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Miscellaneous - 22 UPLAND STREET 4/30/2018
do At Date.........�.................. TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies -that ..... ................ �-°. ........:...................... 5 ........................................... has permission for gas installation ... - ..f. -:.......4..... 1�(?...... in the buildings of ...... �L..21-t ��.............................I l............................ at ... P. �........ `' .. ..................................... North Andover, Mass. Fee ..(e .".1....... Lic. No. � ..K......... �.....::............................................... GASINSPECTOR Check #-32-1 09882 •` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK #. :.CITY tJaR�N-Y/ar�L MA DATE SAPERMIT#..r >�.:�.. � JOBSITE ADDRESS - c.v OWNER'S NAME lT OWNER ADDRESS TE FAX TYPE OR OCCUPANCY. TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CT'EA.RLY NEW: RENOVATION: ® REPLACEMENT: PLANS SUBMITTED: YES © NO ►- APPLIANCES 7 FLOORS BSM 1 2 3 4 1 5 1 6 7 8 9 10 11 12 13 14 BOILER BOOSTER --- [-- CONVERSION BURNER COOK STOVE ti DIRECT VENT HEATER DRYER FIREPLACE r— FRYOLATOR FURNACE GENERATOR�- GRILLE INFRARED HEATER LABORATORY COCKS _ _ j�— MAKEUP AIR UNIT OVEN POOL HEATER ROOM/ SPACE HEATER ROOF TOP UNIT TEST _ UNIT EATER UNVENTED ROOM HEATER WAT' R HEATER 0TH.� J Q INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL. Ch.142 YES BfO 1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ® BOND OWNER'S INSURANCE WAIVER:1 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 hereby certify that all of the details and information I have submitted or entered regarding this application are true.and accurate to the t o m knowledge and that all plumbing work and installations performed under the permit issued for this application will be in .compliance wi 11 Peril r s' n of the Massachusetts State Plumbing Code -and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME LICENSE # 156! SI ATURE MP [a'MGF [3 JP [3 JGF E] LPGI ® CORPORATION PARTNERSHIP ®# LLC COMPANY NAME: ee gra Se2v t e� _ ADDRESS — CITY- STATE D FAX �� CELL �EMAIL � li all ,-f I Date.................................... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ..... E ............ ............... has permission to perform MEW 4�0".4?,S.ac ........... ��.t� .............. ................ .. .. wiring in the building of .... ............................... ........................................... at ...j.,1 .... !�� ....... Z?�� .......... .... North Andover, Mass. A ' . — Feed.. ...... 5 .. 79"ttic. No. ...... .. ......... . ......... .... ...... ............... ... ..... 4ECMCAL INSPECTOR V Check # 3 115 �O� lfl vre a ( use o* - �Qp+to.J�eviees 21TR J BOM? OF FIRE PREVE"ON REGULATIONSbImM l oe ' wat APPLICATION FOR PERNi1T To PER�aR�i ELECTRICAL WORK ANio bepp �tv �cCode{: 47 i2iltf (I'r.E9S9PRr!!fi-MAff ORTDT AU MaRMAnOM chy or TOVM HE _ I'144 By Ibis am&afig aeOmsafte ofhss arbar TQ 1hehwea6r Of WD -W. u (Iet & N�-J 2 2 d�G�4z �� m csz to i dm 0kc W workdarn'bed behm- ORvnes orTeuant �9'/�O�T 1�ih �-3- - ORae3'sAdds ; Telepmse No. Yes Propose of BtdldWg Dr//4L�X Ne Q APn to i3uz) Auhorbmiog Ho .yS�R Besting ser„3ee Amts t Yo#s Overhead Q Uadvd Q No_of Meters Nem Service 2ot7 ` _ � vow eh►dt� t—a Nuwher of Feeders aad An"aty iAt Undgrd Q fte. of Meh= Z- Lmmdoa and Nat m of ftgm ed Eledwieat Worm 6 ofHecesmd Lumhwim- '-" Ho.efC RWOOFans - .r me aeutAvra the r a Tota L OfLmnffiufm tiafies a.�HotTed�s "A . of _ POW KVA . of Reese Uati�sJ^J� of U3 Bi Bur== � ®fes 6d 1 of G= � a. of Zones ��uttedim me - ofRaeges sfAi cm&T y ofWaste Tomb of Iii Nig RW 0 (► Q € of Dryers HeaftgAFPBauces of wa-WiCW #iexters o. of KVY er eat - N- -- eveMOWN Wuim Hy ago Batu _ of itiio�us TOM up or t __ :�ValueofdW� fi3- ar-�ccre �tbyAwIac�reuorel�res 'WwktoStartbyI ►6e- pac=) N�C�}Y Ac :Ibnless m�ew�'ipneI�fgmdqm�,bgftm 1'fte �o�fiiabiiitpjw �cat�micmap�suennless und=i; tbta&isluI andiras �WVMWmtGgwjuoiiice. MkbuWW t. The CHECK UI�i 11+1SURAI+iCE BOMQ pTMR El . (S 3 , I cernJy mrdPr flreparte; �paf�'�F, �tt8e� att thu isirsre and FOM NAM [ i7 comphft &L t &T `& CArL C.vtiT t , Licemee: TAC NO.: i. Ea,r / C�4 Aim] i,IC NO.: sab�earat a-�Aieeiaaaae j=Etb3 _ Address: SaA4aw-l- Sr - yr -P, A< t3i iy'' B¢LTei.Nh,- lf—i$9.-6252- *Per hLG.L e; 141,& �t$i, sem vc �i .�, AIG Tom. lr[as 6- 3 7 -3'73 OWNRB'S IlYSE RAN(M WAIYM I , iuH3ruvc t� iib7LW. Ph covemar Ltmi�oneefirdbylw BYmYa bafawIgwaiveb. y _ Owner/Agent amte{chmknrl Sigatua Qovni ovns r t e%FhoaeNu. PF.RA TMW. •y t.1 - I'Ire Comnmtnweahh ofMaMachuse& DqmrhweWofIadasbiattAn!dtz& OA FW ofimWS L -a go as - 1 COAgMSS S Teets She 100 BosiM MA 0211 4-2 01 7 Print Fn7n-1 - `-` WWW.NzaS&g&V1Aff Workers' Compensation Insurance Mrhlaft IluMa s/ContractorsMIectn�f lumbers Angficant-Information Please Print Le�l"blf Name DAVID ELECTRICAL CONTRACTING LLC Address: 87 BEL.MONT ST C:jty/S p: MVK E t! ANIJtjVM !4 {)'itT45Phone � 97&682M Arra an employee. Check tbeapppropriate bma Type ofproject (requhw : 1-0 I am a em#byerwitir 7 4L 0 lama mal and I emphucm (lull an"rhave hired the zs 1 t% [] New comtracdion 20Iamasole ororpartuer- ship and have no employees wdddmg for me in any tidy_ jlr%wodW& comp_ i�mtaia�e req -j 3_0 Ismahomeownerdoi gau work [No WGdW& comp. -7 listed on the MUW s have employees and have wozlaze comp- insmamce.Z, 5_ 0 We apea, corpordfirm and its office rs have Wren their ofon per MGI. c_ 15Z §1(4) and webave no employees. tNo workers' 7- [❑ Rig s- 0 Demordion 9 nBadirigaddiffon 10-0 Electrical repairs oralditions 11-O PIumbing repairs or add ffons 120 Roofrepairs 13.0 Otker ` J a/'i•..wui runt •_^�� UOb�l miLSi aLSO rllt OQ[ UIC S�ilOfl bt$O1;I �lOWIDg $ICV �� IIti'- HOIRCOIVIICi$whQsubmitdlsWNdavit theymedoiMaUwmkmdamhModeconu=h=east Sabmrt8=w s rg&vit inch swr- {Canfrac�o6flintdiccI dfisboa=mtattachedanadd anal showingthewhetRertirnotE1toSeSEshave emplapers 1ftLesaiKWhaCh=haveemp10yeeS�#heymnstpaavidethea svoti®s CGmmp pohgrmimher d mor an employer LhatisPnvvidarg rrotlres' eno �� a forty' �.ygM Below is &epaKcy andJobsde informQtiooa Insurance Company Narver THE HARTFORD Policy # or self -ins- Lic. ##: 08 WEC C18293 n E) adon Dat .