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HomeMy WebLinkAboutMiscellaneous - 25 WOODBERRY LANE 4/30/2018Date TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ......,..%G has permission for gas installation ................ in the buildings of North Andover, Mass. Fee'.. Lic. NO.L. ....... .... . GA§INSPECTOR Check # FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER INSURANCE COVERAGE 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES ONO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY V OTHER TYPE INDEMNITY E] BOND F 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 El AGENT O 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 w h all P in t provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME �M_ LICENSE # % _I SIGNATURE MP Ej MGF Ej JP El JGF D LPGI Zoo'— CORPORATION D# = PARTNERSHIP #I LLC ®#= COMPANY NAME:CJADDRESS CITY �� STATE ZIP[ TEL _ FAX I CELL EMAIL MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK I _ I CITY AM )I MA DATE PERMIT # JOBSITE ADDRESS WO ek,r f/�9 OWNER'S NAME rj�ll/l l� C C SLCI �S GOWNER ADDRESS _ TEL I• q-y7.R.S.�#Ax TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL EDUCATIONAL�] RESIDENTIAL CLEARLY NEW: RENOVATION: El REPLACEMENT: PLANS SUBMITTED: YES 0 NO APPLIANCES 7 FLOORS- BSM 1- 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER _ ._. _.._ . 1 .... _ E .. BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER I +_ �F1 . DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER INSURANCE COVERAGE 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES ONO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY V OTHER TYPE INDEMNITY E] BOND F 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 El AGENT O 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 w h all P in t provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME �M_ LICENSE # % _I SIGNATURE MP Ej MGF Ej JP El JGF D LPGI Zoo'— CORPORATION D# = PARTNERSHIP #I LLC ®#= COMPANY NAME:CJADDRESS CITY �� STATE ZIP[ TEL _ FAX I CELL EMAIL 0 1 H O z H U W Pk w � o o a z O N�W 4a) � W O a � F- P6q coco w a a W O� w � w co a g a a J H a a Q cn w x w � a In H Z O H U a O a vW� The Commonwealth ofMassa chusetts Department oflndustrialAccidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERIVHTTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: Phone #: Are yy(an employer? Check the appiopriaie box: 1. Q I am a employer with employees (full and/or part-time).* 2.FJ I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3.FJ I am a homeowner doing all work myself [No workers' comp. insurance required.] t 4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.$ 6. Q We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no. employees. [No workers' comp. insurance required.] Type of project (required): 7. ❑ New construction 8. 0 Remodeling 9. ❑ Demolition 10 ❑ Building addition 11. E] Electrical repairs or additions 12. Plumbing repairs or additions 13. E] Roof repairs 14.0 Other *Any applicant that checks box 41 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they 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-corilractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees.' Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. 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 under MGL c. 152, §25A is a criminal violation punishable by a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify W nder the4aipA 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): i 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract bf. iire, 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 them self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)" A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia 18 DAIE A� CERTIFICATE OF LIABILITY INSURANCE 6/9/2015 i 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 TESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. h...- RTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTA NAME: T Diane DeCaria Braley & Wellington Insurance Agency PHONE , (508)754-7255 FAX Nok (508)797-3507 44 Park Avenue Ed1AAlL ,:sg.ddecaria@braleywellingtonaroun.com P.O. BOR 15127 INSURER(S) AFFORDING COVERAGE NAIC # Worcester MA 01615-0127 INSURERA:United States Fire Ins Co 21113 INSURED I INCI IRFR p HEG Inc. 2 International Way I Lawrence MA 01843 I INSURER F: I I rnVGoeccc rFRTICIrATF NI IMRFR•2OIL 5-2016 'RFVISI[fN NIIMRFR- 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. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE OF INSURANCE ADDLSUBRTYPE Town of North Andover POLICY NUMBER M�M/LID� EFF POLICYEXP LIMITS rA GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS•MADE a OCCUR 03-773065-9 /1/2015 /1/2016 EACH OCCURRENCE $ 1,000,000 PREMISES Ea occurrence $ 250,000 MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1 , 000 ,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY AFrT PRO- LOC PRODUCTS - COMP/OP AGG $ 2,000,000 $ MOBILE LIABILITY � ANY AUTO A ALL OWNED X SCHEDULED AUTOS X H R DSAUTOS X AUTOS X MCS90 X Pollution 33-734904-2 /1/2015 /1/2016 E d nDt IN LE LIMIT 1,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ Pe'aca �tDAMAGE $ Uninsured motorist BI split limit $ 20,000 A X UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE 23-800100-8 /1/2015 /1/2016 EACH OCCURRENCE $ 10,000,000 AGGREGATE $ 10,000,000 DED I X I RETENTION 1,00 $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNERIEXECUTIVE YIN OFFICER/MEMBEREXCLUDED? D (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS belo NIA WC STALIMTU- 0TH - TS E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE $ E.L. DISEASE - POLICY LIMB 1 $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, K more spate Is required) n�e�ClfnATc Unr neo rAaJrCI 1 ATInW (978)688-9542 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of North Andover ACCORDANCE WITH THE POLICY PROVISIONS. Building Dept 1600 Osgood St. AUTNORIZEDREPRESENTATIVE North Andover, ice, 01845 Diane DeCaria/DIANE a"00.C- �- ACORD 25 (2010105) cV IVOO-ZUTU ALoUKU GvnruKA I wN. Au ngnls reserves. INIP''Maf4H 1Alifh nrifPot-fnni tria?'ViA"tRRA'i1rAR1t/flTtlff'P!!Y?YMtTQt►`M"'''^^'''" "s Arnon 4221 Date ... //-av-o . . .. Z) ... ........................ TOWN OF NORTH ANDOVER p PERMIT FOR WIRING �c% �fc. �. This certifies that.....=.................................................n............................. has permission to perform/.... Q.io�c .........v!"...I/....L........................ wiring in the building of.....v. �.....A{v.... Q /'� 1 7- �-�r� y l•v . at .... .:5.....u%....................................................((,??N��ortAndover, Mass. Fee . yJ�........... Lic. No. 3%8 yl�...... `�: SWI. i*A(..( .... ELECTRICALSPECTOR t? � D Check # IL-4 v )IC P, r to- fli (i% $7- to- fli ul. -S fli Commonweatlh o/ //%addae1tW'Jts -- 2. parfntenf v1 jire Service9 BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. Occupancy and Fee Checked ,ev. 11/99] flcavP t,h,.l•N APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be per('ornted in accordance with the Massachusetts Electrical Code (MEC), 527 ChIR 12.00 (PLE.ISE PRINT MINK OR TYPE ALL IN1-'ORlL !TION) Date: j 0 _10©,� City or "1'oiv11 Uf:. p To the In ector of •Yit•es: By this application the undersigned gives notice ofhis or her intention to perform the electrical work described below. Location (Street & Number) S (r� tor7 p 2Ril Owner or Tel atIt R/ /� u 1 L I q A f/ 7 Telephone No. Owner's Address sn til -k— Is this permit iu conjunctioli with a building permit'. Yes ❑ No ❑ (Check Appropriate Bos) 1'ut Bose or Building p ,t Utility Authorization No. Existing ServiceAmps / 11olts Overhead ❑ Undgrd ❑ No. of tlleters . Lely Scrvicc Amps / Volts Overhead ❑ Undgrd ❑ No. of bleters. Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work:. t C G No. of Recessed Fixtures --•,•A No. of Ceil.-Susp. (Paddle) Fans • 1— "My uc n-arrea ov the /ns ector of !Vires. No. of Total Transformers WV"' No. of Lighting Outlets No. of I -lot Tubs Generators KVA No. of Lighting Fixtures slyinuuiog Pool above ❑In- ❑ ritd. lzrlld.Battery t o. o mergency tg ittiig Units— No. of Receptacle Outlets No. of Oil Burners FIRE ALARINIS i\'o. of Zones No. of Switches No. of Gas Burners No. of Detection and Inttiatine Devices No. of RangesNo. of Air Cond. iota! Tons No. of Alertina Devices O No. of Waste Disposers, Heat Putnp Totals:... Number •Tons __ —"�� KW __ No. of Self -Contained Detection/Alerting Devices No. of Dis.liwasliers Space/Area Heating KW Local 11Iunicipal El Connection Other No. of Dryers No. of Water Heaters KW Heating Appliances 1iW No. of No. of Signs Ballasts Security Systems: No. of Devices or Equivalent Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. ofAlotors Total IIP _I Telecommunications 1Virlug: Nc. of llevices or E uivalent OTHER: Attach.additional detail if desired, or as required by the Inspector of !Vires. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is ul force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ET BOND ❑ O'I'LIER ❑ (Specify:) (Expiration Date) Estimated Value of Electrical Work:* (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. I certify, under the pains and penalties of perjure, that Ilse information oft this application is true and cottrplete. FIRiNINAME: ' Buddy. Electric Inc LIC. NO.:1201T_.A Licensee: Vircebt B. I,a:nders JR Signature L1C.N0:.: 23684 E (If applicable, enter "ar wpt " in the license number line.) . . 9 — 4 4 5 Bus. Tel. No.. Address: .24 Colgate _Dr lei -Andover. Ma 0 845 Ait. Tel. No.: OWNER'S INSURANCE WAIVER: I am aware that the Licensee floes not have the liability insurance coverage normally required by law. BN my signature below, 1 hereby waive this requirement. I atn the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature 'Telephone No. Pl:R:1fIT FEL: