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PERMIT FOR GAS INSTALLATION
This certifies that ..,f ,�' .�.�G.... l9-� H ................
has permission for gas installation ..�4c..:.�,! ? ........ .
in the buildings of ..........................
at .5--b? !-....... F, North Andover, Mass.
Fee. 4..... Lic. No...7. 3 .. ..:�..; :.... .
yGAS INSPECTOR
Check # 7 �
6761
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
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City/Town: �VOR I ^ �,�JC40V-o, MA. Date: `� 10-0 i /
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Building Location: r S 1-i 001i Owners Name: Jit `1 lLS �i7yvL�
Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential
New: ❑ Alteration: ID Renovation: ❑ Replacement: ❑ Plans Submitted: Yes ❑ No ❑
FIXTURES
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SUB BSMT. V
EASEMENT
Vu 1 FLOOR
FLOOR
3 KV. FLOOR
4, FLOOR
5 FLOOR
6 FLOOR "
7 FLOOR
8 FLOOR
Installing Company Name: APOLLO PLG & •HTG INC check one only Certificate #
a Corporation 3046C
Address: 1 SHATIUCK ST PO BOX466 City/Town: LAWENCE State: . MA
❑ Partnership
Business Tel: 978-688-1755 Fax:978-683-5933
❑ FirrrJCompany
Name of Licensed Plumber/Gas Fitter: Robert M. Demers Jr.
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 Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that tlio licensee does not have tho insuranco coverage required by Chapter 142 of the
Massachusetts General Laws, and that my signature an this parmit :application waives this regairement.
Check One Only
Owner ❑ Agent ❑
Si nature of Owner or Owners A ant
Cy checking tnls oox ; I neret�/ certlry that all or the netaiis ane Intonnanon I nave submlttetl (or encerect) regarding this appllcanon are true and
accunrte to the ixst of my Knowledge end that all plumbing work and installations performer! under the permit issued for this application will be in
compliance with all Pertinent provision of the Massechusctta State Plumbing Code and Chapter 1i2 of the Genercd Laws.
8y Type of License:
❑ Plumber
Title ❑ Gas Fitter '--
lXlMaster 9 ature of Licensed Plumber/Gas Fitter
Journeyman 9737
OV License N'Limbel:
l APPROVED (OFFICE U ONL n ❑ LP Installer
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ACORD, CERTIFICATE OF LIABILITY INSURANCE OP ID JL
DATE(MM/DD/YYYY)
1
APOLL-1
12/24/08
PRODUCER
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Roblin Insurance Agency, Inc.
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
144 Gould Street, Suite 100
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Needham MA 024942321
EACH OCCURRENCE $ 1000000
Phone:781-455-0700 Fax:781-449-8976
INSURERS AFFORDING COVERAGE
NAIC#
INSURED
INSURER A: Selective Insurance Co of Amer
12572
INSURER B:
Apollo Plumbing & Heating, Inc
Robert Demers
INSURER C:
P.O. Box 466
Lawrence MA 01842-0966
INSURER D:
INSURER E:
CLAIMS MADE a OCCUR
COVERAGES
THE POLICIES OF INSURANCE. LISTFD RFI.n�P: I1AVr REFN ISSUrDTn TI IF: INS;uRr.rl f IA1arD Ar.!O`✓1= FOR TI R:: POLICY PERIOD InIDICA1 LD. NoTWI r11SrAIIDIrIG
ANY REQUIHLtv1ENT, I ERM OR CONDI MON OF ANY CONI RAC f 0110 [1 ILR UOCU6ILI'J T WI I I l RESPEC I' TO WHICI I THIS CERTIFICATE MAY 13E ISSULO OH
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSIT'ADD' —POLIC�FFFF?`TIVE POLICY EXPIRATION
I
LTR INSRD TYPE OF INSURANCE POLICY NUMBER DAI E (MMIUD/YY) DATE (MMIDWY'r) LIMITS
GENERAL LIABILITY
EACH OCCURRENCE $ 1000000
A