- MARCH 1.201If job Site Add,... 7-2—(%f 4,--> i',rt3►1Stabe/Zig: !o- 0<ap-5— 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 M(3L c.152 can had to lite imposition ofcrimind penalties of a fee UP to $1.500.00 audlor one-year irnprisonmeM as well as civil penabies in the farm of a STOP WORKORDER and a fine Of up to 5250.00 a day against the violator. Be advised ghat a copy of this statement may be forwarded to the Office of Investigations of the DIA for' verage verification - I ielrmeeord correct teased DarratwiiteinThismwa6tobecomWkted5yeLy6rtmua�uL City or Town: Authority (errdeonek PernMAcewe# L Board ofHealth 2 Seng Departraeut Cit yl%wn Clerk 4 Eka,.:.d r Ptembing Iaspecior 6- Other phase #-- rThis certifies that ............. has permission to perform plumbing in the buildings ofd. q-1-2 . ............ at ... North Andover, Mass. Fee .O.C).�a..Lic.NoWY.?5'. ......... ... PLUMBING INSPECTOR Check# P TYPE OR PRINT CLEARLY MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO. PERFORM PLUMBING WORK CITY o i Njlovf,2 _ _ MA DATE z$ 3 ( PERMIT# A9 ©�rk JOBSITE ADDRESS 22 ao OWNER'S NAME L S94Qi 'mmt3 OWNER ADDRESS Z 2 A U t°�A�u b_ TEL $i7 sjj�lQ jj FAX OCCUPANCY TYPE COMMERCIAL Q EDUCATIONAL Q NEW: [N RENOVATION: EO REPLACEMENT: M FIXTURES 7 FLOOR- BSM 1 BATHTUB _i CROSS CONNECTION DEVICE LZI DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM _...__ DEDICATED WATER RECYCLE SYSTEM DISHWASHER _I DRINKING FOUNTAIN —^ i FOOD DISPOSER [ FLOOR /AREA DRAIN INTERCEPTOR (INTERIOR)- INTERIOR)KITCHEN KITCHENSINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK _T_I TOILET URINAL j q WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER f! t f 2 1 3 1 4 1 5 1 6 1 7 RESIDENTIAL ►;Q PLANS SUBMITTED: YES EQ O M -I �MM om O M—M—r—rte I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES 19 NO M OF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY RM OTHER TYPE OF INDEMNITY Ej BOND 0 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 I hereby certify that all of the details and information I have submitted or entered regarding this ap and that all plumbing work and installations performed under the permit issued for this application IMlassachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAMEl�Ot�fi�T (='/L4— E LICENSE # _f q? -.S CHECK ONE ONLY: li/IP]`I JP �..i CORPORATION 0# i PARTNERSHIPQ#[ COMPANY NAME ,yt9.r? ®(,iJ/y1 Q�,(JG i ADDRESS �PD ,60 CITY �2�/ _ STATE ZIP D-jO3 TEL F�AX _ CELL i EMAIL L�r� OWNER AGENT 10 e tg4hb best of my knowledge P rti nt provision of the SI LLC 0 U W P4 0 El z 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 Leizibly Name (Business/Organization/Individual): 80,c PWA4S1.c,)6 Address: P O 160)l 69 y City/State/Zip: �)&nay IJ14 0303 Sea Phone #: 603 32S'- 80 - 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. IQ 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. 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.]r employees. [No workers' comp. insurance required.] Type of project (required): 6. New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 11.0 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' compensation policy information. I Homeowners who submit this affidavit indicating they a're doing all work and then hire outside contractors must submit a new affidavit indicating such. #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 thepolicy and job site information. Insurance Company Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one=year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up, to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi under the Vain and penalties of perjury that the information provided above is true and correct. 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 - 11 Contact Person: Phone #: . 11 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 ofhire,. express or implied, oral or written." An employer is defined as "an individual, partnership, association; corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to, be. an employer." MGL chapter 152; §25C(6) also states that `,`every state or local licensing _agency ;shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced -acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not.hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachv..setts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA. 0211 It Tel. # 61.7-727-4900 ext 406 or 1-877.7MASSAFE Revised 5-26-05 Fax # 61.7-727-7749 www-mass,govfdza c/ COMMONWEALTH OF MASSACHUSETTS • PLUMBERS AND GASFITTERS :. LICENSE.D AS A MASTER PLUMBER�t�� ISSUES THE ABOVE LICENSE TO: ROBERI" J FRAZIER PO BOX 694 1 U) DERRY NH 03038-0694 