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HomeMy WebLinkAboutMiscellaneous - 21 EMPIRE DRIVE 4/30/2018i N m V This certifies that . C ". 1.3�. `4�� . ............... . has permission for gas installation .. VA- ,% -(.......... .. in the buildings of ...fi................. y at ... ? . C— v i ..1��-4.-............ , North Andpver Mass. 17 , Fee I.e,a.A,)... Lic. No. � PI�-f .. = ......... ... GASINSPECTOR Check # X601 ha -r W 2 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. PLUM BER/GASFITTER NAME: STEPAE"N C. GALINSKY LICENSE# 1034's SIGNA COMPANYNAME: GAi.#n KII PLOrA810C + I4CKf-Q&, ADDRESS: P.©• WX 1'7®i CITY: 0AV1=Pui I TEL: 97K' 371q- 1743 MASTER [/ JOURNEYMAN ❑ STATE: 111 • A • ZIP: 01%31 CELL: moo'$ - 60q- 590q EMAIL: FAX: 479- Gal - 4131 LP INSTALLER ❑ CORPORATION [�# 8 y� PARTNERSHIP ❑ # LLC ❑ # MASSACHI.It ETTS •UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK GOWNER TYPE OR PRINT CLEARLY CITY: Nom At, NO Cin- MA. DATE: 3�'L�'1� PERMIT# JOBSITEADDRESS:_ e�,l C—oxp)Aizt IJC�,. OWNER'SNAME: ADDRESS: TEL FAX: OCCUPANCY TYPE: COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL NEW: fid 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 I 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 j r INSURANCE COVERAGE I have a current liabili 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 [�J' OTHER TYPE INDEMNITY ❑ BOND ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER [-IAGENT ❑ SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted (or entered) regarding this application are true and accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUM BER/GASFITTER NAME: STEPAE"N C. GALINSKY LICENSE# 1034's SIGNA COMPANYNAME: GAi.#n KII PLOrA810C + I4CKf-Q&, ADDRESS: P.©• WX 1'7®i CITY: 0AV1=Pui I TEL: 97K' 371q- 1743 MASTER [/ JOURNEYMAN ❑ STATE: 111 • A • ZIP: 01%31 CELL: moo'$ - 60q- 590q EMAIL: FAX: 479- Gal - 4131 LP INSTALLER ❑ CORPORATION [�# 8 y� PARTNERSHIP ❑ # LLC ❑ # 7� O C x 0 a b r� n H 0 z z 0 H m = m � v+ v � H c7 `� D � r � h z � o � = C7 rn o � z CD vt o z ❑o K El r b r� H 0 z z o H Y Division of Professional Licensure: License Search The Official Website of the Office of Consumer Affairs and Business Regulation (OCABR) Division of Professional Licensure Mass.Gov Home State Agencies A -Z Topics Home > Division of Professional Licensure > Check A Professional License By the Division of Professional Licensure LICENSEE Name:STEPHEN C. GALINSKY HAVERHILL, MA —This Licensee has additional Licenses, click here to view them."` Licensing Board: PLUMBERS 8 GASFITTERS License Type: MASTER PLUMBER License Number: 10348 Status: CURRENT Expiration Date: 5/1/2014 Issue Date: 11/18/1986 Exam Date: School: This web site displays disciplinary actions dating back to 1993. This license has had no disciplinary actions taken during this time. The page above has been generated by the Division of Professional Licensure web server on Monday, March 25, 2013 at 12:14:30 PM. © 2007-2011 Commonwealth of Massachusetts Page 1 of 1 Mass:Gov ONLINE SERVICES Check a License Locate a Licensed Professional Online Address Change Contact the Agency More... REFERENCES & RELATED INFO Disclaimer Regarding Website License Searches Enforcement Process Glossary Glossary of License Status Codes More... Site Policies Contact Us http://license.reg. state.ma.uslpubLiclpubLicenseQ. asp?board_code=PL&type_class=_M&1... 3/25/2013 This certifies that .. G l G..�� ,.,.�j.