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HomeMy WebLinkAboutMiscellaneous - 26 MAIN STREET 4/30/2018 (9)N Z N w � This certifies that ...?Q� ..�.� ....-� —( ......... has permission to perform ....-.— q-�'. rail, PD ................ w),!JAg in the building of C®.. ........... vk `. ........ , North Andover, Mass. Fee3'-�. ��.®6 Lic. No. -4NKF� � .�C........ . ,•�. ELECTRICAL INSPEC�TOR Check # � B� �S `i '134.5 " Official Use Only A''� commonwealth of Massachusetts 2 � � Permit No. Department of Fire Services Occupancy and Fee Checked @� BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT WINK OR TYPE ALL INFORMATION) Date: / 9 % \ City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perf � e electrical work described below. Location (Street & Number) Z M lw t o 5� l Owner or Tenant ,'eiP r-00 k r% cl- Telephone No. Owner's Address 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 ❑ No. of Meters New Service oZ� Amps 1 Za J 2 Molts Overhead ❑ Undgrd [9"� No. of Meters Number of Feeders and Ampacity 4,r Location and Nature of Proposed Electrical Work: 1L1 / n� 9 IC ?_,'Ay No. of Recessed Luminaires ' No. of Luminaire Outlets No. of Luminaires No. of Receptacle Outlets ! No. of Switches / No. of Ranges i No. of Waste Disposers No. of Dishwashers No. of Dryers No. of Water KW Heaters No. Hydromassage Bathtubs No. of Cell: Susp. (Paddle) Fans No. of Hot Tubs Swimming Pool Above ❑ In grnd. gr No. of oil Burners No. of Gas Burners No. of Air Cond. Total Tnnc table may be waived by the Generators KVA o. o mergency ig ting ❑ Rattery ilnits ME ALARMS INo. of Zones o. of Detection and o. of Alerting Devices Space/Area Heating KW Local ❑ ji Heating Appliances Key Security' No. of No. of No. of Data Wir Signs Ballasts No. of Telecomm No. of Motors Total HP No. of or ❑ Other OTHER: Attach additional detail if desired, or as required by the Inspector of 97res. 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. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability in rance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such cover e 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 per'ury,.that the information qn this application is true and complete. : C. e, le f � V C,LIC. NO.: FIRM N Licensee: d Signature LIC. NO.: (If applicablegntr "exe�ptt in the license number line.) e� Bus. Tel. No.: Ar �J IC'ly i t �i a .�/�0 L Alt. Tel. No. Address: er G.L c. 147, s. 57-61, security work req s Department of Pu lic 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 agent. Owner/Agent Telephone No. PERMIT FEE: $ ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shall be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012. ❑ Rule 8 — Permit/Date Closed: *** Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: ection A:mments: Failed 0 Re- Inspection Required ($.) ❑ Inspectors Signature: Date: SERVICE INSPECTION: Pass [N Failed Re- Inspection Required ($.) ❑ Inspectors Comments: . Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass V Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pa Failed ❑' Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INS ION: Pass Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF ME RIMAC, MA. .......dweinhold@t ownofinerrimac.com 1 w P 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):��[:� �i�2�-lel ( / �7 eY�% ✓�C,70 15 Address: Z- 1622-, City/State/Zip: ��C l / ®30hone #: Are u an employer? Check the appropriate box: 1. I am a employer with �_ 4. ElI am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. I am a sole proprietor or partner- listed on the attached sheet. t 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 10. F-1 Electrical repairs or additions 11. E] Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other *Any applicant that checks box 41 must also fill out the section below showing their workers' compensation policy information. t Homeowpers who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors 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. �j Insurance Company Name:' C �� 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 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. Sienature: v Date:/ --7 — / 3 LJ -7 � -I/Z, Official use only. Do not write in'this area, to be completer) by city or town official. City or Town: Issuing Authority (circle one): 1. Board of Health 2. Building Department 6. Other Permit/License # 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector Contact Person: Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as ".:.every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The 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 Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE .evised 5-26-05 Fax # 617-727-7749 WWW_mace anv/rlia 4 ..r:.. r ' .e . o m ..r:.. G�1-Al Ao �lv.tui, In N . o m j g .. y f ,v EI S E pEll Z P4 M. cu Q WN w . momLo ti d Qz Q) cio N -j i r 181e �F i Date. ........ , TOWN OF NORTH ANDOVER p PERMIT FOR MECHANICAL INSTALLATION This certifies that has permission for mechanical installation in the buildings of .. �/rQ. C.d0........... ................. . at -f�'. r? i�'?r . r�`�.'.. '�.! , North Andover, Mass. Fee.(O�a�-'.. Lic. N00 -3k. � ............ f ! ..... . %j() GAS INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer V Commonwealth 0f Ad'assZchusett:s 'qhv.vd; 104d,.ts7l l< p.vrnit Date; `6 1 13 Gstimated.Job Cost; $ `� C� 00 Plans Submitted: YES NO Business License t/ (9 Business Information: Name: ��,i S o� p N 5A rl`tu.t,K .S scat; �d Street: --S 5 S ��I V\ S -E- _ City/Town: Tclephone: Photo l,D, required / Copy of Photo l.D. attached: r 81:11TIII ltinI `�L��'a- unrestricted license ,J-2 / M -2 -restricted to dwellings 3 -stories or less and co1Yrmercial up to 10,000 sq. ft, / 2 -stories or less Residential: 1-2 family Nrulti-family C'ondo /'l'ownhou seS Othcr Permit fi Permit Fee: `f _ Plans Reviewed: V11'S NO Applicant License 11 _ 7 3 Property Owner /Job Location fnformation: Name: 4- Street; JUJ� / r t U' l' S-�' v" k •t City/"Town: _k o� AtIv-c Telephone: YES NO Commercial: Office Retail ON Institutional It Square Footage: LlnClel' 10,000 sq. ft. ✓- Industrial Other over' 10,000 sq. ft, Street metal work to be completed: New Worlc: HVAC V' Metal Watershed Roofing_ F,Clucational Number of Stories: 3 Renovation; Kitchen Exhaust System Metal Chimney / Vents Air Balancing TA Provide detailed desuIiption of work to be clone: (/ 1 c _t� �J °` S2 Vow 5-c C 04 �� ue4 6-c t It INSURANCE COVERAGE: I have a current liability insurance policy or Its equivalent which rnects the requirements of M.G,L. Ch. 112 Yes dNo ❑ If YOU have checked Yes, indicate the type of coverage by checking the appropriate box below: A liability insurance policy [ Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 112 of the Massachusetts General Laws, and that my signature on this permit application waives this regUlrement. Check One Only Owner ❑ Agent ❑ Signature of Owner or Owner's Agent By chocking thls box , 1 hereby certify that all of the details and Information I have suhmittod (or entered) regarding this application are true and accurate to the hest of my knowledge and that all sheat motal work and Installations performed under the permit Issued for this application will be in compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws, Duct inspection rec)Ulred prior to InsUlation Installation: YES NO Progress Inspections Date Comments 7{irlttt �ns'�ectiogi Date Comments Inspector signature of Permit Approval Signature of Licensee License NUrnber: + 5-7 -3 1 Check at www.mass,gov/dD1 Type of License: By ❑ Master Title ❑ Master -Restricted Cily/Town ,,��� t�'Joilrneyperson Permit # ❑Journeyperson-Restricled Fee $ ❑ Inspector signature of Permit Approval Signature of Licensee License NUrnber: + 5-7 -3 1 Check at www.mass,gov/dD1 1. 1 A =0 W& HEATING SERVICE Load Short Form Entire House Franks Heating Service 555 Woburn St, Tewksbury, MA 01876 Phone: 978-851-4403 Fax: 978-851-0398 Job: Date: Jan 16, 2013 By: mfh #Informatonk 'f ra7� _ <, ���.a, .„�r w,a- . � .. .:� a w •,= m>,3��`J+: _aa .,�,.-zfr. � ,.-.