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HomeMy WebLinkAboutMiscellaneous - 25 MARTIN AVENUE 4/30/2018TOWN OF NORTH ANDOVER Office of the Building Department NORTH I `Ep , qti Community Development and Services - p 1600 Osgood Street, Bldg. 20, Suite 2035 North Andover, MA 01845 o q co- �. ACHUS���� Gerald Brown, Inspector of Buildings April 4, 2016 To: Mary D'Angelo Fr: Gerald Brown Re: 25 Martin Avenue, North Andover, MA Dear Ms. D'Angelo, Thank you for your inquiry on the above mentioned property, 30 Martin Avenue, North Andover, MA. The kitchen located in the basement of the above property has been in existence since the home was built in 1964 which is the construction date on the Town of North Andover's Assessor Property Card. Sincerely, Gerald Brown Inspector of Buildings 3/17/2016 Community Software Consortium OE ,ko : North Andover Boafdjof Assessors Back to Results Search for Parcels I Search for Sales I View/Print Record Card View Summary Property Totalvalue: Card OPGRADY, OWER BaDfiv vatoe: Residence Map View D'ANGE11.0, NAM View Land Abutters Segments Properties Chapter Lard Value - City Detached State: Structure NeWftKhoo± Sales Land Area: History Use Code: Value Total FsMhed Area History Tax Class Con(,'o Parcel ID: 210/045.G-0011-0000.0 FY: 2016 Community: North Andover notation: 25 MAI" AVENUE Previous Year Totalvalue: Owner Name: OPGRADY, OWER BaDfiv vatoe: 158,9w Owner Name2: D'ANGE11.0, NAM 170,800 164-qDD Owner Address 25 MARTDt AVENUE Chapter Lard Value - City NORTH ANDOVER State: MA Z* 01845 NeWftKhoo± 5 Land Area: 0.23 acres Use Code: 101SNGL-FANLRM Total FsMhed Area 1564 sgft Tax Class T Pd-Exenq*41.ind: 0 D Sewer_ Road Type: T V&ter: Road ConfffiwL P Assessments Current Year Previous Year Totalvalue: 329,700 319AW BaDfiv vatoe: 158,9w 154,900 Land Vahhe: 170,800 164-qDD Martcet Land Vahw: 170,800 Chapter Lard Value - Latest Sale Sate Prioe: 3514W Sale Date: 03H9rAN Anes Length Sale Code: WNFES-VALID Grantor: TERRANOVA, DOWERLG Cert Ooa Bolt 10573 Page: 314 Copyright © 2015 Community Software Consortium. All Rights Reserved Photo (Click on Photo to Enl Sketch (Click on Sketch to Enlar e) http://epas.csc-m a.us/Publ icAccess/Pages/Parcel Sum mary.aspx?M enul D = 3&Li nk ID = 180334&Com m code= 210 1 /1 a 0 O 0 0 6 6 T o N 4 F N OD OD O^1 O O x J u O O O 1,1 2 J t O O Ct C Ad !� o N N ` m m O O Q (0 N Q W Q U (n U C V U LL d 9 J N r- O O C C N m C O N O. S 2 W U C O y 7 0 O a Co M J J Y Y > r O (� 00 N e � z Q O O i • Zm 0 o v Z LL U Q¢ p0N H d o Z ¢ w o L i j a Z 'C '� { e 0LL N co o Z N¢ O u a' ¢¢ e J Z "! a o x U W o -p N m� N 'o ¢ W R F` > - '� fn O W W O) ; n: W J U U Q D Q v f"Z w N i L m d d1 O1 W M Z 2 (n E m m (r0 V p O M O p O 0 O U r M M c � ■ .? ■cr Q o ■ oo an d 2 0 O a o LO m a U O U U t o w s= N T -m o O o z Z in a d U d a y O N ¢ O M o a } H O O O . v r v m z r` to to c m a° iD OC `° ¢° o= o) m m d O FT >° mo > > ¢ w(n 0 W Q m Li m L W} U Q Q V F cM- O O Z LL O co N m � m m O N o �L LL C C U .U. 'wo- 0 0 C m Q LL LL c- ii t Y 'o 'c U � c o o i m¢ -O o m, c .. a m Z O O.•ao p X U .¢ F- Y w C7 U a 0 a 67 y PNS U x 3 _ a� LL w aa) w Fm H F (n W Z w CA W a Q W_ m LL X i r i LL ai U T LL W E m ro m°~ ca cu o m Z� H m Li 2 w 0 2 Li m m a N N v N N Z O 0 o w G O z Z z ' N w r ¢ F z 7 Q.' W W ju Z Y m N 2 _ �. j .. U Q' U) T Uo �... o O Q c fl m r U C 'D 1n O O a Z O o N w '0it N d Q Q C in Of w 2i m In LL L% •¢ a d cYn Date. .�11?7�/.!./ ........ ..o TOWN OF NORTH ANDOVER PERMIT FOR GAS- INSTALLATION This certifies that .. 9f?.. 11a t rt? ......... . ......... . has permission for gas installation ... k nt�.. . in the buildings f/of ..�✓..1-�� ��?...................... . at . 25-" lrr`Ih, ,/w...... ......., /North Andover, Mass. Fee.,AQ.,,5— Lic. No..?