�.................. . has permission to perform...-E ;: .-\A .................. s plumbing in the buildings of ... v., c.%.a_ �::..l)% ((.VZ--......... . at .. :?. ` ..L� -P -0m V t............... . North Andover, Mass. Fee/)o . c. o. • ��1 LiN PLUMBING INSPECTOR Check # 6\ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK POWNER TYPE OR PRINT CLEARLY CITY l�`I��V'�' C Ip¢o��,t..� nJMA. DATE 3 Z PERMIT # n JOBSITE ADDRESS �) M A�� OAA— OWNER'S NAME ADDRESS TEL FAX OCCUPANCY TYPE: COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL NEWV RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES ❑ NO ❑ FIXTURES Z FLOOR- BSMT 1 2 3 4 5 S 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYS DEDICATED GAS/OIUSAND SYS DEDICATED GREASE SYS DEDICATD GRAY WATER SYS DEDICATED WATER RECYCLE SYS DRINKING FOUNTAIN DISHWASHER FOOD DISPOSER / FLOOR / AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK LAVATORY ( 2, ROOF DRAIN SHOWER STALL i SERVICE / MOP SINK TOILET t 2 - URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER INSURANCE COVERAGE: have a current liabili insurance policy or its substantial equivalent which, meets the requirements of MGL Ch. 142. Yes &No ❑ IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [R OTHER TYPE OF INDEMNITY ❑ BOND ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE BOX ONLY: OWNER ❑ AGENT ❑ Signature of Owner or Owner's Agent I hereby certify that all of the details andinformation 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 Chaptef 142 oft General Laws. PLUMBER NAME 5-rEpt+60 C, GAI-10SKY SIGNATURE LIC # I03if S MP d JP ❑ CORPORATION X# 319 b PARTNERSHIP ❑ # LLC ❑ # COMPANYNAME 601yijsKY PI -O MW Jb *- 1,1yAmIC ADDRESS: P•0- Gcsx 1701 CITY HAV6RFtiL1. STATE M•A- ZI_P 01531 EMAIL N/wvv. mrpfumberW1. c,om TEL 47t- 3,7y- 1 iq 3 CELL •SOB- 50'1- 5g0q FAX '97,5-591-14131 __It O C O x r C z r -71 0 z � z 0 7 T —1 = m cn u ZZ � v — a Z c� z < o *, m C m z a iJ t � 1 lz� DE r o m o ❑C o z El a r z b y O z z 0 r� Division of Professional Licensure: License Search 4 , The Official Website of the Office of Consumer Affairs and Business Regulation (OCABR) Division of Professional Licensure Mass.Gov Mass.Gov Home State Agencies A -Z Topics Page 1 of 1 Home > Division of Professional Licensure > ONLINE SERVICES ......._.. - ................... ........................................._.......... -.......... ............. ............ ........................_.............................. ................ . ..................... ........... Check a License Check A Professional License Locate a Licensed Professional By the Division of Professional Licensure Online Address Change Contact the Agency More... LICENSEE Name:STEPHEN C. GALINSKY REFERENCES & HAVERHILL, MA RELATED INFO Disclaimer Regarding **This Licensee has additional Licenses, click here to view them.** Website License Searches Enforcement Process Glossary Licensing Board: PLUMBERS Et GASFITTERS Glossary of License Status License Type: MASTER PLUMBER Codes License Number: 10348 More... Status: CURRENT Expiration Date: 5/1/2014 Issue Date: 11/18/1986 Exam Date: I School: This web site displays disciplinary actions dating back to 1993. This license has had no disciplinary actions taken during this time. The page above has been generated by the Division of Professional Licensure web server on Monday, March 25, 2013 at 12:14:30 PM. © 2007-2011 Commonwealth of Massachusetts Site Policies Contact Us http://license.reg. state.ma.uslpubLiclpubLicenseQ. asp?board_code=PL&type class=_M&1... 