�.. _ � f ,_� ,r «s. F. � } , x1Tw .. .:'Y andover Htg Clg Infiltration Outside db (°F) 1 88 Method Simplified Inside db (°F) 70 75 Construction quality Tight Design TD (°F) 69 13 Fireplaces 1 (Tight) Daily range - M Inside humidity (%) 30 50 Moisture difference (gr/Ib) 28 28 HEATING EQUIPMENT Make Trade Model AHRI ref Efficiency Heating input Heating output Temperature rise Actual air flow Air flow factor Static pressure Space thermostat 80 AFUE 0 Btuh 0 Btuh 0 OF 625 cfm 0.036 cfm/Btuh 0.50 in H2O COOLING EQUIPMENT Make Trade Cond Coil AHRI ref Efficiency Sensible cooling Latent cooling Total cooling Actual air flow Air flow factor Static pressure Load sensible heat ratio 0 SEER Area (ftz) 0 Btuh 0 Btuh 0 Btuh 625 cfm 0.050 cfm/Btuh 0.50 in H2O 0.89 2225 ROOM NAME Area (ftz) Htg load (Btuh) Clg load (Btuh) Htg AVF (cfm) Clg AVF (cfm) ent 128 2623 860 95 43 din kit 200 2689 2225 97 111 lav 46 57 10 2 1 liv 298 3029 3695 110 185 bed2 174 1535 759 56 38 wic 33 394 55 14 3 bath 55 0 0 0 0 bed1 158 1899 1935 69 97 hall 123 714 572 26 29 wic2 91 675 183 24 9 m bath 56 107 572 4 29 ---- 070 0070 COO 470 QO Calculations approved by ACCA to meet all requirements of Manual J 8th Ed. 2013 -Jan -16 13:11:17 -r- wrightSOW Right -Suite® Universal 2012 12.0.09 RSU10062 Page 1 ACCK ...ghtsoft HVAC2\Project\24 Main st north andover middle unit.rup Calc = MJ8 Front Door faces: Y \" Entire Nouse d 1734 17293 12506 625 625 Other equip loads 0 0 Equip. @ 1.00 RSM 12506 Latent cooling 1574 .4T]!10 4An7n R7F Cii ri Calculations approved by ACCA to meet all requirements of Manual J 8th Ed. 2013 -Jan -16 13:11:17 1 wrightSOW Right -Suite® Universal 2012 12.0.09 RSU10062 Page 2 iiCCP. ...ghtsoft HVAC2\Project\24 Main st north andover middle unit. ruP Calc = MJ8 Front Door faces: Sheet Metal Residential Guidelines / Inspection Cheeldist Yes 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 i/ All sheet metal work being performed with proper joumeyperson-to- apprentice ratios Equipment sized per heating / cooling load calculations Duct work sized per manual "D" 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" V, 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 -off) The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA. 02111 ,v www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information ,/r Please Print Legibly Name (Business/Organization/Individual): x A_o C My Q&A (wK S It�- q .h Address: SS S �- Al-'- S1 City/State/Zip: 7�w Ips �, AA 0 t'6-) Phone #: (wi) S l' 4y o 3 Are you an employer? Check the appropriate box: EqTam a employer with 4 () 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors E] 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 ❑ I 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 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12. ❑ Roof repairs 13.EVOther 14 UA L- .ny applicant that checks box # 1 must also fill out the section below showing their workers' compensation policy information. lomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. ontractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. im an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site formation. surance Company Name:. 6150/15 ,licy # or Self -ins. Lid. #: `� CA d 0 5 i `� Expiration Date: to 5 0 15 b Site Address:_ �- -s ( w + City/State/Zip: X1.114, v,, ( j AAA :tach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). ilure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a Le 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 up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of vestigations of the DIA for insurance coverage verification. !o hereby certify under the ' _&,andpenalties ofperjury that the information provided above is trate and correct. ,nature: Dated 1 I -k.e(�k55 �-A) t5 (-440 3 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 M Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) 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 fixture 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 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 Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 021.11 Tel. # 617-7274900 ext 406 or 1.877-MASSA.FE Fax # 617-727-7749 ajnitu6iS CO) LU J-.6 Ln Ln W N) Q ova CO fA to Y. z 4 no uj C) OZ U. 0 3::1;n ui > ce LU E co N —JW 0 • <w ca<J X: LU > LIJ LLI>- m: < < O ui LU z 0 LU UJM Cl) LU :r -j U) :0 Client#- 53676 HILLISFRAN2 ACORD.. CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) TYPE OF