�IW.kr�1-A. GAS INSPECTOR Check #,& r% 7931 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING City/Town: \; , MA. Date:L�_-i l Permit# Building Location: �%�� ',1 Owners Name: Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential ❑ New: ❑ Alteration: ❑ Renovation: ❑ Replacement: ❑ Plans Submitted: Yes ❑ No ❑ FIXTURES lY co C6W W W rn z �. co v = m = O W W UO ~ 0 2 W W Z J Z z O W = R 0 W CO 1— W cn v z M m o QQO w O a W a= X W~ W Q W W W z a' 0= W f- W~ p er u_ Z JQ Q m w O z 0 0 t W P W w fn > Z 2 v o o u�. cQ7 _ Lu 0 a. a� W > > > 0 SUB BSMT. BASEMENT 1FLOOR 2FLOOR 3 FLOOR 4 FLOOR 5 FLOOR 6 FLOOR 7 FLOOR -e-FLOOR Check One Only Certificate # Installing Company Name: �� �C_/ ` 4 ❑ Corporation Address: "'/ � �(,(/1 �+ �.. ,� ,/Town: t _ State: Business Tel: _�7j� v70 g�❑Partnership �3 Fax: El Firm/Company Name of Licensed Plumber/Gas Fitter: INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes No ❑ If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy E9�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 ❑ Signature of Owner or Owner's Agent Owner 1:1 Agent By checking this box❑ II 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 Plu g Code and Ch of the General Laws. By f Type of License: ❑ Plumber _ Title _ /Z�/i ED Gas Fitter S gn icensed Plumber/Gas Fitter ❑ Master City/Town ❑Journeyman License Number: 6 APPROVED OFFICE USE ONLY) ❑ LP Installer The Commonwealth ofMassachusetts Department of lndustriat Accidents Office of Investigationg 600 Washington Street Boston, MA 0211-1 SV www,mass golAdia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Mlicant Tnfnrmaf•:n„ Nalne (Business/Organization/Individual): /K C O Address: -City/State/Zip: � t (�(� � � Phone #: i —) 9 3Y.3 A re 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).* 2. ❑ I am a sole proprietor or have hired the sub -contractors listed partner- on the attached sheet. # ship and have no employees These sub -contractors have working for mein any capacity. workers' comp. i workers' comp. insurance. 5* reqnsurance required.] a are a corporation and its 3. ❑ I am a homeowner doing .officers have exercised their all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' COMA insurance required ) Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. [] Demolition 9. E]Building addition 10. ❑ Electrical repairs or additions 11.0-Numbingrepairs or additions 12.[] Roofrepairs 13.[] Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. I 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 their workers' comp, policy information. tam an employer that is providing workers' compensation information. insurance for my employees Below is tlae policy and job site Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: , City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required winder 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 ofthis statement may be forwarded to the Office of Investigations of the D9 for insurance coverage verification. Ido IZereby Cern y under thepains ayld nalties o 'wry that the informationPTO vided above is true andcoprect. Date (� u —t! 3413 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): I. Board of Health 2. Building Department 3. City/Town CIerk 4. Electrical 6. Other Inspector 5. plumbing Inspector Contact Person: Phone #: el* 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 apartinents 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 shallwithhold 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 confuination of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy; please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/liceuse applications in any given year, need only submit one affidavit indicating current policy information (ifnecessary) and under "Job Site Address" the applicant should write "all locations in (city or town)" A copy of the affidavit that has been 'officially stamped or marked by the city or town ,may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to 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: T e ConunaowweaM of Arjassaeiaosetts Dep neat of l dustxial Accidents Office of Investigations 600 Washington Street Boston; MA. 0211 X 6.17-7.27-4904 ext 406 ox 1. -877 -•MA ".SAFE Revised 5-26-05 Fax # 617,727-7749 www.mass.jz-ov/dia. I 02b5 Date // ........... tTOWN OF NORTH ANDOVER 0 j X� 40 PERMIT FOR WIRING 17 This certifies that ...... 4Z/ -7a ........4-0.1 . . ................................... has permission to perform ...... X1. ........................................... wiring............................ in the building of 7 . ........... at .17 ..... /9f .......... 1.) ... _Nogh-4n.. .........dover, Mad. ....... .. Fee....n.''