Location and Nature of Proposed Electrical Work: Duplex receptacles (17), 1 -pole switches (4), wall occupancy sensors (5), GFCI receptacles (1), Floor receptacle (1), Tel/Da a oca sonstrack w heads, Recessed down--lights2x2 3 - parabolic fixtures (1.0), Pendant fixtures (6), Exit signs (6), Ceiling fans (4), Dedicated JB (5), Disconnect/reconnect HVAC units (4). FA null Stations (1). FA H/S (2). FA Strobe (3) r Completion o the ollowing table maybe waived by the Inspector of Wires. j No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans r o o a Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Above n -o. Swimming Pool rnd. 1:1rnd. ❑ ot Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total No. of Alerting Devices No. of Waste Disposers ea ump um er """ ons """""""""""' """"'""""""" No. o Self -Contained Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Q41 No. of Dryers Heating Appliances KW eza curi y ystems: No. of Devices or Equivalent no. ol water KW Heaters o. of No. of Data Wiring: Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: 14 Estimated Value of Electrical Work: $21,400.00 Work to Start: 12/15/2014 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 X❑ BOND ❑ OTHER ❑ (Specify:) I cert, under the pains and penalties of perjury, that the information on thisplication is true and complete. FIRM NAME: W Electrical Services Corp. a LIC. NO.: 21748A Licensee: William T Werle Signatures/ NO.: 21748A Address: 480 Wildwood Ave. Woburn, MA 01801 Bus. Tel. No.: 781-281-2229Alt. Tel. No.: 617-212-3880 *Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. SS -002039 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 Signature 4 JelephoneNo. ERMIT FEE. $125.00 \ o I`� o`Zrl `1 2e_ rP \ ZS0--e--S * I -:� a- , b -n The Commonwealth of Massachusetts Department oflndustrialAccidents I Congress Street, Suite 100 Boston, AM 02114-2017 www.mass.gov/dna Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Name (Business/Organization/Individual): - City/State/Zip: Are you an employer? Check the appropriate box: Phone #: 1.Q I am a employer with • employees (full and/or part-time).* 2.Q I am a sole proprietor or partnership and have no employees working for me in any capacity. No workers' comp. insurance required.] 3.Q I am a homeowner doing all work myself [No workers' comp, insurance required.] t 4. Q I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5. Q I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.1 6. Q 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): 7. Q N w construction 8. =odeling 9. ❑ Demolition 10 (] Building addition 11.0 Electrical repairs or additions 12. Q Plumbing repairs or additions 13.0 Roof repairs 14.0 Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t homeowners who submif }his 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 state whether or not. those entities have employees. If the sub-contraciors have employees,1hey must provide their workers' comp. policy number. I am an employer that is pioviding workers' compensation insurance for my employees.' Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lie. #:. Expiration Job Site Address: Z-��?�C�� �Q� City/State/Zip: '� • ��0�"�� Attach a copy of the workers' comdensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL 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. r, Ido hereby the information provided above is true and correct. Official use only. Do not write in this area, to be completed by city or town of 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 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 Jure, 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 atfidavit. 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 burn leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MA.SSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia • 0 . COMMONWEALTH OF MASSACHUSETTS r •� • -• ••F-11 MIR Lei =1061ill- t3 ` ELECTRICIANS ^I ISSUES THE FOLLOWING Ll CENSE AS :A I { I' REGISTERED MASTER ELECTRL;GI,AN:`� W EL. CTRICAL SERVICES CORPEORKTIO'nr 1 :W 1 LC`I AM T WERLl"� W f 480 W I LDWObD AVE 's l\'l�oLu WOBURN MA 01801 2063 21748 'A 07/3.J /.1.6.. :.:. 183179 Date ... �A?.!�;� TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that .. ............ d. has permission for gas,installation ��r ................... in the buildings of ....... at.......... 2 ....... 2 ..... \ ............. G ............................................................... . North Andover, Mass. Fee �0� ....... Lic. No.....) M .......................................................... Check# GAS INSPECMR -4-- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK jF CITY ANJ>OVER MA DATE PERMIT " G JOBSITE ADDRESS Su -T7ZDO _-JOWNER'S NAMEex T A_�, j7� h111E OWNER ADDRESS FAX TYPE OR PRINT OCCUPANCY TYPE COMMERCIALVI EDUCATIONAL RESIDENTIAL CLEARLY NEW:Ej RENOVATION: REPLACEMENT PLANS SUBMITTED: YES[] NOZ APPLIANCES 1 FLOORS— BSM 3 4 1 5 16 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYCLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ---I ROOM LSPACE HEATER F_ ROOF TOP UNIT TEST UNIT HEATER ..... ..... LINVENTED ROOM HEATER WATER HEATER' . --- OTHER IF. -1 IF 771 _J Ji CE J INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 1z OTHER TYPE INDEMNITY F_ 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: OWNERF-]AGENT 171 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 bes my wledge and that all plumbing work and installations performed under the permit issued for this application will be jlin�complia a 11 Perfifine Isio the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME LICENSE #Es-b� :0- SIGNA RE MP0, MGF[:] JP JGFF--LPGICORPORATION e# PARTNERSHIPF# LLC COMPANY NAME: 1 FEENtY _M970CM- ADDRESS L -r.-J CITY STATE [��►K] ZIP TEL L FAX LIQ zea_J9 CELL EMAIL Q_ "I 1?..S C 0 f -A -4-- 2.1..WILL, K'TON 156: �� . FEENBRO-01 CLEDDUKE kh ® CERTIFICATE OF LIABILITY I UPIANCE �' DATE (M/2014YY) 2!25!2014 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 Rogers i3c Gray Insurance Agency, Inc. 434 Rte 134 South Dennis, MA 02660 CONTACT April Skala aCNNo Ext : aC No): (877) 816-2156 A DREss: askaia@rogersgray.com INSURER(S) AFFORDING COVERAGE NAIC # 02/01/2014 INSURERA:01d Republic General insurance Corp. EACH OCCURRENCE $ 1,000,000 INSURED INSURER B: INSURER C: Feeney Brothers Services LLC 103 Clayton St PO Box 220801 INSURER D INSURER E: Dorchester, MA 02122 INSURER F: AUTOMOBILE 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. ICY LTR TYPE OF INSURANCE NSR UBR SWVD POLICY NUMBER POLICY M DDY/YEYYY EXP MM/DD1YM- LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE I OCCUR A2CG07501400 02/01/2014 02/01/2015 EACH OCCURRENCE $ 1,000,000 PREMISESEaoccurrence $ 1,000,000 MED EXP (Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: POLICY X PRO- LOC PRODUCTS - COMP/OP AGG $ 2,000,000 EBL AGGREGATE $ 2,000,000 AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS HIRED AUTOS NON -OWNED AUTOS COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ PER ACCIDENT $ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION $ $ A WORKERS COMPENSATION AND EMPLOYERS'LIABILITY ti./ N ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N/A A2CW07501400 02/01/2014 02/01/2015 X I WC STATU- OTH- TORY LIMITS ER E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYE $ 1,000,000 E.L. DISEASE - POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) L:tK l IVIUA 1 t HULUtK UArdl;tLLA I IUIV Town of North Andover 1600 Osgood Street North Andover, MA 01845 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 ( � ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD