The URL can be used to link to this page

Home My WebLink AboutMiscellaneous - 30 MIFFLIN DRIVE 4/30/2018N r �O N �"' ..a c b 3 T �j 2 ! v. 0 m E Date. t'j, ............................ TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ..`� .............. ............................. 0..� ........................ has permission for ga§,installation A I —) . ......... in the buildings of ........ D.I..( .... ....................................................................... ..... . .. ... ... . at ...... .......... North Andover, Mass. ........... ...... . . .. ... ... ... ...... ................... Fee...... Lic. No.' �� ........ ..................................................... GASINSPECMR Check # MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY 1_ North Andover MA DATE 14/1/2014 PERMIT#J�67 6L JOBSITE ADDRESS ( JOWNER'SNAME10 GOWNER ADDRESS I Same I TEI�_ _ _ . _ ]FAX TYPE OR OCCUPANCY TYPE COMMERCIAL[] EDUCATIONAL RESIDENTIAL[] PRINT CLEARLY I NEW:0 RENOVATION: El REPLACEMENT: El PLANS SUBMITTED: YESE] NOn' APPLIANCES -1 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE LF DIRECT VENT HEATER r- r DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER F LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER LINVENTED ROOM HEATER F -J. IF -- WATER HEATER OTHERI Rep ace I Ga Meter Ga IF F and Piping as Needed INSURANCE COVERAGE I have a current liabili!y-insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES ONO n I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [Z] OTHER TYPE INDEMNITY E] 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 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 c withn all Pertinent provision ofthe - Massachusetts State Plumbing Code and Chapter 142 of the General Laws. YW &mpliance PLUMBER-GASFITTER NAME I.Joseph Mariino LICENSE# 8736 SIGNATURIE ] LPGI F-1 CORPORATIONE]# PART SHIPF-1# LLC[ MPED MGF[:1 JP[:] JGFF T P0#L COMPANY NAME:j RH White Construction Co ADDRESS 141 Central St CITY I Auburn STATE =ZIPJ-01�01 :DTEL 1 (508) 832-3295 FAX 1508-926-4347 ]CELLI 508-832-4614 EMAILI JMarino@RHWhite.com V A O\ 0 F] F] LLJ a- LLI F- U) < U) LLI > w LLI U) z 0 I-- iL a. < CO LLI LLI U- "Alt, cc tm. LL> - Wim w <Z .0. LL (Dix - �! ..w 0 Q� > 0. 7d .0 U) it Irv) �. UJ4:4 w U) LrI . . . . . . . .. 0 04/03/2014 14:04 5088326751 RH WHITE CONSTRUCT PAGE 02/02 ACVR0 TDATE (MM'MONYYYI (MM 98/ CERTIFICATE OF LIABILITY INSURANCEP... 08/29;/2013 THIS CERTIFICATE IS ISSUED ASAMATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELYOR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED SYTHE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT SETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the policy(jes)must be endorsed. if SU13ROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies ay require an endorsement. A Statement on this certificate does not confer rights to the Certificate holder in lieu of such andorsoment(s). m willia of masaffebunottB, Inc. c/o 26 coAtury Blvd. P. 0. BOX 305191 NffgAville, TH 37230-9191 R- K- WhiL8 COn6truction Company, Znc. 41 Central Street P. 0. Box 257 Auburn, MA 01501 7_MMC_ -NO)' 11!Z J'/ b _ADJDR�u�__ce.rgif icates gurillim. com INSURER(S)AFFORDING COVERAGE NAIGrt INGURERA.- The Chartor Oak riro InBurancog Company 25615-001 INSURERB- TrILVOlArs Properey Casualty COA�PY of Am 25674-00� INSURERC: NAtiOAAI :Cn8ur1mcQ CcmPauY Of 3.9445-001 INSURERD; TrakvelerI3 Indamity Company 25658 -Dal INSURER F:: I 1,;UVLKAGES CERTIFICATE NUMBER: 20287680 -_ REVISION NUMBER, THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED 13ELOW HAVE BEEN [$SUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED SY THE POLICIES DESCRIBED HEREIN Is SUBJECT TO ALL THE TERMS, —EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LIM17S SHOWN MAY HAVE 13EEN REDUCED BY PAID CLAIMS. 'NSR -�_UIJI -, — POLICYEPP OLICY EXP LtL TYPE OP INSURANCE impin POLICY NUMBER :I�Dwl -mm - _090MOM00— LIMITS A GENERAL LIABILITY VTC2000 977RD948-13 9/l/2023 '9/l/2014 EAC�I OCCURRENCE 2 000 X COMMPRCIAL GENERAL LIA9II.ITY TO RENTED IC CLAIMS-MADET OCCUR k8r(te ooeuroncr�_ S LO -01-0-C MED EXP (Anv one oem6ni % -i n nnn DED I X IRETENTIONS lo, 000 D � WORKERS COMPENSATION AND EMPLOYERS'LIABILITY IPARTNERIEXECUTIVE FN] N(A 1) ANYPROPRIETOR YIN OFFICER/MEMS�REXOLUDI!D? below Evidence of Inauxance VTJCJLP 977K95SA-13 19/1/2013 19/1/20-14 BES766140 19/1/2013 19/1/2014 VTRKUB 820SA185-13 19/l/2013 9/1/2014 VTC2KUB 8203A71A-13 19/3,/2013 19/1/2014 Acord 101, Additanol Remarks Schadula, It more ep sea WaNERALAGGIRFGATE PRODUCTS-COMP/OPAGG 2,000,000 BODILY INJURY(Pervemon) 1� BODILY INJURY(PeraCcldeni) JQ; AGGREGATE E.L. EACH ACCIDENT s 1'000'_000 E.L. D18EASe-EA EMPI,QYEE S 1,000,000 E.L D18EAsr-- - POMOY LIMIT S 1,000,000 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THERSOF. NOTICE WILL 13E DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, AUTHORIZED REPRESUNTATI[VE Colli4297604 TpJ11694012 Cert:2028?6,80 @ 1988-2010 ACORD CORPORATION. All rights reserved. ACORD25 , (2010/05) The ACORD name and logo are registered marks of ACORD GEN'LAGGRr:G %Tr.- LIMITAPPLIES PER; POLICY aLjlrR T LOG P� )3 AUTOMOBILE LIABILITY ANY AUTO ALI OWN SCHEDULED ED AU�611 F.:�AUTOB X HIREoAUTOS WON -OWNED AUTO$ X Col Ded 111 Ded 3 _; 0 LX $MAA C UMBRELLAUAS LX I OCCUR HX r=xcrss LIAO [ I CLAIMS -MADE DED I X IRETENTIONS lo, 000 D � WORKERS COMPENSATION AND EMPLOYERS'LIABILITY IPARTNERIEXECUTIVE FN] N(A 1) ANYPROPRIETOR YIN OFFICER/MEMS�REXOLUDI!D? below Evidence of Inauxance VTJCJLP 977K95SA-13 19/1/2013 19/1/20-14 BES766140 19/1/2013 19/1/2014 VTRKUB 820SA185-13 19/l/2013 9/1/2014 VTC2KUB 8203A71A-13 19/3,/2013 19/1/2014 Acord 101, Additanol Remarks Schadula, It more ep sea WaNERALAGGIRFGATE PRODUCTS-COMP/OPAGG 2,000,000 BODILY INJURY(Pervemon) 1� BODILY INJURY(PeraCcldeni) JQ; AGGREGATE E.L. EACH ACCIDENT s 1'000'_000 E.L. D18EASe-EA EMPI,QYEE S 1,000,000 E.L D18EAsr-- - POMOY LIMIT S 1,000,000 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THERSOF. NOTICE WILL 13E DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, AUTHORIZED REPRESUNTATI[VE Colli4297604 TpJ11694012 Cert:2028?6,80 @ 1988-2010 ACORD CORPORATION. All rights reserved. ACORD25 , (2010/05) The ACORD name and logo are registered marks of ACORD 0 '/ 1 5-4 Date./0`A`/"/ . . TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that . .71-�valga- 41�rnpl) ................. 0 IV, I 1 1 ZC4 has permission to perform . .1791r-&-M'0't� . ........... plumbing in the buildings of .... 0. .................. at . . 9-4,- .,x2i ................ North Andover, Mass. Fee.49�. 4A) . Lic. No. 102a PLUMBING INSPECTOR Check# MASSACHUSETTs UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING City/Town: MA. Date: 2611 Permit'# Building Location. _br- 0 ners Name: 2_PL� �%_ _0C(,k,C, e Type of Occupancy: Commercial[j EducatlonalE] . IndustrialEl InstitutionalEl Resident EJ Renovation:Ej - Replacement:Ej Plans Subm . itted: Yes [I No FIXTURES DEDICATED LU CIO SYSTEMS IJU 0 > U) V_ LU =� Ln 0 z U LU Z' < W Q) Ce Z: — 1-� W Z = W 0 W W < W 0 Ln j3 _j =3 < LU W ,F_�:En < LU LL. _j IL LZ _j U 0 > U h4 LLJ 0 !00 :5U0 Ent— U3 LU CC W W -SUB BSMT, 0 BASEMENT ,IT FLOOR 2 ND FLOOR 3RD FLOOR 4' FLOOR FLOOR FLOOR 7' FLOOR FLOOR lnstal�- a m e: vfut�� Y,. Address. )k.- I Cit Town:—kl State:&A El Corporation Business Tel: 04-&-336 Fax: El Partnership Name of Licensed Plumb Firm/Company 9L4 �, A- C', INSU I have a current Ra�lnsurant:e policy or its substantial equivalent which meets the' requirements 'of MGL. Ch. 142 Yes El No Ej If You have checked �Les, Please indica e the type Of coverage by checking the appropriate box below. A liability insurance policy. Other type of indemnit . I ,. � Y El Bond Ej OWNER'S INSURANCE WAI ER: I am aware that & licensee does not have the insurance coverage required by Chapter 142 of the - 'NMassachusetts General Laws, and that my signature 011n this pe—r—m—It a_*I��_iica ion waives this