..... Lic. No. ...... VJ ELECTRICAL INSPECTOR "Check # Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only, Permit No. 10 Z0'-5 Occupancy and Fee Checked [Rev. 1/071 leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Co (MEC), 27 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: City or Town of: NORTH ANDOVER To the In pector f Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Owner or Tenant Owner's Address "C:�C,,, t: Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps Volts Overhead ❑ Undgrd [:1 No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: 1.skil S�,& , 4rh .►fs �►�/ nc� �(r�5 Completion of the ollowing table may be waived by the In ector o Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑In- E] rnd. grnd. No. o mergency Lighting Battery Units No. of Receptacle Outlets S No. of Oil Burners FIRE ALARMS I No. of Zones No. of Switches -3 No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges5 No. of Air Cond. Total Tons No. of Alerting Devices g No. of Waste Disposers Fr,, ,t 5 Heat Pum Totals Number ..................................'.".."..'.".".'....."...'...'.'_.... Tons KW No. of Self -Contained Detection/Alerting Devices No. of Dishwashers w Space/Area Heating KW Local E] Municipal E] her Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KW Heaters No. of No. of Si ns Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: 06 Attach additional detail if desired, or as required by the Inspector of Wires. estimated Value of Electric 1 Work: (When required by municipal policy.) Work to Start: g /S ti Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE C VE GE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE �& BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: `, Ill LIC. NO.: Id 3 U - 8 Licensee: "VId %e�anr Signature LIC. NO.:,g//cq - 4 (If applicable, enter "exempt" in the license number line. Bus. Tel. No.: 9 7 PY 5V*7q Address: 13 SogoJd0o& h.111 rJ P,&,^ XIJ ©3O L Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, sechrity work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's Owner/Agent Signature Telephone No. PERMIT FEE. $:��D The Commonwealth of Massachusetts �,,Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 &K www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual):e4 p e / o � —7TH Address: /3 S'or,,lbo rd. City/State/Zip: ,)UR Ci36'76 Phone Are you an employer? Check the appropriate box: L ❑ 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. K�,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.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10J[ 4Electrical repairs or additions 1 I. El Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other *Any applicant that checks box # I must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. +Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: ��,�5 „ r- W Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address:'? S City/State/Zip: /�, /�,r�a„u n,ttl- 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 l fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby certify under the pains andpenalties ofperjury that the information provided above is true and correct Sienature: 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 Person: Phone 9211 Date. dzq11j ... . TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ... F� �- .G h ..� ..��C� .T. /Pry? .I.. // ..... ....." has permission to perform.. hlahI Cem,041.,i Ar -4J.'/.. �lk�� plumbing in the b ildings of .. A'?f ..., w. e X? ............ at ...?-� /?qr ... .. ............... . North Andover, Mass. Fee . !' . Lic. No..96 � PLUMBING INSPECTOR Check # 491 SUB BSMT. BASEMENT 1sT FLOOR 2ND FLOOR 3RD FL OO R 4T" FLOOR 5T" F OOL R 6T" FLOOR 71' FLOOR 8T" F OOL R MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING City/Town :_ t---r-[-LSC— MA. Date: Permit# Building Location:_ ov ii—NApwners Name: IType of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential New: U Alteration: ❑ Renovation: ❑ Replacement: plans Submitted: Yes FIXTURES Instal€ingCoi,1pe'rly fuame: —L__\ ( l —0l Address.-`,-�d Ft rfG� City/Town: �3 , Stater Business Tel: q& Fax: Names a of Licensed Plumber: C C;9 r Ck 0ri3 4: nh, ❑ Corporation ❑ Partnership ❑ Firm/Company M19 DEDICATED SYSTEMS Z L z s -j Q � ❑ I I- Ln W z 14 a 3 ow �iH2-3,- ' c�i H wp w O x Q vi cr ❑ ❑ x w z in W z U ii LLUj '� > O O w w w> g 3 �02 ° 3 'n o Instal€ingCoi,1pe'rly fuame: —L__\ ( l —0l Address.