INSURANCE 1118/2013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: if the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: nee.certificates@hubinternatio HUB International New England A1C No EKt : 978 657-5100 Ali NO: 866475-7959 299 Ballardvale St E-MAIL Wilmington, MA 01887 ADDRESS: PERSONAL & ADV INJURY $1,000,000 INSURER(S) AFFORDING COVERAGE NAIC p 978 657-5100 INSURER A: Peerless Insurance Co 24198 INSURED INSURER B: Atlantic Charter 44326 Hillis Corp LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS HIRED AUTOS X NON -OWNED AUTOS DBA Frank's Heating Service INSURER C: BA1059735 555 Woburn St INSURER D: Ea acc dentSINGLE LIMIT $1,000,000 Tewksbury, MA 01876 INSURER E: PROPERTY DAMAGE $ Per acddent INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADD INSR SUBR WVD POLICY NUMBER POLICY EFF MM/DD/YYY POLICY EXP MM/DD/YYY LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE a OCCUR X Blnkt Add Ins: Prod/ X X CBP1059734 Compl Ops:as per 6/30/2012 executed 06/301201 contract OCCURRENCE $110001000 -EACH PREMISES Ea oNcu renre $300,000 MED EXP (Any one person) $5,000 PERSONAL & ADV INJURY $1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY X PRO- JECT LOC PRODUCTS - COMP/OP AGG s2,000,000 A AUTOMOBILE X X LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS HIRED AUTOS X NON -OWNED AUTOS X BA1059735 6130/2012 06/30/201 Ea acc dentSINGLE LIMIT $1,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ Per acddent A X UMBRELLA LIAR EXCESS LIAR X OCCUR CLAIMS -MADE X CUSS17751 6/30/2012 06/30/2013 EACH OCCURRENCE s3,000,000 AGGREGATE s3,000,000 DED I X RETENTION $10000 $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE V / N OFF'CER/MEMBER EXCLUDED? � (Mandatory in NH) I(yes, describe under DESCRIPTION OF OPERATIONS below N / A WCA00514205 6/30/2012 06/30/201 X TORY LIMIT OTH- E.L. EACH ACCIDENT $500,000 E.L. DISEASE - EA EMPLOYEE $500,000 E.L. DISEASE - POLICY LIMIT 1$500,000 DESCRIPTION OF OPERATIONS I LOCATIONS /VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is required) Town of North Andover SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1600 Osgood Street, Bldg 20 ACCORDANCE WITH THE POLICY PROVISIONS. Suite 2-36 North Andover, MA 01845 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD #S853214/M745169 DKO04 The Commonwealth of Massachusetts Department ofIndustrial Accidents Office of. Investigations 600 Washington Street Boston, MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/Organization/fndividual):��"^� Address: *,02 to S -t - a City/State/Zip: ©� , MQ . oi5o6 Phone #: fb g - `i Lta 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 2J& 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. ❑ I 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. E] Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. El Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other *Any applicant that checks box#1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they gce doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. Yam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lie. #: Job Site Expiration Date: City/State/Zip: Attach a copy of the workers' compensation -policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one=year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. X do hereby cert user tlzeBa�rts antlpertaities ofperjury that the information provided above is true and correct. Phone #: �% Lt Lt 00 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 #: 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 Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington. Street Boston? MA. 02111 Tei, # 617-727_4900 at 406 or 1-877,7N SSAFE Revised 5-26-05 Fax # 617-727-7749 www.mtass,gov/dia k I a> ¢t iALM IW Massachusetts - De +. H061E IF;W OVEMeNT iCONjRAC , {;;ft Reglstr.�;uon: 10P470 Corr,truciion ncniwr � ,t , Expirtion ►3t'l8r1A� t + =,t��;.�. ,. ibd NtAL RESTORAT1aNS THOMAS O GREG r r , Thomas Green. - 1 26 Main St << Brookfield, MA 01506 1. iALM IW Massachusetts - De i NW Board of Suttuttay r%cyutatiu+ta and 5ranc aros f Corr,truciion ncniwr Licenser CS -042165 ,. THOMAS O GREG 26 MAIN ST BROOKFIELD MA 0%O6t Expiration 05131!2094 . Commissioner