requirement. S1 --- Check One only 1A 1 d'�Pe OT Uwn eILOW Ownees Agent OWj10F E] 11 Aclz-� -re,JY certify that all of the details and Information I have ubmitted (or entered) rE Knowledge and that all Plumbing work and installatiolls pe ormed under the permit Pertinent provision,, f th'e Massachusetts State Plumbing de and Chapter 142 of tj 3y Type of License: 'itle -------------- P umber nature of Li fty/Town ------ (4aster - n IF ^ � � 1 7 Journ ym PPROVET) (OFFICE USE ONLY) e an License Numbi are ed __LQ26 _/ LHU Des! 01 my with all 4 The Commonwealth ofMassachusetts DePartment Oflndustria[Acclde�ts Office of Investigationy 600 Washington Street Boston, MA 02111 WWW-Mass-govldia Workers' Compensation Insurance Affidavit: Builders/ContractorsAElectricians[Plumbers mlicant Ynfnrrnn+;nn Name (]3usiness/Organization&dividual): le% — —1 � , C. Address: 0 City/State/Zip: d Phone #:_9 A U an employer? Chee e 2PPropriate box: am a employer El with 4. I am a general contractor and I employees (full and/or Part-time).* 2.E] I am a sole proprietor or have hired the sub -contractors listed partner- oil the attached sh5et T ship and have no employees These sub -contractors have Working for me in any capacity. [NO Workers' comp. insurance workers' cOmP. insurance. 5. El We aie a corporation and its required.] 3. 1 am a homeowner doing all work of ficers have exercised their ]right Of exemption per MGL myself [No workers, comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers, COMD, SuranCe re ;r,-,4 i I)Ipe of project (required): 6. E] New construction 1)-�f Remodeling 8. El ijemwition 9. 0 Building addition 10 -El Electrical repairs or additions II-ElPlumbingiePairs or additions 12.ElRoof repairs ME1 other !Any applicant that checks box #1 must —a U_ ' L . T Homeown ]so fill out the section below showing their workers, compensation policy inforrn&ion. tContracto ers who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. Ts that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' COMP. Policy information. am an eMployer that isproviding workers' coinpensation insu information. ranceJoF MY emPloYees. Below is thepolicy andjob site fnsurance Company Policy # Or Self -ins. Lic. #: Exi3iration Date: Job Site Address: -a z -r e— 4-1 City/State/Zip: Attach a copy of the workers' c OmPensat!On Policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required Wider Section 25A o� c. 152 can lead to the imposition of criminal penalties of a d1or on 'ar as ry penalties in the form of a STOP WORK ORDER and a fine 'n up to e -ye f L.s g up 250-00 da st th 'VIO of this statement may be forwarded to the Office of of � y 0 Env tigations ofle D . f insuran r do hereb v e ain nd en lat the infop"latiouppOVIded above is true and correct. ,ignature. Date: Z�— �_G 'hone 4. �_33- Ofilicialuseonly. DO n0twrlte.in th,ls area, to be completedby city ortown offy-clal City or Town: -Permit/License Issuing Authority (circle one): 1- Board of Health 2. Building Department 3. CitY/TOwn Cle rk 4. Electric 6. Other al Inspector 5. Plumbing Inspector CiOntflef'Pprenn- Information and Instructions Massachusetts General Laws chapter 1.52 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an em plopee is defined as "...every person in the service of another under any contract of hire, express or implied, ora� 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 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 dwelling house having not more than three apartiments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenan . ce, 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 forany applicant who has not produced acceptable evidence of compliance with the insuranc� 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 comp- liance 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) narne(s), address(es) and phone number(s) along with their certificate(s) of - insurance. Limited Li6ility Companies (LLQ 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 qVestions rega�ding the law or if you are required to obtain a workers' compensation policy.; please call the Depal-tirient 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 referencd number. In addition, an applicant that must submit multiple permit/licerise 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 firture permits or licenses. A now 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 affiddvit. 