-`,-�d Ft rfG� City/Town: �3 , Stater Business Tel: q& Fax: Names a of Licensed Plumber: C C;9 r Ck 0ri3 4: nh, ❑ Corporation ❑ Partnership ❑ Firm/Company M19 DEDICATED SYSTEMS INSURANCE COVERAGE: I have a current Iia,_bility 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. A liability insurance policy. a Other type of indemnitv M o..w-1 r, 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 mysignature on this permit application waives this requirement. Check One Only ii nature of owner or Owner's A ent Owner ❑ Agent ❑ Th-ereby terrify that all of the details and information I have submitted {or entered) regarding this app►ication are true and accurate to the beat of my Knowledge and that all p!umbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision'o the Mass c6usetts State Plumbing Code and Chap r 142 of the Gene aws. Type of License: le /Zz� El Plumber Si nat re of Licensed Plumber `Y[Town ❑ Master i 1PROVED (OFFICE USE ONLY) ❑Journeyman License Number: b Z � H d s -j Q � ❑ I I- Ln W a 14 a 3 INSURANCE COVERAGE: I have a current Iia,_bility 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. A liability insurance policy. a Other type of indemnitv M o..w-1 r, 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 mysignature on this permit application waives this requirement. Check One Only ii nature of owner or Owner's A ent Owner ❑ Agent ❑ Th-ereby terrify that all of the details and information I have submitted {or entered) regarding this app►ication are true and accurate to the beat of my Knowledge and that all p!umbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision'o the Mass c6usetts State Plumbing Code and Chap r 142 of the Gene aws. Type of License: le /Zz� El Plumber Si nat re of Licensed Plumber `Y[Town ❑ Master i 1PROVED (OFFICE USE ONLY) ❑Journeyman License Number: b r� The Commonwealth ofMassachusetts Department of -Industrial Accidents Office oflnvestigations 600 Washington Street Boston, MA 02111 yY www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors[FIectricians/Plumbers iplicant Infnrmafin„ Name (Business/Organization/fndividual): �• +. avuuv .L 110.16 LG IUUA Address: c City/State/Zip:�i� , �� �L-- Phone #: Are you an employer? Check the appropriate box: I. D I am a employer with 4. ElI am a general contractor and I'pe of project (required): employees (full and/or part-time).* 2. I am a sole proprietor or have hired the sub -contractors listed 6 ❑New construction partner ship and have no employees on the attached sheget. These sub -contractors have 7. D Remodeling 8' D Demolifion working for me in any capacity. [No workers' comp. insurance workers' comp, insurance. 5.P�e area corporation and its 9• ❑ Building addition required.] 3. D I am a homeowner doing all .officers have exercised their 10. [] Electrical repairs or additions work myself. [No workers' comp. right of exemption per MGL c. 152, § 1(4), and we have 11. Bing repairs or additions insurance required.] q ] • 7 no employees. [No workers , 12.D Roofrepairs comp, insurance re wired i 13.0 Other !Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing orkers' 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 Wider Section 25A ofMGL c.152 can lead to the imposition o fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a Sf criminal penalties of a Of up to $250.00 a day against the violator. Be advisWORK ORDER and a fine ed that a copy of this TOP statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido Hereby cer ' under the pains an ofperjury that the information p ovfded above is true and correct. Si ature: V (/ Bate: 'hone #: vfftctal 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): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector S. Plumbing inspector 6. Other Contact Person: Phone #: i DateG.. 7 .... . 1 NORTp pftao ,°11.0 16 Ok TOWN OF NORTH ANDOVER p ;- PERMIT FOR GAS INSTALLATION This certifies that ..... S... ..' . `...../. .G ............ has permission for gas installation .. V . ................. in the buildings of ... (-2.'!q. h -:4 .