13425 05/01/14 240124 :COMMONWEALTH OF MASSACHUSETTS PLUM-BERS AND GASFITTERS LICENSED AS A JOURNEYMAN PLUP P ' , t 'ISSUES THE ABOVE LICENSE TO:`� ROBERT J FRAZIER F N PO BOX 69465 V DERRY NH 03038-0694 2099 05/01/14 240125' Fold, Then Detach Along All Perforations • Date �el� ! .. . • gsTLkU ' TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION .... This certifies that .. ......wt has permission for gas installation in the buildings of. ... I .........t.0y\-p S � �--C, at.. f ...............North Andover, Mass. Fee /N-' - . Lic. No. \.':��`? .. t1Y ................... .. . GASINSPECTOR Check # V\w MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FATTING WORK CITY North Andover MA DATE 6/6/13 PERMIT # JOBSITE ADDRESS 22 Upland St. OWNER'S NAME Seaport Homes LLC G PO Box 8225, Bradford MA 01835 OWNER ADDRESS TEL 508-509-4018 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL PRINT CLEARLY NEW - Z] RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES ® NO ❑ APPLIANCES 7 FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 V BOILER BOOSTER CONVERSION BURNER COOK STOVE 2 -� DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE 2 GENERATOR GRILLE g INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST - UNIT HEATER 'UNVENTED ROOM HEATER WATER HEATER 2 i OTHER INSURANCE COVERAGE 1 have liabili insurance its a current policy or 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 ® 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. ti CHECK ONE ONLY: OWNER ❑ AGENT ❑ s SIGNATURE OF OWNER OR AGENT t I hereby certify that all of the details and information I have submitted or entered regarding this application are true a d accur e , o t best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in pli wit II ent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. o PLUMBER-GASFITTER NAME Robert J. Frazier LICENSE #13425 A U E Cn MP ® MGF ❑ JP ❑ JGF ❑ LPGI ❑ CORPORATION ❑ # PARTNERSHIP # LLC ❑ # COMPANY NAME Bomar Plumbing & Heating ADDRESS PO Box 694 CITY Derry STATE NH zip 03038 TEL 603-325-8958 FAX CELL EMAIL Bob@BomarPH.com V\w y l 1 y 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): Bomar Plumbing & Heating Address: PO Box 694 /State/Zip: uerry, lvri ususrs Phone #: 603-32: 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. X❑ 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. [No workers' comp. insurance required.] 5 ❑ 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] f employees and have workers' comp. insurance.l 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.] i-8958 Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑X 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' compensation policy information. I 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: Liberty Mutual Fire Insurance Company Policy # or Self -ins. Lic. M WC2-31 S366059-022 Expiration Date: 22 -Apr -13 Job Site Address: 22 Upland St City/State/Zip: N Andover MA 01845 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 certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: 6/6/13 Phone #: 603-325-8958 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 #: 1 ' T -COMMONWEALTH OF MASSACHUSETTS PLUMBERS AND GASFITTERS LICENS.i=D AS A JOURNEYMAN. PLUS $,E ISSUES THE ABOVE LICENSE TO: �j RQBERT_J FRAZIER _ d F.O. BOX. 694 DERRY::, NH 0303.8-069..:. `:20499 05/01/14 240125` Fold, Then Detach Alorig All Perforations 4 .f 1� i 1 .0993.2 Date TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING Phis certifies that D0��- M. A ........ ,has permission to perform P -J CA plumbing in the buildings of.. ............. at ... 22.... � F. ,A,4 ......—5�� ... North Andover, Mass. Fee Lic. No. PLUMBING INSPECTOR Check 4 5--02-14 --6P �O— C3 cr-v, 2—t S- 1 13 \/ , �'w MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK U'r POWNER TYPE OR PRINT CLEARLY CITY North Andover MA DATE 5/8/13 PERMIT # —20 JOBSITE ADDRESS 22 Upland St. OWNER'S NAME Seaport Homes LLC ADDRESS PO Box 8225, Bradford MA 01835 TEL 508-509-4018 FAX OCCUPANCY TYPE COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL NEW: ® RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES ® NO ❑ FIXTURES 7 FLOOR— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB 2 CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER 2 DRINKING FOUNTAIN FOOD DISPOSER FLOOR/ AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK 2 LAVATORY 2 2 ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET 2 2 URINAL WASHING MACHINE CONNECTION 2 WATER HEATER ALL TYPES 2 WATER PIPING 2 OTHER Sillcock 4 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 CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING 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 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 application are true an accura to the best f my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in comp 'an with e n nt pro ision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME Robert J. Frazier LICENSE # 13425 MP ® JP ❑ CORPORATION ❑ # PARTNERSHIP ❑ # LLC ❑ # COMPANY NAME Bomar Plumbing & Heating ADDRESS PO Box 694 CITY Derry STATE NH ZIP 03038 TEL 603-325-8958 FAX CELL EMAIL -Bob@BomarPH.com A" \/ , �'w OOMMONWEALtH OF MASSACHUSETTS Date ..... .�"......�r.:...Z.3.... TOWN OF NORTH ANDOVER PERMIT FOR WIRING I . JD �ilf �/ol�G.................. This certifies that......................:.........��...:.....L=--...:........ has permission to perform .........1 �✓f'I J Se -If - G .................. wiring in the building of......:..........................71/5.................................... .......... set ....... Z...... ��G:. : ..... ............................ > North Andover, Mass. Fee..`r`r'�",'..... Lic. No. � C� . ................. .. ...................... ................. LECIRICALINSPEL-TOR Check, 1515 ------------ 0 Um �Ue�re�� JiRriae� Fetm�tNo. 6' � BOARD OF FIRE PREVE"()N REGULA-ilONS � and Fee Necked ftm blakJ APPLICATION FOR PERMIT TO PERFORIN ELECTRICAL WORK Aid work to lm in accm mm � mem cone {td W CMR 12.W {PLMWPRMTM,MW OR 27PBAUWgM.WO mate: City or Tota of By this ctnthe kion tc pe& TO m� T of doss: i:md9B ( &rr�•; 22 4,1 ' �cb 5 a d o . OwnerorTenant �jxj,C}�T I-�.��5 Telephoee No. (3wner's Address - h thb Permit in svnjwaetion wlth aperum-&-Yes No ❑ (Check Appropriate Boz) Purposeor Bn�g l�%�Lr/ �a.�,,iT�2JCTi�-I - .QJAcc•a' UiBit9 Auibori�#ion No.`+� Ezisting Service Amps ! Ynks ----.__ 0Vfthettd❑ Undgrd❑ No- ofMeters New SService .Amps I VOHS Overhead ❑ Und Number of Feeders and Arapscity Q Ro. of Meters Location and Nature of Proposed Electrical Work: No. ofBecessed Ltrminait-es - ---- - o...—....,G , No. ofCCiL-Susi (pie) Fms - o. of . BONA= und— No. of Luzahmim outlets orams KVA o. ofHotTubs fors KVA Na. of Lsmippong- - Poal . ❑RrXHL o. � Ban Units No. of Rent de ooh of OB Deers ALAS e. of Zones No. ofd No. of Gas Burgers o. a� No. of Ranges No. of Air Coad. Tons 1L OfAbx tg Devhm No. of Waste Di$posess Z•omM I - - No. of Dishwashers Devices No. of Dryers - Heating HW Q C4 ❑Other � °. of Watero. of ICW mar �or hment Heaters KW Ballet Data No. ofDeviees or Equivalent No. Hydromassage Batitfoias Na- of motors Total HP Devices r uiv ! No: aEi'Devi�es or t OTMM:Affod Estitmtmd Value of Chitaslt Work ad�lfond dmd1 d� arastegeaed by the Iaspeuor of t�t„es i bymunicipal po�3=i Waak to Start Vons to be icquested iu wigt MEC Rok 1% and upon completion. INSURA71fClECOYSRAM, Wawdbydmomm. art �itinr#ba og{ wank may issue unless the its Pmyic�spmofofT�ity- Or its sulastantiet t. The undersigned smdz ecsveaage is is fid, anti has paiaofafsa c fa thepertnit issoiog oEiice CHECK ONE- MURANCE 5h BOND ❑ (Yl [❑ (Spear) icertify, ler the peimmdpeeawofpgrjku7, lhatfhea farmmaom art dd, and comptdf FIRM NAPAIlk i a eL ficriTz CAL !PL + 4c r.Q& lets TAC iiia_ Licensee: 10A:t.t? MA f. b. r sure G NO,,� �►b � Afgp em- `tv&.-rrameeaarGPitmej "' Address: _/3`1 0CLVWAWrT �sr 1yi7�t[�',`(N79L'Yc-� tom, tjj Bas.TeLNo.``i7r� *Per hLG-L. c. I47, s. 57-51, sect�y Vm* nequees Ih�# afFubfic �• AIL Td. Na:c i6- T 3 x'73 f �Y Lia No. OWNER'S INSURANCE WAIVEW I ern mWW &A do I kensm does iWkam Me OwaerJAgent yrequired bylaw. By mysit�turzbelow,Iherebywaivethis - Iacthe (�eg am Q owner Q owner's t Sfgnature Tekphoae No. �! ` j , � e J;-jty/S ip: 1MUK E li AN#JUYi:K ti_ 01845 phos #. 978-682-6262 Areyoa an empioyer*! ( the apprqpriaft be= Type of P (requked): 1.0 Iama employ iffi 7 4� ❑ Iamageneral audI €funendfarpar"mer 2.0 I3maso1epmpsdewrorpa nw_ ship and have ao employees wbdft fWmein any cqwky. [No vvodm& comp- -I = 3-0I21mah d aff vvo& mYsdE (No wedw& comp- e, Dave hived the =s rMWd enthe s i�esah-�actmsha�ne employees and have m dme comp- .3 s Q Weareacaponifionand its oWmershaveexammedthew riebt oEexmiption Per mm c- tsz, §l(4). and we have no soyas- [No mss' CoInp- inISUFRUCC reeemed_7 6 ❑ New sanction 7- ❑ Remodeling a- Q Demortian 9 Q $UH&Mgaddition I0-0 Elechicd ams or additions 11-0 Plumbing repaEs or additions 120 Roofrepaks. 13-0 Outer 8ffidavft t±►c+E. �tt�,lae&atffil s 1F_� rher ofrhe or,mt�een haw empIoy�fty - cP`i-tom + I am as enrloy4razatisPssvv gWWW Sy coon celormy employ, is tyre information pOKCy andjob Inswance Company Name: THE HARTFORD, Policy # or Self Lic. #_ 08WE G C18293 Expitudon DatMARCH 1, 201> e: lob Site Mdre= _ 22 (A4A D $T' CrtylStateJZip: {2"i� -/tel Pte' y1 ��Ci S� S� Attach a copy of the workers$ aompeosadon policy dedatation page (showmg the PAY number and expiration date). Failure to secure coverage as required ander Section 25A ofNIQ. c I52 can lead to The imposition of crimbnaj pena ies of a fine up to SI,500_oo an&or one -Year imprism"nalt as weft as civ& Peres in the form of a S"POp WORK ORDER and a fine Of up to V50AO aday agamsttfte violater. Be advised tim a copy ofthis statement may be fbmwded to tate Offaof Iavwtkatioas of the DIA for insara;lec'over�4 verri' cation. provided above Is Mw and cwraert Phone # V F dWeo� Dnmrtwridziathaarra,�lAe j��arrtarvao�t CRY orTmm: Authority(dmjcone): I'ermwLicense # LBow of Bedth Z 3. CHyfrown Cferk 4. Electrical Iesp�ns S numbing i qmj r Cope: Phone #_ The Conmmrtwealth of Hanaehuseits Pdnt Form � gaiionr - 1 QW43SS&M%ShiteIN Bost^ K4 02114-2.017 Workers' ComPmaGm inswumm Affidavk BW1dMWC9nUU06rsWedrkimWP1nmbers Amficoat Informafien Please Print i W -W Name (BuSMeW0rg+animti0nMdividu0): DAVID ELECTRICAL CONIRAC7! iNG LLC Address: 87 BELMONT ST J;-jty/S ip: 1MUK E li AN#JUYi:K ti_ 01845 phos #. 978-682-6262 Areyoa an empioyer*! ( the apprqpriaft be= Type of P (requked): 1.0 Iama employ iffi 7 4� ❑ Iamageneral audI €funendfarpar"mer 2.0 I3maso1epmpsdewrorpa nw_ ship and have ao employees wbdft fWmein any cqwky. [No vvodm& comp- -I = 3-0I21mah d aff vvo& mYsdE (No wedw& comp- e, Dave hived the =s rMWd enthe s i�esah-�actmsha�ne employees and have m dme comp- .3 s Q Weareacaponifionand its oWmershaveexammedthew riebt oEexmiption Per mm c- tsz, §l(4). and we have no soyas- [No mss' CoInp- inISUFRUCC reeemed_7 6 ❑ New sanction 7- ❑ Remodeling a- Q Demortian 9 Q $UH&Mgaddition I0-0 Elechicd ams or additions 11-0 Plumbing repaEs or additions 120 Roofrepaks. 