3/25/2013 Date .....� NORTH TOWN OF NORTH ANDOVER PERMIT FOR MECHANICAL INSTALLATION This certifies that ... .`... .... `.. . has permission for mechanical installation 2. 2v ^' e. l�l�G�c.74_4 !'1 in the buildings of ...... • ' North Andover, Mass. . Fee. r:r,.. : Lic. No.ljPc�' �'%Q..................... E GASINSPECTOR r.. WHITE: Applicant CANARY: Building Dept. PINK: Treasurer r Commonwealth of Massachusetts Sheet N.Metal Permit Date: 1 A Estimated Job Cosi 5. 7 J O Pians Submined. YES NO Business License Business information,: \2me: I `,' l Photo :.D. required , nI ho -C i.D. 3Cd,:ne{: J-1 , M-i-_nresiri^cd license ?ermtt r# J Permit Fee: S-36, Plans R.eviewe:-4: 1'ES V V O .-I.pciicant P:opere;4.�ne; ,' Joo Lr. cca[ic,:nierrrauon: , Cit; Town. A%.A..4e;,4-C6� TelCnr.ore/: 778 03 -7 55S-3 staii initial J-2 ;' y{_?_r���rlC;�fi CO G'wC19 �'s CC riCS Oi .'S3 a.^.�=V":IT1Cr-l: I LLw :O 10,0("7 Sc. _j'a S� Residential: L-2 r2^:iii _ Muiti fs ,ii> Condo ' -I cwnrouses Cotr.meru.ai: 0":Ylc_ cc:aii ind_s,:ial - ucati n�': Square Foota'c: ur.dc: l �,�CO i:. __ o.e i0.00v sC,. ` �umher o: stories: Sl'cer metal work to be cotnpleted: ,l.w'w a.0 \fetal Water.,.,ed Rcaftn_ ivtetai Chi:-:ne % ve, ovi.:e dvai!ed descric .cn e.:v r to ce dcr::: K:, hen �.:aaust Svzte:r, A(r �3iflGC:'2 w N The Commonwealth of Massachusetts Department of Industrial 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):'P. 0 - a2e_d),11_%/ ,�f/ Zde Address: ))zor I -1G3 Phone #: , i �- Are you an employer? Check the appropriate box: ❑ 1 I am a employer with 4. I am a general contractor and I .� employees (full and/or part-time).* have hired the sub -contractors 2. ❑ 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 comp. insurance.* required.] 5. ❑ We are a corporation and its 3. ❑ I am a homeowner doing all work officers have exercised their myself. [No workers' comp. right of exemption per MGL insurance required.] t 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 10.7 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other Any applicant that checks box #1 must also fill out the section below showing their workers' compensationpolicy 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: C t"d rr f TJ Policy # or Self -ins. Lic. #: l s l� ' / /C -,V9 Expiration Date: Job Site Address: �' 1 jnh Df— 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 $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. I do hereby cerdfy under the pains ggdpenalties of perjury that the information provided above is True and correct 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 Contact Person: Phone #: 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 chedced Yes, indicate the type of coverage by cheddng the appropriate box below - Liability Insurance Policy ❑ 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 Ma G�eneira� Law and that my signature on this permit application waives this requirement G/l Signature of Owner or Owner's Agent Owner ❑ Agent By checiting this box I hereby certify that all of the details and information l have submitted (or entered) regarding this application are true and accurate to the best of my imowiedge and that all sheet metal work and installation performed under this 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. Duct inspection required prior to insulation installation: Yes No Progress inspections _ Date Comments