`........................... at .. ........... , North Andover, Mass. Fee.d ,Lic. No.. V GAS INSPECTOR Check # 13 � 6210 4... tiff -- G MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) NORTH ANDOVER ,Mass. Date 10/25 2007 Permit # G Z to Building Location 25 MARTIN AVE Owner's Name MICHAEL 0 OGRADY Owner Tel# 978 886 8800 - 978 208-0033 Type of Occupancy RESIDENTIAL New 11 Renovation? Replacement Plan Submitted: Yet No[] FIXTURES Installing Company Name Eastern Propane & Oil, Inc Address 131 Water Street Danvers, MA 01923 Business Telephone # 800-322-6628 Name of Licensed Plumber or Gas Fitter SCOtt Cohen Check one: Certificate ZCorporation Partnership Firm/Co. INSURANCE COVERAGE: I have a cures liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes ✓ I No ❑ If you have c ecked yLs, please indicate the type coverage by checking the appropriate box. A liability insurance policy F✓ 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 Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner ❑-' Agent ❑ Signature of Owner or Owner's Agent I hereby certify that all of the details and information I have submitted (or entered) in above app (cation are true arA accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for ttfis applica 'on will 6 in compliance with all City/Town APPROVED (OFFICE USE ONLY) State Gas Code and Chapter 142 of the General La s. Type of License: Plumber Signature of nsed P mbe4or Fitter as fitter • •Master License Number 4199 Journeyman • • I . - Installing Company Name Eastern Propane & Oil, Inc Address 131 Water Street Danvers, MA 01923 Business Telephone # 800-322-6628 Name of Licensed Plumber or Gas Fitter SCOtt Cohen Check one: Certificate ZCorporation Partnership Firm/Co. INSURANCE COVERAGE: I have a cures liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes ✓ I No ❑ If you have c ecked yLs, please indicate the type coverage by checking the appropriate box. A liability insurance policy F✓ 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 Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner ❑-' Agent ❑ Signature of Owner or Owner's Agent I hereby certify that all of the details and information I have submitted (or entered) in above app (cation are true arA accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for ttfis applica 'on will 6 in compliance with all City/Town APPROVED (OFFICE USE ONLY) State Gas Code and Chapter 142 of the General La s. Type of License: Plumber Signature of nsed P mbe4or Fitter as fitter • •Master License Number 4199 Journeyman ACORD�,---[ CERTIFICATE OF INSURANCE ISSUE DATE 10/12/2007 PRODUCER MCGRIFF, SEIBELS & WILLIAMS, INC. P.O. Box 10265 Birmingham, AL 35202 205-252-9871 This certificate is issued as a matter of information only and confers no rights upon the Certificate Holder. This Certificate does not amend, extend or alter the coverage afforded by the policies below. COMPANIES AFFORDING COVERAGE ComApany Liberty Mutual Insurance Co INSURED Eastern Propane Gas, Inc. 28 Industrial Way Rochester, NH 03867 Company B Company C Company D Company E This is to certify that the policies of insurance described herein have been issued to the Insured named herein for the policy period indicated. Notwithstanding any requirement, term or condition of 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, conditions and exclusions of such policies. Limits shown may have been reduced by paid claims. CO LT TYPE OF INSURANCE POLICY NUMBER EFFECTIVE EXPIRATION LIMITS OF LIABILITY A GENERAL LIABILITY ® Commercial General Liability ❑ Claims Made ® Occurrence ❑ Owners' and Contractors' Protection ❑ ❑ General Aggregate Limit applies per: ®policy ❑ Project ❑Location TBI641435806027 10/01/2007 10/01/2008 EACH OCCURRENCE $ 1,000,000 FIRE DAMAGE $ 250,000 MEDICAL EXPENSE $ 5,000 PERS. AND ADVERTISING INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 PRODUCTS AND COMP. OPER. AGG. $ 2,000,000 A AUTOMOBILE LIABILITY Any Automobile ❑ All Owned Automobiles Scheduled Automobiles ❑ Hired Automobiles ❑ Non -owned Automobiles ❑ AS1641435806017 10/01/2007 10/01/2008 COMBINED SINGLE LIMIT $ 1,000,000 BODILY INJURY Per erson $ BODILY INJURY Per accident $ PROPERTY DAMAGE Per accident $ COMPREHENSIVE COLLISION A WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY WC7641435806037 10/01/2007 10/01/2008 WC Statutory Limit Ix I Other EL EACH ACCIDENT $ 1,000,000 EL DISEASE Each employee) $ 1,000,000 EL DISEASE(Policy Limit $ 1,000,000 EXCESS LIABILITY ❑ Occurrence ❑ Claims Made EACH OCCURRENCE $ AGGREGATE $ Division #: 2 CERTIFICATE HOLDER Town of North Andover Massachusetts City or Town All Municipalities, MA 00000 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. 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