HomeMy WebLinkAboutMiscellaneous - 28 QUAIL RUN LANE 4/30/2018I
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Cunningham Lindsey U.S., Inc.
P.O. Box 703689
Dallas, TX 75370-3689
Telephone (888) 738-8714
CLCAT@CL-NA.COM
Facsimile (214) 488-6766
****'*****'****"******AUTO**3-DIGIT 018
758 T3 P1 95000058948
Building Commissioner or
Inspector of Buildings
120 MAIN STREET
N ANDOVER, MA 01845
Claim Number:
Policy Number:
Company Name:
Cause of Loss:
Date of Loss:
fA
Cunning�am vzr
indsey
Form of Notice of Casualty Loss to Building
Under MASS. GEN. LAWS Ch. 139, Sec 3B
1473318
147331823
MERRIMACK MUTUAL FIRE INS
ICE DAM
2/15/2015
Insured: CHRISTINE DEWHURST
Property Location: 28 QUAIL RUN LN
Claim has been made involving loss, damage, or destruction of the above captioned property, which
may either exceed $1,000 or cause Massachusetts General Laws, Chapter 143, Section 6, to be
applicable.
If any notice under Massachusetts General Law, Chapter 139, Section 313 is appropriate, please direct it
to the attention of the writer. Kindly include a reference to the captioned insured, location, date of loss
and claim number.
Section 313. No insurer shall pay any claims (1) covering the loss, damage, or destructions to a building or
other structure, amounting to the one thousand dollars or more, or (2) covering any loss, damage or
destruction of any amount, which causes the condition of a building or other structure to render section
six of chapter one hundred and forty-three applicable, without having at least ten days previously given
written notice to the building commissioner or inspector of buildings appointed pursuant to the state
building code, to the fire department or arson squad of the city or town and to the board of health or
board of selectmen of the city or town in which the same is located. If at any time prior to the payment
the said city or town notifies the insurer by certified mail of its intent to initiate proceedings designed to
perfect a lien pursuant to section three A, or to section nine of chapter one hundred and forty-three, or
section one hundred and twenty-seven B of chapter one hundred and eleven, the said payment shall not
be made while the said proceedings are pending; provided, however, that said proceedings are initiated
within thirty days of receipt of such notification.
Any lien perfected pursuant to section three A, or to section nine of chapter one hundred and
forty-three or section one hundred and twenty-seven B of chapter one hundred and eleven, shall
extend to and may be enforced by the city or town against any casualty insurance policy or policies
covering any loss, damage, or destruction pursuant to which the proceedings to perfect the lien were
initiated.
No insurer shall be liable to any insured owner, mortgagee, assignee, city or town, or other interested
party for amounts disbursed to a city or town under the provisions of this section, or for amounts not
disbursed to a city or town under the provisions of this section.
On this date, I caused copies of this Notice to be sent to the persons named above at the addresses
indicated above by First Class Mail.
Cunningham Lindsey
Catastrophe Department
cicat@cl-na,com
800-867-3885
. . .. . ..... 4y .....
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
,,—A�e f -,JN RzN
This certifies that ....................................
has permission for gas -installation ..................................
,�� 11.1 �1� ...............
in the buildings,,of
at ....... Y A-� North Andover, Mass.
....................... .............. . ............................ r
Fee. ......... Lic. No. 1 ... Z)qPI �-.,-N ... S. -P ... E. C.- T. ... 0. R. ...............................
Check
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY A Voy-e 1Z MA DATEE el PERMIT#
JOBSITE ADDRESS j,-2&auAjj Rq4
OWNER'S NAME
G OWNER ADDRESS TE4
FA
TWE OR OCCUPANCYTYPE COMMERCIAL EDUCATIONAL RESIDENTIAL41
PRINT
CLEARLY PLANS SUBMITTED: YESF- N
NEW: El RENOVATION: El REPLACEMENT: 0 Olm
APPLIANCES'l FLOORS -
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
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
WXER HEATER
BSM 1 1 1 2 1 3 1 4 1 5 1 6 1 7 1 8 1 9 1 10 1 11 1 12 1 13 1 14
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL. Ch. 142 YES ip NO
I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY * OTHER TYPE INDEMNITY [j BOND
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER 0 AGENTE-Di
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are true 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 comWplhal �rt i t prorvin of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME -P/cij.A
LICENSE #[13 Z �NATU�E���
MP 2 MGF E:11 JP [] JGF LPGI CORPORATION PARTNERSHIP #= LLC RN#
COMPANY NAME: lVe 490 46 DRESS
AD
CITY STATE=
ZIP [���<___JTEL
FAX CELL EMAIL= rO
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The Commonwealth ofMassachuseas
Department ofIndustrialAccidints
Office Of investigations
600 Washington Street
Boston, M4 02111
Workers' Compensation Insurance Affidavit: BundersfContractorsfFIelctriciansfplumbers
Applicant Information Please Print Legibly
NaMo (Business/Organizationftdividual):
V7 LaAl',
Address: Peve )exe_-,,4
City/State/Zip: Phone#:
Are you an employer? Check the appropriate box: -
Typo of project (required):
1. F1 I am a employer with
4. D I am a general contractor and 1
6. F1 Now construction
employees (fiffl and/or part-time).*
have hired the sub -contractors
listed on the attached sheet. I
7. Remodeling
24 1 am a sole proprietor or partner-
ship and'have no employees
These sub -contractors have
8. Demolition
working for me in any capacity.
workers' comp. insurance.
I
9. E] Building addition
[No workers' comp. insurance
5. We are a corporation and its
10. n Electrical repairs or additions
required.]
3. El I am a homeowner'doing all work
officers have exercised their
right of exemption per MGL
I LE] Plumbing repairs or additions
myself. [No workers' comp.
e. 152, §1(4), and we have no
12.Q Roofrepairs
insurance required.] t
employees. [No workers'
l3JJ Other
comp. insurance required.]
�Any applicant that checks bDx#f must also fill out the sectionbel6w showingtheir workers' compensation policy information.
I Homeowners who submit this affidavit indicating they Rie doing all workand then hire outside contractors must submit anew affidavit indicating such.
tContractorsthatcheckthis box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
I am an employer that 1sproviding workers'compensation insurancefor my employees. Below is ffiepollcy andiob site
information.
Insurance Company
Policy 9 or Self -ins. Lie. #: ExpirationPate;
Job Site Address: -Pity/State/Zip:
Attach a copy of the workers' compensation -policy ileclaration page (showingthe policy number and expiration date).
Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
firie 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 firie
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwardedto the Office of
investigations of the DIA for insurance coverage verification.
I do h eriby cert! d, �epa an alfles perjury that the inforinationprovided above is true and correct
Official use only. Do not write in this area, to he eompletedby city ortoWn offlclaZ
City or Town: PermitUcense #.
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
ContactPerson: Phone
Information and Instruction' -s
Massachusetts General Laws chapter 152requires 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 empkeiis defined as "an individual, partnership, association, corporation or other legal entity� or any two or more
Of the foregoing engaged in ajoint 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 dweag 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 requ.1red."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance ofpublic 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 anLT—C orLLP does have
employees, a policy is required. Be advised that this affidavit maybe, submitted to the Department of Industrial
Accidents for confirma�tionof insurance coverage. Also be sure to sign and date'the affidavit Theaffidavitsbould
be returned to the city or town that thie 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,
componsationpolicy, please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate he.
City or Town Officials
Please be sure that the affidavit is complete and printedlegibly. Tfie 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.