13-0 Outer 8ffidavft t±►c+E. �tt�,lae&atffil s 1F_� rher ofrhe or,mt�een haw empIoy�fty - cP`i-tom + I am as enrloy4razatisPssvv gWWW Sy coon celormy employ, is tyre information pOKCy andjob Inswance Company Name: THE HARTFORD, Policy # or Self Lic. #_ 08WE G C18293 Expitudon DatMARCH 1, 201> e: lob Site Mdre= _ 22 (A4A D $T' CrtylStateJZip: {2"i� -/tel Pte' y1 ��Ci S� S� Attach a copy of the workers$ aompeosadon policy dedatation page (showmg the PAY number and expiration date). Failure to secure coverage as required ander Section 25A ofNIQ. c I52 can lead to The imposition of crimbnaj pena ies of a fine up to SI,500_oo an&or one -Year imprism"nalt as weft as civ& Peres in the form of a S"POp WORK ORDER and a fine Of up to V50AO aday agamsttfte violater. Be advised tim a copy ofthis statement may be fbmwded to tate Offaof Iavwtkatioas of the DIA for insara;lec'over�4 verri' cation. provided above Is Mw and cwraert Phone # V F dWeo� Dnmrtwridziathaarra,�lAe j��arrtarvao�t CRY orTmm: Authority(dmjcone): I'ermwLicense # LBow of Bedth Z 3. CHyfrown Cferk 4. Electrical Iesp�ns S numbing i qmj r Cope: Phone #_ 207 Date I ... 41;- ........ NORTM TOWN OF NORTH ANDOVER pF .ao ,n1ti0 p� PERMIT FOR MECHANICAL INSTALLATION 0-4 9 This certifies that ........................ � has permission for mechanical installation -- .... ... ............. . in the buildings of . S ...` ... .................... . I at Z 2pi S - .. � �, North Andover, Mass, Fee. a. .. Lic. No .... ti .................... GAS INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer Commonwealth of Massachusetts Sheet fetal I CUL EUMIL Date: Permit 4 Estimated Job Cost: $ 710 0 t3 eL�(,W,0 j -O+) Permit Fee: $ &A, Plans Submitted: YES — NO Plans Reviewed: YES— NO Business License # Applicant License # Business Information: Property Owner /Job Location Information: Name: of Name: S:AA eat 40 v -L 5 A Street: Street: )-J+ ILL A aPc City/Town: —zZj C ity/Town: T cleplione: ��}��S' s (- `-(.4 03 Telephone: Photo LD, required Copy of Photo 1,D1, attached: YES NO Staff 1111thil (J-1 M -1 -unrestricted licensee J-2 M -2 -restricted to dwellings. 3-stori I 's or less and commercial LIP to 1.0,000 sq, ft. 2 -stories or less Residential: 1-2 family Multi - Condo Townhouses Other Commercial: Office Retail Industrial Educational Institutil`al Other Square Footage: Linder 10,000 sq. ft. ��over 10,000 sq. ft. Number of Stories: C'� Sheet metal work to be completed: New Work: Renovation: HVAC Metal Watershed Roofing_ Kitchen Exhaust System Metal Chimney/ Vents Air Balancing Provide detailed description of work to bt, done: 1 0 L � C Vj (logy Dep ai*Pill, I? Y vqAdYdsi'r I jI Ac6tl"6)ft I ,.ri• �fi�;�ll�ti• �.iJ�lce r��''.,Yalveydl�r�r'rorts „ 60 b1��r.slaiyr,�z'o>'i>�'ireez' WOH(brs' Compens�ition Znsur�� ce A'ftl�lwit. Bui]clotl's/corltxncto s/7 lect.iicilns/1'irzm�ez,, cent LkLO >crxnonPlease Print X,eLnl I I Nance (F�usiness/0 rganiantion/Individual); "t I 1 SI n'c cldress, S .S .S i City/State/Zip;' tw_� IVA Ulelll Are you an employer? Check the ,ipprop.rinte box; I r- � I '; ' �Typ©ofprojcct(rcryttirod); am a employer with � 4.0 1 am a general conb-nctol and I I employees full and/or art time .* llav:e hiiecl fht sub contractors' "6 New construction ( p ) 2. ❑ I am a sole proprietor or partner- listed on the attacl 8d,'sh'eet• ;+7• ❑ Remodeling ship and have iio employees The lse sul)-contractors have ❑ Demolition I working for me in any capacity, emi?loyees and have workers' com insurance:t„ ❑ 131ulciing addition (No workers' comp. insurance P required.] 5, ❑ {i/elare a corporation <nd its 10.❑ Elacirical repairs or additions 3, ❑ 1 am a homeowner doing all work officers have exercised'theil' is 11,❑ I'liunbing repairs or additions myself. [No workers' comp• right of exemption',p'er,MOL L l2•[] Roofi,epairs insurance required•] .t C. 152, § 1(4) and we h.live no ,t i, employees. [No workers' 13•[l� Othel�i�`i�f�C comp, insuranceteihiired] ;, 11.: "Any nPPI icn(it Ihnt chccks box til must nlso fill out 1116 sccllon below showing lhclr wnrlirrs';compcnsnIIon' PI) llay rnforrnnllon ' t Homeowners whn submit this nrtidnvit incllcnting they me doing All work find then hire outside cnntrenlors must ubinit n new fiftidnvit indlonting such. 'fCOntrnCtOrS Ihnf eI1CCl: thl9 box 1I1115t nllfiCllCd Ila I1d(IIlI0n111 SIICL't SIIOWIng the nnnle Orthe SIII)-Conlrfictor9 filld !;Inle wllerlior or not tlloso'Cntitic3llllve cmployccs. If flee sub-conlrnotors Itnve employees, Illcy musl prnvirle their, worknrs':comn. policy nliinbrT r, X. aryl an ewnployer• /hat !r provtrling worlrem' Millmnstrtlrrt 1rl.clar'alsre for. aty erolploycrIs,; J3e1att,, thelpoltcy an1ljob stta' I� Insurance Company Name; �� �'�1255 ;: t lI ,I; J C'olicy It or St1'f-ins. Li,c, 11: Bxpllation.Dale 11 a�Job Site Adcl.ress; Ciiy!`�tntc/lip: ! A ttrtrla a' copy of the worlte'a s' comp8nsntioln policy declsa'rkl6n page (shoWiIiLy th6 yioltcy Ygnllibexplra lon Mite), Failure to secure coverage as required under Section 25A oaf tv(CL, c• 152'celiflpad to the'Jmposthot'of"criminal, penalties of a fine up to 61,500.00 and/or one-year imprisonment, as well'as Civilpenaltles to the fotm'ot a ST01',;CX/ORIC';ORD$R anrl'aFine; . oi'Lip to $250.00 s day against the violator. Be advised thatln copy of t}us slniernent may, be fol arclec1 to the OfCCe of nves'tigat,ions of the DIA for:ins Trance coverage verlilcation,f; l r If" l , I.;, { 1 { ,� I,lu I;' 410 lier'eby cer'- I I *] W,der IP'Pailu anrlpenaltles ofperjilry .. 