X COMMERCIAL GENERAL LIABILITY
S 1840821
01/01/09
01/01/10
AMAGE-TO'RENTE--
PREMISES (Ea occurence) $ 100000
CLAIMS MADE a OCCUR
MED EXP (Any one person) $ 10000
PERSONAL & ADV INJURY $ 1000000
_
GENERAL AGGREGATE $ 3 0 0 0 0 0 0
GEN'L AGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMP/OP AGG $ 3000000
POLICY PRO-
JECT LOC
AUTOMOBILE
LIABILITY
COMBINED SINGLE LIMIT $1000000
A
ANY AUTO
A 9091247
01/01/09
01/01/10
(Ea accident)
BODILY INJURY
ALL OWNED AUTOS
X
SCHEDULED AUTOS
(Per person) $
HIRED AUTOS
BODILY INJURY $
NON -OWNED AUTOS
(Per accident)
PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY
AUTO ONLY - EA ACCIDENT $
OTHER THAN EA ACC $
ANY AUTO
AUTO ONLY: AGG $
EXCESS/UMBRELLA LIABILITY
EACH OCCURRENCE $ 5000000
A
OCCUR EICLAIMSMADE
BINDERS1840821
01/01/09
01/01/10
AGGREGATE $
$
DEDUCTIBLE
X RETENTION $
$
WORKERS COMPENSATION AND
TORY LIMIT ER
AS
EMPLOYERS' LIABILITY
WC 7264182
01/01/09
01/01/10
E.L. EACH ACCIDENT $ 500000
ANY PROPRIETOR/PARTNER/EXECUTIVE
E.L. DISEASE - EA EMPLOYEE $ 5 0 0 0 0 0
OFFICER/MEMBER EXCLUDED?
If es, describe under
E.L. DISEASE - POLICY LIMIT $ 5 0 0 0 0 0
SPECIAL PROVISIONS below
OTHER
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS
Issued as evidence of Insurance.
CERTIFICATE HOLDER CANCELLATION
er_nan gn r9nnirnnl
AVICI II I SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATIONI
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 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
,-. �......... .............. �..,. r moo
Date
T, 4160
l HORTF�
•�ti° TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
,SSACMUS�
This certifies that ...
has permission to perform . ...........................
plumbing in the buildings of ..... PK
. ...................
............
.. . . , , ... , North Andover, Mass.
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4 Feb....-.... Lic. No.�A .1�� .. � ...
PLUMBING I TOR
10/15/49 13:51 20.00 PAID
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Print or Type)
N, Anidou ck , Mass. Date 10— 13 19 77 Permit #
Building Location Owner's Name rl %ZU h 1;
A
i
2 6 ShAJV IVO A-) k nrV ~e Type of Occupancy
New ❑ Renovation 61 Replacement ❑ Plans Submitted: Y ❑ No ❑
FIXTURES
B.P. # SEWER # SEPTIC #
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BASEMENT
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. ..-
■■■■■■■■■■■■■■■■■■■■■■■■■■
WAGNIK6161-
■■■■■■■■■■■■■■■■■■■■■■■■■■
••
11-01114117,01-
■■■■■■■■■■■■■■■■■■■■■■■■■■
Installing Company Name _HPO4LO N/ -e- � &-Tm- /jVt' Check one: Certificate #
Address 1 '�WTuc-K.. ST .U, 80 X W 6 Od Corporation 1057 L
Aw 2P-A)LP A. 01 k ya -- 0 9 ❑ Partnership
Business Telephone (7-70&99`11SS- ❑ Firm/Co.
Name of Licensed Plumber 1�Sk.UIS.SEAU�(
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes 0? No O 11
If you have checked yes, please indicate the type coverage by checking the appropriate box.
A liability insurance policy. 19 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 application are true and accurate to the best of my knowledge
and that all plumbing work and installation performed under the permit issued for this application will be in compliance with all pertinent provisions
of the Massachusetts State Gas Code and Chapter 142 of the General Laws.
By
Title
City/Town
APPROVED (OFFICE USE ONLY)
Signature of Licensed Plumber
Type of License: Master V.,' Journeyman CJ
License Number _ U 9 1
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