Pleas ' e be sure to fill in 6e, permit/lice'nse number which will be used as a reference number. In addition, an applicant
that mtst submit multiple permit/license applications **in any given year, need only'submit one, affidavit indicating current
policy information (ifnecessaty) 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 ii on Me for future permits or licenses. Anew affidavit must be filled out each
year. 'Where a home owner or citizen is obtaining a license or'-parmit 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 oflnvestigations'would like to thank you in advance for your cooperation and should you have any 4questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Comm
of Massorhu
Depaftent offadusbial Accidents
Wee of lavestigatiom
600 WmWVoa Steet
BostonMA02111
TQL # 617-727-4900 oxt 406 or. 1-877',M AFE
.ASS,
Revised 5-26-05 Fax# 617-727-7749
9374 D a t e . llllqII7—. . .
lo
TOWN OF NORTH ANDOVER
wpm PERMIT FOR PLUMBING
This certifies that ... ........
I lah(2�
has permission to perform
plumbing in the buildings of ... ........
at ... ip� North Andovet, Mass.
Fee. Lic. No..
Check 4t -,=5:-o �&gv �
Date ........
. .6N 6% TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that ................. .......
has permission for gas installation <1402,f�? ....
in the buildings of
. . . . ... ....... ....
at ... N orth Andover Mass
Fee:4��,P Lic.
GAS INSPECTOR
Check #
8*119
W,
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY NORTH ANDOVER MA DATEFI-4tC11R�-11 PERMIT#
JOBSITE ADDRESS ,.28 QUAIL RUN OWNER'S NAME LDEW4 RES
GOWNER ADDRESS TE FAX
TYPE OR OCCUPANCY TYPE COMMERCIAL[] EDUCATIONAL RESIDENTIALLA
PRINT
CLEARLY NEW: EA RENOVATION: Lj REPLACEMENT: 01. PLANS SUBMITTED: YESE] NOLI
I I
APPLIANCES -1 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
. .... .. .. ....
COOK STOVE
F—
DIRECT VENT HEATER
DRYER
F
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
J,
ROOM SPACE HEATER
...... . ------
- ------ - --
ROOF TOP UNIT
TEST
. .........
- ------ ---
UNIT HEATER
UNVENTED ROOM HEATER
........... ...... ..
WATER HEATER
OTHE�1—
..... .. .....
-,F-
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES Ej No FJ
I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY Ll BOND
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER Dj AGENT
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are true and ccurate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in compli yVith�ll Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME [I�FFREY HUTNI� �K��� LICENSE # 1521=12 StRATURE
PART nP El #= LLC Lj#
MP [:1 MGF 0 JP Lj JGF 0 LPGI CORPORATION Ej#'2840 PARTNE SHI
COMPANY NAME: CALLAHAN AC & HTG ADDRESS L91 �BE=LMONT ST
C I T Y L7N 0 �T —HA _N6 -0—V 7E —R
STATED DAZIP 01845 ITEL 1'-9'-7-8-689-9233
FAX CELLL----JEMAIL PLUMBING@CALLAHANAC.COM
7Z— A0
Address:_
Clty/State/Zlp: 5hone #:
4V/h11 7��'dj /3/�V e
Are you au employer? Check the appropriate box:
X1 -r'- 4.
The Coinnionwealth ofMassachusetts
n I am a general contractor and I
Department ofIndustrialAccidents
have hired the sub -contractors
Office of Investigations
listed on the attached sheet.
600 Washington Street
A
Boston, MA 02111
employees and have workers'
www.tnass.gov1dia
Workers' Compensation Insurance Affidavit: Builders/Contractox-s/Electriciaus/13lumbeirs
Applicant Information
'Please. Priat Legibly
NT@Ille(Busiiiess/Oro-,inizatioii/Individual): 1-"alk7la,,� -A,
Address:_
Clty/State/Zlp: 5hone #:
4V/h11 7��'dj /3/�V e
Are you au employer? Check the appropriate box:
X1 -r'- 4.
am a employer with �>Z 6—
n I am a general contractor and I
employees (full and/or part-time).*
have hired the sub -contractors
I am a sole proprietor or partner-
listed on the attached sheet.
sMp and have no employees
These sub -contractors have
working for me in any capacity.
employees and have workers'
[No,wozkers' comp. insurance
comp. insuranceJ
required.]