1.. 1. ::t:;:= tlrni the iuforrri<r>ln . pros%Irlerl d- j. !s,'itrue ant! correct, - _it U9P at a i —Ur , , 0fflClal Ilse only, bo not iurlte 1n this area, to be eotnp�eletlll�y city nr{toivyr' of clalIS' `I {,' City or Town: ; I I' �Crmlt/.LlCcn5('!1 , Zsstaing Autltorii� (circle o"n c) �;' I ,;,: i t �!1 l� 1 Board of Y=lcnitli 2, X3ttildtng ncpnrtmcnt 3, City/Town Cinrlc l i lectt'icnl7>1Yspcctot ; InhnbIng.Ynspcctor I'"III 6, Other ', lfi' =1' Contact 1?crson; if t l Client#: 53676 HILLISFRAN2 ACORD,. CERTIFICATE bF LIABILITY' INSURANCE DATE(MM/DDNYYY) 10/11/2012 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 NOf 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 I HUB International New England 299 Ballardvale St Wilmington, MA 01887 NAME: C7 nee certificates_@hubinternatio PHONE 978 657-5100 rFA a6G-475-7959 t�c,No EXI): rA/c Ne): EMAIL ADDRESS• 06/30/2012L executed contractPERSONAL 978 657-5100 INSURERS AFFORDING COVERAGE NAIC N INSURER A: Peerless Insurance Co 24198 INSURED I Hillis Corp INSURER 8: Atlantic Charter 44326 , INSURER c: DBA Frank's Heating Service INSURER D GEN'L AGGREGATE LIMIT MPLIES PER: POLICY ^I JECI LOC 555 Woburn St INSURER E: Tewksbury, MA 01876 INSURER F: AUTOMOBILE X — X I 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 ADOL SUER ---I { POLICYEFF; POLICY EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER __ jMW0gNYYY) MM/DD/YYYY LIMITS A GENERAL X X LIABILITY COMMERCIAL GENERAL LIABILITY CLAIMS -MADE n OCCUR Blnkt Add Ins: Prod/ X X CBP1059734 COmpi Ops:as per 06/30/2012L executed contractPERSONAL EACCHp�OEC7CU_RRENCE $1,000,000 RPEMISES a occlu� ore)_ $ 300,000 MED EXP (Any one person) $5 000 &ADV INJURY $11000,000 GENERAL AGGREGATE $2OOOOOO GEN'L AGGREGATE LIMIT MPLIES PER: POLICY ^I JECI LOC PRODUCTS - COMP/OP AGG s2,000,000 $ A AUTOMOBILE X — X LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS HIREDAUTOS X NON•OWNED AUTOS X BA'1059'735 !A 06/30/2012 06/30/201 ' ) - COMBINED SINGLE LIMIT fEaaccidenq 81,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per eccldent) $ PROPERTY DAMAGE 1Per arcident) — $ A X UMBRELLA LLA EXCESS LIAR X OCCUR CLAIMS -MADE X CU8917751 -'. I 06/30/2012 �t 06/30/201 .� �:AGGREGATE$3 EACH OCCURRENCE $3,000 000 000 000 _ DED X RETENTION$10000 $ B 1 WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N OFFICER/MEMBER EXCLUDED? � (Mendatary In NH) - If yes, describe under DESCRIPTION OF OPERATIONS below N / A WCA00514205 I I `. 06130/2012 06130/201FE.L.EACH �i ..— '.I �' TATII OTI I• Y LIMITS FR ACCIDENT $500 OOO ASE- EA EMPLOYEE $5OOOOO ASE- POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, It more space Is required) I: UMM I Wlt,/k I t NUILLILIN CANCELLATION SHOUL"D ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE: EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN iIi ACCORDANCE WITH I THE POLICY PROVISIONS. I AUTHORIZED REPRESENTATIVE i ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 252010/05 ( ) 1 of 1 The ACORD name and logo are registered marks of ACORD, ' 4SB06316IM745169 I DK004 Yes Sheet Metal Residential Guidelines / Inspection Checklist No N/A Detailed description and sketch of sheet metal system to be installed has been provided All workers performing sheet metal work onsite has valid Massachusetts sheet metal license All sheet metal work being performed with proper joumeyperson-to- apprentice ratios Equipment sized per heating / cooling load calculations Duct work sized per manual "i" calculations Bath / shower rooms contain mechanical exhaust fan vented outdoors Electric dryer exhaust properly installed maximum total run 35'-0", maximum flexible run 8'-0" Flexible duct runs installed 14'-0" maximum length Volume dampers installed for each supply air branch duct Ductwork installed using proper gauges and hangers Ductwork / plenum connections sealed substantially airtight . Ductwork insulated by means of external covering or internal lining New/clean - properly sized filter installed (final inspection) Testing and Balancing report complete (final sign-ofo Sheet Metal Commercial Guidelines / Life Safety / Critical Systems Inspection Checklist Yes No N/A, Set of stamped engineering documents and detailed description of mechanical system to be installed has been provided All workers performing sheet metal work onsite has valid Massachusetts sheet metal license All sheet metal work being performed with proper joumeyperson-to-apprentice ratios Fire dampers with access door properly installed and checked for operation Smoke and combination fire / smoke dampers with access doors properly installed - actuator checked for proper operation (May also be verified by fire department during fire alarm testing) Duct smoke detectors with access doors properly located (May also be verified by fire department during fire alarm testing) Smoke / atrium exhaust systems installed and operation verified (May also be verified by fire department during fire alarm testing) Stair pressurization systems -installed (where required) and operation verified (May also be verified by fire department during fire alarm testing) Grease / kitchen hood