Final inspection Date Type of License By. — Title: Permit Fee S: Inspector Signature of Permit Approval Comments u Master ❑ Master -Restricted ❑ Joume erson ❑ Journeyperson -restricted Signature of Licensee License #: SHEET METAL PERMIT 0219.11 ACOR0 CERTIFICATE. OF LIABILITY INSURANCE DATE m*«°DIYYYY) 12/28/2012 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 CONTACT MANE: NORTH ANDOVER INSURANCE AGENCY, INC. P"ENE En: (978) 686-2266 (pO Ne): (978) 686-6410 ADDRESS: C£ernandez@na£ins.com M.J. FOSTER INSURANCE SERVICES CUSTOMER ID IR -A . Mechanical, Inc. 163 MAIN STREET INSURERS) AFFORDING COVERAGE NAIC s NORTH ANDOVER MA 01845-2508 INSURED INSURER A M>rRCHANTS INSURANCE CO 1k.31, . Mechanical, Inc. INSURER B :GUAPM INSURANCE 16 Lomax- Park INSURER C Suite 1 INSURER D / / Pepperell MA 01463- INCIIVFV F INSURER R 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 RE3PECT TO WHICH TH13 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. NSR LTR TYPE OF INSURANCE INSR WVO POLICY NUMBER POLICY EFF (MWOONYYY) POLICY EXP IMNVOD/YYYY) LINKS A 6BI.ML LIAeLRY Y tlP915j499 1/01/2013 1/01/2014 EACHOCCURRENCE $ 1,000,000 AGE TO RI:N FFD PREMISES Ea occurrence $ 100,000 X COMMERCIAL GENERAL LIABILITY / / / / CLAIMS•MAOE F_x1 OCCUR / / / / MED EXP (Any one person) $ 15,000 nrnr,0NAL s ^DV INJI-)PY C 1,000,000 GENERAL AGGREGATE $ 2,000,000 / / / / GEN'L AGGREGATE LIMIT APPLIES PER' PRODUCTS - COMP/OP AGG $ 2,000,000 E13LIA $ X POLICY PRO LOC IFCT / / / / A AUTOM0131LE LU1BLrrY 9CA0000008 1/01/2013 1/01/2014 COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) BODILY INJURY (Per person) $ ANY AUTO BODILY INJURY (Per accident) $ ALL OWNED AUTOS X SCHEDULED AUTOS PROPERTY DAMAGE X HIRED AUTOS / / / / $ (Peraccident) $ X NON -OWNED AUTOS / / / / A X UwREUA Lue X OCCUR DP9145439 1/0112013 1/01/2014 EACH OCCURRENCE $ 1,000,000 AGGREGATE $ 1,000,000 EXCESS LWB CLAIMS -MADE / / / / / / / / nFnt ICTIRIF $ $ RETENTION $ / / / / B WORKERS CONDENSATION t7C466048 1/01/2013 1/01/2014 WC STATU- OTH- X IT ER AND EMPLOYERS' LRBILRY 1 N Y - E L EACH ACCIDENT $ 500,000 ANYPROPRIETORIPARTNERfiDlECU TIVE / / / / OFFIr6"IiMOGA 6XOWD6D9 F7NIA (Mandatory In NH) / / / / E.L. DISEASE - EA EMPLOYEE $ 500,000 E.L. DISEASE - POLICY LIMIT $ 500,000 If yes, describe under DESCRIPTION OF OPERATIONS below / / / / DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attuh ACORD 101. Aedrtlonal RaMWks Schowe. / mon apace Is squired) CERTIFICATE HOLDER CANCELLATION ACORD 25 (2009/09) O 1988-2009 ACORD CORPORATION. All rights reserved. INS025(2ooeo9) 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 ACCORDANCE WITH THE POLICY PROVISIONS. R.A. MECHANCIAL, INC. AU1"011ra10 RVRESGNTATIVG 16 LOMAR PARK SUITE 1 PEPPERELL MA 01463— ACORD 25 (2009/09) O 1988-2009 ACORD CORPORATION. All rights reserved. INS025(2ooeo9) The ACORD name and logo are registered marks of,ACORD � w — - — COKAK8ONYVEALTHOFiMAS3ACHUSETTB SHF -;---T METAL INORKe-Rb 'ssussTHE ABOVE uCsyss`o DONALD J JUELLETTE 657 MAMMOTH RD � - ORACUT MA 01826-4349 _ 4688 07/28/1* 223I39 . Sheet 1 s�oo�y N ri 7 7" C C' . II at I Job #: RA MECHANICAL INC Sczfe: 1: 7, Performed for. Page 1 16 LOMAR PARK Rignt- EudeiD Unive _ni P r -PERE; 1 MA (31463 7.1.17 RSU11�a7 Phone: 9784=86-71 Fax 97 B42:24GC0 Mla-CC-1 c11''1.ae rameCtanir�t�aai.cm C:.0Q=me = and . nsingawL>+v1.. • i .e� : I—�r—�7—w�2=., '\:. � �� �!��.....�r: i.riC.-=L ,�1��—•.r1E: — -771 Vit,:. • ;:- .., ..�.::.:.' ..:-:�... ..yik