5. We are a corporation and its
I am a homeowner doing all work
officers have exercised their
myself [No workers' cornp.
right of exemption per MGL
insurance required.] t
c. 152, § 1(4), and we have no
employees. [No workers'
insurance required.
Type of project (required):
6. Ej New construction
7. E]Remodelhio-
8. Demolition
9. Building addition
10.E] Electrical repall's or additions
I L [2'Pllumbing repairs or additioDs
12. R Roof repairs
13.R Other
*.A.n3 applicant that checks box N I must also fill out the section below showing their workers' compensation policy information.
t I-loineow-ners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
lContractois that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have
eMPION ees, If the sub-contmctors have employees, they must provide their workers'comp. policy number.
Jain all employerthal isproviding workers'compensation insurancefornzyep��Ployees. Below is fit e policy andjob site
information.
Insurance Company Name: 6&f A'l—
Policy *# or Self -ins. Lic. zf e:
� Expiration Dat
0 UIP L /2(.) LU IV,
Job Site Address-. C1ty/State/Zip:A&4->,-)_U49� bh�- LfO6
Attach a copy of the workere 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 penallies of a
fine up to $1,500.00 and/or one-year imprisom-nerit, 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 01 , fice of
InvestiGations of the DIA for insurance coverage verification.
I do hereby cert�� under thepains andpenalties ofperjury that the information provided above is trite and correct.
Phone #: 19�1 ( �- Af Y --?- 3 -3
Qjjicial use only. Do notwrite in this area, to be completed by city or town officiaL
City or Town:
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 #:
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY I NORTH ANDOVER 0 PERMIT #
MA DATE F
4M/2012
OWNER'S NAMEJ
JOBSITE ADDRESS 28 QUAIL RUN
P OWNER ADDRESS FAX
TYPE OR OCCUPANCYTYPE COMMERCIAL EDUCATIONAL RESIDENTIAL
PRINT
CLEARLY NEW:[] RENOVATION:E] REPLACEMENT:E] PLANS SUBMITTED: YESE] NO[:]
FIXTURES -1 FLOOR- 8SM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB
r
CROSS CONNECTION DEVICE E—
DEDICATED SPECIAL WASTE SYSTEM
. ..... .......
DEDICATED GAS/OIL/SAND SYSTEM
................... ....... . . .
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR / AREA DRAIN
INTERCEPTOR (INTERIOR)
. ... .......
KITCHEN SINK
LAVATORY
....................
ROOF DRAIN
SHOWER STALL
SERVICE / MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER BACKFILOW PREVENTOR
FOR BOILER
..... . ........ JL
. . . ... .......
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 CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Ej OTHER TYPE OF INDEMNITYE] BOND [:]
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER F-1 AGENT 0
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are 4,A/n6l accurate to the best of my knowledge
om 1, .
and that all plumbing work and installations performed under the permit issued for this application will be in c ' I' ew a ert nent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 177' 4 -
PLUMBER'S NAME IICK LICENSE # //7 %' INXTURE
m P 0 ip El CORPORATION El C2 -84-6---j PARTNERSHIP 0 # LLCEI#
COMPANY NAME I CALLAHAN AC- & HTG ADDRESS 191 BELMONT ST
CITY 'ER ZIP 101845 TELFj7-8 - 6
JSTATE 74�_Rq
FAX CELLI EMAIL I PLUMBING,@CALLAHANAC.COM
ACC)RDF CERTIFICATE OF LIABILITY INSURANCE
DATE IMMIDDrrfm
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.
11/01/2011
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 PRODUC"AALD.X"EAC"TJFJCA.ZE.HDLDER
IMPORTANT: If the certificate holder is an ADDITIONAL I NSURED, 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 etWorsement(s).
PRODUCER
CONTACT
NAMF_'
NORTH ANDOVER INSURANCE AGENCY, INC.