exhaust system installed with all seams and connections welded airtight with properly located cleanouts. Proper ole &ances, fire rated enclosures and pressure testing required: Sei u:?i es;;:arnts install .d -.xrli :{r ri✓quired 'on egtiipment and d1=_: tv. are. _ — Duct -penetrations in fire'tatc&l~tx!all:r and floors sealed Metal roofing systems installed watertight using proper materials and fasteners Flexible duct nuns installed 6'-0" maximum length Ductwork installed using proper hanger spacing, hanger stock, threaded rod and angle iron Ductwork / plenum connections sealed substantially airtight Ductwork insulated by means.of external covering or internal lining Volume dampers installed for each supply air branch duct New/clean - properly sized filters installed (final inspection) Testing and Balancing report complete (final sign -off) F; m I .Q E E CN _0 14.1 sr CD Ali 44" Xj, j Cu CY) NAW k mftv% it 1; CD IT U) .Q E E CN _0 sr CD I US oma. U co 'r7: ' r ' dc' 4— U CIO tf j -V , ,r V <—f Nr- co r x U s 00 I X U A ;4 2 -1 z Load Short Form Job: , /,. Date: Mar 14, 2013 Entire House By: mfli HEATING SERVICE Franks Heating Service 555 Woburn S1, Tewksbury, MA 01878 Phone: 978-851-4403 F.'M 978-851-0398 For: 22 upland st north andover ma duplex Aii Joi51 iiIX i Make -,�.Iiiva Trode Clg load Htg AVF ill Htg C1g Infiltration (Btuh) Outside db -F) (cfm) 88 Simplified 17418 Inside db ("IF) D (IF ) 70 75 !.1, 13 Co'nstructib 6! qublity Tight Pi�bplaces 1390 B Daily -ran ge 14151 M 1 (Tight) Btuh Inside hu 'cl— rn I Ity, N Moist&6:dI#erehce 30 50 0 Btuh (gr/Ib)`28 N 28 ta 0 Btuh "[W 5A G EQUIPMENT' fj "RYWIMARMWO -OOLING EQUIPMENT A Aii Joi51 iiIX i Make -,�.Iiiva Trode Clg load Htg AVF ill ti, Cond (Btuh) (Btuh) (cfm) (cfm) Coil 1437 17418 -11. -'I 4t n/a: AHRI ref Efficiency 1390 rI,WiEfficien6y,� ,�, 0" 1 1 - 1WHeating 14151 Sensible cooling n/a 0 Btuh Heating output: 0 Btuh Latent cooling 0 Btuh 2? Temperature rise 0 :PF Total cooling 0 Btuh Actual air flow,;, •;. 0 cfm Actual air flow, 0 cfm �.P;'Air flo,,k factor . I., ..j, 1�-'�Static pressure 4-r- : ..P O;bfm/Btuli 0in; H2O Airflow factor,, 0 cfm/Btuh Space thermostat: n/a Static pressure Load sensib[Oi heat ratio 0 0 in H2O ROOM NAME Area Htg load Clg load Htg AVF C1g AVF (ft") (Btuh) (Btuh) (cfm) (cfm) unit b d unit a d 1437 17418 15803 807 807 1390 16338 14151 807 807 Entire House d Other equip loads 282.7. 33756 26734. 1614 1614- [Zquip. @ 1.00 RSM 9817 1849 Latent cooling TOTALS 787 A MZ 7a Iv I -t IV 114 Calculations approved by ACCA lo meet all requirements of Manual J 8th Ed Rlgllt-SLilteOLInIvemil2Oi2i2.l.o7lR$LjlooC,2 I ei, �11 a'Adaver mn duplex 2 n. r u p C.11C = MJ 8 Front Door face 9: N 0111�...'H g�'j q.j. V 2013 -May -18 14:22!09 Page I 7 Iv I -t IV 114 Calculations approved by ACCA lo meet all requirements of Manual J 8th Ed Rlgllt-SLilteOLInIvemil2Oi2i2.l.o7lR$LjlooC,2 I ei, �11 a'Adaver mn duplex 2 n. r u p C.11C = MJ 8 Front Door face 9: N 0111�...'H g�'j q.j. V 2013 -May -18 14:22!09 Page I HEATING SERVICE Load Sholl''brm unit a Franks Heating Service 55CN Woburn SI, Tewksbury, Mn 01078 Phonr.; 970.001.4403 Fax: 07e -a51-0398 m m m � For: 22 upland st north andover ma duplex Job: Date: Mar 14, 2013 13y: mfh `hi;;, '' IIG EQUIPMENT j�t¢r. f^lt ;" All; �I •"p�t��p�� ;,al ., 'h.ke Outside db (°F) Htg 1 Clg Infiltration 88 Method Simplified Inside db (°F) Design TD (°F) 70 69 75 Construction quality Tight 13 Fireplaces 1 (Tight) Baily range - M Inside humidity (%) 30 50 Moisture difference (gr/Ib) Vi 28 28 `hi;;, '' IIG EQUIPMENT j�t¢r. f^lt ;" All; �I •"p�t��p�� ;,al ., 'h.ke :i'P'!i'il� `i'4ti�' Ti` iStandard Trade ta'U'LD XI Model AUH1B040A9HZ1A" AHRI ref 4988790 Efficiency Heating input Heating output Temperature rise Actual air flow Air flow factor Static pressure Space thermostat 95 AFUE Area 40000 MBtUh 38000 Stull 43 OF 807 cfm 0,049 cfm/Btuh 0 in H2O LL"COOLING EQUIPMENT Make American Standard Trade ALLEGIANCE 13 Cond 4A7A3024G1 Coil 4TXCB025SC3 AHRI ref 5595572_ Efficiency 11.5 F_F_R, 13 SEER Area Sensible cooling 19360 Stull Latent cooling 4840 Btuh Total cooling 24200 Stull Actual air flow 807 cfm Air flow factor 0.057 cfm/Btuh Static pressure 0 in H2O Load sensible heat ratio 0.85 141 ROOM NAME_ Area I-Itg load Clg load Htg AVF Clg AVF (ft2) (Stuh) (Stull) (cfm) (cfm) kits liva 257 2458~ 2299 121 131 lava 224 2.849 3160 141 180 FOY$ 72 143 949 2381 72.6 1464 47 118 41 84 bedla 132 1722 1334 85 76 bed2a 112 1486 1 799 73 46 batha 95 1459 1234 72 70 masa 249 3034 3134 150 179 hall a 1 nR n A Calculations approved by ACCA to meet all requirements of Manual J 8th Ed. wri htsoll"t" 2,013 -may -1s 1a:22:oe g Right-Sulte� Unlver:al 2012 12.1.07 RgU10002 AI JCA ,,,102 upland at north indovor ma duplex 2zn.rup C:+to = MJe Front Door f lms: N Page 2 V Unita d 1390 16338 14151 807 807 Other equip loads 4953 933 Equlp, @ 1.00 RSM 15084 Latent cooling 2693 TOTALS 11an 4'7'7'7'7 Calculations approved by ACCA to meet all requirements of Manual J 8th Ed. � wr1 htsOf� g g RI ht-Sulte4nUnivr,,rse1201217.,1,07RoU10002 2013-May-1014:22:00 /tiVh ...t122 Uplend st north Andover me duplex 2zn.rup Calc = ma From Door faces: N page 3 22 upland st north andover ma duplex Heating input Heating output Temperature rise Actual air flow Air flow factor Static pressure Space thermostat 40000 HEATING EQUIPMENT Make American Standard Trade i•: Outside db (°F) Htg 1 Clg '; {10,,;88 "'s.. Infiltration Method ;�; ° .,,,n,l;r:. Simplified 0 Inside db ('F) 70 r,';1,1i,75 Construction>t�`.U211ty Tight Air flow factor Design TD (°F) 69 r�';Ik'" 13 Fireplaces"'1 (Tight) I?' in H2O Baily range _ M bed1b 68 154 Inside humidity (%) 30 50 42 95 bed2b Moisture difference (gr/lb) 28 28 60 Heating input Heating output Temperature rise Actual air flow Air flow factor Static pressure Space thermostat 40000 HEATING EQUIPMENT Make American Standard Trade GOLD XI Model AUH16040A9H21A° AHRI ref 49887J`0 0 in H2O Efficiency ""'":'(!' 