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: rM 111.0 Conunonwoalwh ofMassaclau . setts Depafte,at of 1ndustriall Accidents Office of Investigations 600 Washington Street Boston;MA-02111 Teel. # 617-727-4900 ext 406 ox- 1-877-M-ASSAFE Fax # 617,727-7749 Date. Aov-+O/� ......... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that.. has permission for gas installation Cg M 6-1 in the buildings of ... .......................... at i,�AlrlAkA:� ............... North Andov;ere,ass. 4��t 1<4 Fee.4 ?0. Lic. No.IAAI.. A GASINSPECTOR ,17/, ... 9(,, Check # 78711 1 "-.10 Low � M 50 SUB IBSMT. BASEMENT 15'FLOOR 2"" FLOOR 3"" FLOOR FR—FL—OOR 5 "' FLOOR WH FLOOR VH FLOOR i'—FLOOR MASSACHUSE I 10 UNlt-UKM APPLICATION FOR PERMIT TO D S FITTING City/Town: n: MA. Dat7e::/ 201 t�Permit# Building Location _A 101 Oiners Name: Type of Occupancy: Commercial El Educational E] Industrial E] Institutional El Residential 2r New: Alteration: El Renovation: El Replacement Plans Submitted: Yes F-1 Non FIXTURES W W U) z Cd X 0 0 W 0 W 0 W W z=!>- wonwix 0 z 0 W W D W W 0 1-- M V5 W ca W 0 1-- . 0 < W > W z 1-- < a. I-- C3 W UJ W 1-- co L) UJ U) UJ 0 L) Lu W 0 X P: C3 LL > _j W Z W W z l'- 0 z J 0 z _j W P W W g M W 0 z 0 0 > z 0 LE W W < R Lu u- > 0 9 0 W z W 0 m W i-- = > 0 Installin pany Name: I �iom!P AddressV-6Zt* r)Q City/Tol Business Tel: Name of Licensed Plumber/Gas Fifter '-',I N1 t h -A --j" State: Fax:9)11--W-�—�--360 Check One only Certificate # El Corporation El Partnership PfFirm/Company INSURANCE COVERAGE: 11Z I have a current liability insurance policy or i . ts substantial equivalent which meets the requirements of MGL. Ch. 142 Yes [I No n If you have checked )�es, please indicate the type of coverage by checking the appropriate box below' A liability insurance policy / . Other type of indemnity El Bond n OWNER'S INSURANCE WAIVER: I am aware that the licensee!jOes not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only Signature of Owner or Owner's A —t Owner 0 Agent E3e**'7 �2 By checking this box E]; I hereby certify that all of the det [sand infor-mationi haves accurate to the best of my Knowledge and that all plumbin work and installations pei compliance with all Pe��n!,provislon of the Massachuse State Plumbing Code ani By umber Title as Fitter Signatu Master City/Town Eliourneyman APPROVED (OFFICE USE ONLY1 D LP Installer License N ittea (o tered) regarding 1 r K 71 ed un e the pep 111SNue 'hapte I of th eneral v sed PlumberiGas Fitter /63o/ true and will be In Q Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS, Ch. 139, Sec. 3B To: Building Commissioner or Inspector of Buildings 1600 Osgood Street North Andover, MA 01845 RE: Insured: Michael Staropoli, Jr. & Maria Paone Property Address: 94 Mornin-side Lane W Policy Number: YS8165 Date/Cause of Loss: 9/9/2011, Water Damage/Washer Hose File or Claim Number: 25283-J Claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or cause MASSACHUSETTS GENERAL LAWS, CHAPTER 143, SECTION 6, to be applicable. If any notice under MASSACHUSETTS GENERAL LAWS, CHAPTER 139, SECTION 313 is appropriate, please direct it to the attention of the writer and include a reference to the captioned insured, location, policy number, date of loss and claim or file number. Jim Taylor On this date, I caused copies of this Notice to be sent to the pers named above at the addresses indicated above by First Class Mait, � 17�1 16 - /�? Sig nalbre ja6d) Date ANDERSON ADJUSTMENT CO., INC. 50 Nashua Road, Suite 303 PO Box 1098 Londonderry, NH 03053