M.J. FOSTER INSURANCE SERVICES
FAX
jPH,0,NIN., ,M: (978) 686-2266 (AIC, N.): (978) 686-6410
E-MAIL
ADDRESS: cfernandez@nafins.com
163 MAIN STREET
PRODUCER #Callahan Air Conditioning & Heating
CUSTOMER ID
INSURER(S) AFFORDING COVERAGE NAIC
NORTH ANDOVER MA 01845-2508
INSURED
INSURER A -PEERLESS INS CO
Callahan Air Conditioning Heating
INSURER B -GUARD INSURANCE
91 Be lmont Street
INSURER, C
INSURER D
INSURER E
North Andover NA 01845-
INSURER F
U�Vnn�"�a umniirsumir mtimm�w- mlf"Dco.
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
I TYPE OF INSURANCE
ADUL
INSR
SUBR
WVD
3�i
POLICY NUMBER
POU Y EFF
MMID
PO CY
(MMIODNYYY)
LIMITS
A
G L LIABILITY
Y
P4016154
09/25/2011
09/25/2012
EACH OCCURRENCE Is 1,000,000
x COMMERCIAL GENERAL LIABILITY
CLAIMS -M I ADEFx_1OCCUR
DAMAGE To RENTED 13 3
PREMISES (Ea occurrence) 00,000
MED EXP ny one person) Is 5,000
X CONTRACTUAL
PERSONAL & ADV INJURY J$ 1,000,000
GENERAL AGGREGATE Is 2,000,000,
GEN'L AGGREGATE UMIT APPLIES PER:
—1 -1
PRODUCTS - COMP/OPAGG S 2,000,000
RO-
POLICYFx SECT F LOC
NOWND $ -
A
AUTOMOBILE
LIABILITY
ANY AUTO
BA4544035
09/25/2011
)9/25/2012
COMBINED SINGLE LIMIT
(Ea accident) $ 1,000,000
BODILY INJURY (Per person)
ALL OWNED AUTOS
BODILY INJURY (Per accident)
x
SCHEDULED AUTOS
PROPERTY DAMAGE
(Per accident) $
X
HIRED AUTOS
y
NON -OWNED AUTOS
X
COMP.$10D0 DED COLL$10W DEC)
A
X I
UMBRELLA LIAB
OCCUR
B09
8809334
9/25/20
)9/25/2012
EACH OCCURRENCE 4 5,000,000
-c— UAB
CLAIMS -MADE
$ 5,000,000
4
UCTI
D�ED CTIBLE
-AGGREGATE
$
RETENTION $
B
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY YIN
ANY PROPRIETORIPARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED? El
(mandatory In NH)
mesif , describe und
SCRIPTION OF OPERATIONS below
NIA
C246100
6100
09/25/2011
09/25/2012
X WC STATU OTH
[TORY LIMIT -S PR
E.L. EACH ACCIDENT $ 500,000
E.L. DISEASE - EA EMPLOYEE $ 500,000
E.L. DISEASE - POI ICY I 'Mrr $ nno, 000
A
INLAND HARIM
=BP4016154 09/25/2011
ID
9/25/2012
LIMIT 50,000
'EQUIPMFM
'
/ /
/ /
DEDUCTIBLE 1,000
DESCRIPTION OF. OPERATIONS I LOCATIONS I VEHICLES (Aftach ACORD 101, Additim2d Rerks Schedule, if mnore space is required)
CEIRTIFICAlt: t1ULLJ1:_K CANCELLATION
(978) 688-9500
(978) 688-9542
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXI2=TtCN 17ATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
TOWN OF -NORTH ANDOVER
120 MAIN STREET
NORTH AMOVER NA 01845-
ACORD 25 (7UUUIU.4) @ 1988-2009 ACORD CORPORATION. All rights reserved.
INS025 poogog) The ACORD name and logo are registered marks of ACORD
Date.. .