95 AFUE Heating input Heating output Temperature rise Actual air flow Air flow factor Static pressure Space thermostat 40000 MBtuh 38000 Btuh 43 OF 807 cfm 0.046 cfm/Btuh 0 in H2O COOLING EQUIPMENT Make American Standard Trade ALLEGIANCE_ 13 Cond 4A7A3024G1 Coil 4TXCB025BC3 AHRI ref 5595572 Efficiency 11.5 EER, 13 SEER Htg load (Stuh) Sensible cooling 19360 Stuh Latent cooling 4840 Btuh Total cooling 24200 Btuh Actual air flow 807 cfm Air flow factor 0.058 cfm/Btuh Static pressure 0 in H2O Load sensible heat ratio 0.84 76 ROOM NAME Area (ft2) Htg load (Stuh) Clg load (Btuh) Htg A\/F (cfm) Clg AVF (cfm) livb kitb 203 2929 2728 136 159 2.94 2517 '" "'2862 117 167 foyb lavb 154 2.672 1300 124 76 bed1b 68 154 832 2380 723 1624 39 110 42 95 bed2b 154 1293 1270 60 74 masb 210 1871 1980 87 116 hallb 143 2052 102.1 95 60 bathb 5R a7) Inc Calculations approved by ACCA to meet all requirements of Manual J 8th Ed. 1 + wri htSOft'^ 2013 -May -18 14;22:08 ,�- g RIyh1-SuIIeQD Unlvrrsal 2012 •12.1.07 RSU1oo02 /it.a,,,i`P.2 upland at norlli nndo�oor ma duplox 2zn.rup Calr, = MJ8 Front r)oor f.-jcos: N Pepe 4 unit b 1 1411 17411 13803 807 807 Other equip loads 4863 916 Equip. @ 1.00 RSM 14719 Latent cooling 2701 TOTAI.(!, 4A'2-7 Calculations approved to meet all wriightscft, .Ounlverssml2 12.1.07RSL]10062 ACCk ...1122 upland at norm -I)ndovrr mm duplex 2znnip Cole - MJB T--fnnI Door focea: 14 �,'i'of Manual J 8th Ed. 2013 -May -18 14:22!00 P-agr 5 L0 V tT 5 LOCUS PLAN SCALE: 1'-sw m m I NJF DA16EL 4 k LADEN Z M. NOONE GEORGE 8 DIANE ROBERTSON AND EI K: S. h JESS" AL ERS RIF C N/f �. USE L KRAKNEROAARD 115E 1. NNZVOAMD 5' MADE DRIVEWAY EASEMENT. SPIKE ( Z �. J RR SPKE(SEl) 5 . WE DMVEWAY EASEMENT (SET) ... / RR 5PKE(SET) — — 160.39• N079W0O — - r '. D WT B � 1 .... 2 PAIBGNO g 8.097 S.F. MA AEZ aDCOSMC 1{ EAS11NG OARADE i PROPOSEDLUNQ 2_FAMILY # 70.6' LD7 B I �' OWE ( �( KENIA BAEZ 8.097 S.F. . s. 4. 4. ""a on rENCE (SET 2 PARI@W SPACES 183.'1: f4NCE . (SES) AIL(FND.) ...163.18 OG'E iENCE ONSET) NJF DA16EL 4 k LADEN Z M. NOONE GEORGE 8 DIANE ROBERTSON AND EI K: S. h JESS" AL ERS 0 NG BUILDINGS FIRST FLOOR — 990 S.F. SECOND FLOOR — 990 S.F. GARAGE — 1,104 S.F. TOTAL 3,084 S.F. uNRECDNDW PMN 'HICH.AND UK" STS, NORTH• ANDOVER. MASS DATED APRIL 1% 1957. OMW BY LEO COPPETA ET AL RALPH 8. BRAS". ENGINEER' PLANS ON PK£ AT* THE ESSEX COMITY REGISTRY GP O FDS. NORTHERN Do T. 1).. PUN 0321L 2). PLAN 12& 31 PLAN 1357.. P P 1 NG FIRST FLOOR — 1.500 S•F. SECOND FLOOR — 1,500 S.F. TOTAL 3.ODO S.F. t I HEREBY CERTIFY THAT THEPROPERTY LINES SHOWN ON THIS PLAN ARE THE LINES OF EXISTING OWNERSHIPS AND THE LODES OF THE STREETS AND WAYS SHOMM ARE THOSE OF PUBLIC OR PRIVATE STREETS OR WAYS ALREADY ESTABLISHED, AND THAT NO NEW ONES FOR EX!STINO OWNERSHIP OR FOR NEW WAYS ARE SHOWN. AND THAT THIS PLAN CONFORMS TO THE RULES AND REGULATIONS OF THE REGISTERS OF DEEDS OF MASSACHUSEM, SURVEYOR ss�LriD.. R- LAND LAND rC L b t`h"-�wOMev�Hfr�s1 N 81Y11��[� RECORD OWNER A NAR11H AN)OWER MASS ASSESSORS MAP 67. LOT 69 TIM DOW 8818, PAGE 215 PLAN SHOWING PROPOSED BUILDING 22 UPLAND STREET NORTH ANDOVER, MASS. PREPARED FOR: FREDERICK COPPETTA DATE: FEBRUARY 14, 2012 SCALE: 1'=2d e a N� 9nsuitants o nc. 7 1 East River Plate Peter 0. Goodwin . Methuen, Maas. 01844 Reg. Prof. Land Surveyor 0 20 40 60 60 Ft. msam0 10 20 Mater RIF { �. USE L KRAKNEROAARD SPIKE 5 . WE DMVEWAY EASEMENT (SET) ... / RR 5PKE(SET) — — 160.39• N079W0O — _ — .... 2 PAIBGNO 1 PROPOSEDLUNQ 2_FAMILY N/F LD7 B I �' OWE ( �( KENIA BAEZ 8.097 S.F. . 2 PARI@W SPACES ...163.18 OG'E iENCE ONSET) iy710E . .SET) AIL(FNO.) � M/F JJFF t4SE M. "COME GEORGE R DIANE ROBERTSON DANIEL J. d AND ERIC S. s JESSICA M. ERB .. 0 NG BUILDINGS FIRST FLOOR — 990 S.F. SECOND FLOOR — 990 S.F. GARAGE — 1,104 S.F. TOTAL 3,084 S.F. uNRECDNDW PMN 'HICH.AND UK" STS, NORTH• ANDOVER. MASS DATED APRIL 1% 1957. OMW BY LEO COPPETA ET AL RALPH 8. BRAS". ENGINEER' PLANS ON PK£ AT* THE ESSEX COMITY REGISTRY GP O FDS. NORTHERN Do T. 1).. PUN 0321L 2). PLAN 12& 31 PLAN 1357.. P P 1 NG FIRST FLOOR — 1.500 S•F. SECOND FLOOR — 1,500 S.F. TOTAL 3.ODO S.F. t I HEREBY CERTIFY THAT THEPROPERTY LINES SHOWN ON THIS PLAN ARE THE LINES OF EXISTING OWNERSHIPS AND THE LODES OF THE STREETS AND WAYS SHOMM ARE THOSE OF PUBLIC OR PRIVATE STREETS OR WAYS ALREADY ESTABLISHED, AND THAT NO NEW ONES FOR EX!STINO OWNERSHIP OR FOR NEW WAYS ARE SHOWN. AND THAT THIS PLAN CONFORMS TO THE RULES AND REGULATIONS OF THE REGISTERS OF DEEDS OF MASSACHUSEM, SURVEYOR ss�LriD.. R- LAND LAND rC L b t`h"-�wOMev�Hfr�s1 N 81Y11��[� RECORD OWNER A NAR11H AN)OWER MASS ASSESSORS MAP 67. LOT 69 TIM DOW 8818, PAGE 215 PLAN SHOWING PROPOSED BUILDING 22 UPLAND STREET NORTH ANDOVER, MASS. PREPARED FOR: FREDERICK COPPETTA DATE: FEBRUARY 14, 2012 SCALE: 1'=2d e a N� 9nsuitants o nc. 7 1 East River Plate Peter 0. Goodwin . Methuen, Maas. 01844 Reg. Prof. Land Surveyor 0 20 40 60 60 Ft. msam0 10 20 Mater