TOWN OF NORTH ANDOVER
0
PERMIT FOR GAS INSTALLATION
'4 US
This certifies that ..... ............................
has permission for gas installation V. .11-� ..................
in the buildings of ... � '.. '\. ,.,? ...................
C-
at ( ... P. �, ,—. . , North Andover, Mass.
Fee.';U'0.:-- . Lic. No—i01
S*INSPECT�4 ........
Check #
64 57
11
MASSACHUSEM UNUDRMAPPUCATONFORPERNUr To DO GAS FTMNG
(Type or print)
Date C/
NORTH ANDOVER, MASSACHUSETTS
Building Locations Ok�
Owner's Name
New 11 Renovation 1:1 Replacement 0-
U B-BASEM ENT
�ASEM ENT
ST.
F L 0 0 R
N D.
FLO 0 R
RD.
FLOOR
TH.
FLOOR
TH.
FLOOR
T H .
F L 0 0 R
TH.
TH.
FLOOR
FLOOR
(Print or type)
Name /— Q
Address S—D
Permit # 1;1,,r 7
Amount $ t,
Plans Submitted
(A
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Business I elephone
Name of Licensed Plumber or Gas Fitter
Check one: Certificate Installing Company
0 Corp.
INSURANCE COVERAGE Check one:
I have a current liability Insurance, policy or it's substantial equivalent. Yes 13 -
If you have checked Yes, please indicate the type coverage by checking the appropriate box.
Liabilihf ino I.,
rm/Co.
NoO
UIWWC P0 cy U Other type of indemnity 13 Bond 13
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:
Signature of Owner or Owner's A—g`7nt _ — Owner 13 Agent 13
1 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 insta I s perf med under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachu tts e
e Code and C�pt%l 4�2o the Gener��aws.
Title
City/Town
JAPPROVED (OFFICE USE ONLY)
Signature of Licensed 141[rmber Or Gas Fitter
[3 Plumber 77) 1�
[:] Gas Fitter License N U-1110er
13—Master
0 Joumeyman
U
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W
C9
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U3
Check one: Certificate Installing Company
0 Corp.
INSURANCE COVERAGE Check one:
I have a current liability Insurance, policy or it's substantial equivalent. Yes 13 -
If you have checked Yes, please indicate the type coverage by checking the appropriate box.
Liabilihf ino I.,
rm/Co.
NoO
UIWWC P0 cy U Other type of indemnity 13 Bond 13
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:
Signature of Owner or Owner's A—g`7nt _ — Owner 13 Agent 13
1 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 insta I s perf med under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachu tts e
e Code and C�pt%l 4�2o the Gener��aws.
Title
City/Town
JAPPROVED (OFFICE USE ONLY)
Signature of Licensed 141[rmber Or Gas Fitter
[3 Plumber 77) 1�
[:] Gas Fitter License N U-1110er
13—Master
0 Joumeyman
;,00oo,o-
NORTH ANDOVER BUILDING DEPARTMENT
4ra. 400 Osgood Street
c
Tel: 978-688-9545
Fax: 978-688-9542
B US17WS—S FORM FOR TOWN CLERK
DATE:
ADDRESS: A)&,
ZONING DISTRICT
TYPE OF BUSINESS:
-)41
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A/
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BUILDING LAYOUT PROVIDED:
AVAILABLE PARKING SPACES: <V
ZONING BY LAW USAGE: _E:f� �1)��NQ
BUILDING INSPECTOR SIGNATURE
WA k) A V Cy\ ak� Co
Revised 11.5.04
BUSDWSS FORM FOR TOWN CLERK
Location
No. Date
TOWN OF NORTH ANDOVER
V
,jrm
%
Certificate of Occupancy
$
41 -IW44 . rww--
Building/Frame Permit Fee
$
CHU
Foundation Permit Fee
$
Other Per ee n a
$
PA!,qe*brCoffhectlon
Fee
$
e
Water Soign�lon Fee
W I
$
1 L
TOTAL
$
Building
Inspector
Div. Public Works
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