Loading...
HomeMy WebLinkAboutMiscellaneous - 337 MARBLERIDGE ROAD 4/30/2018 (2)\\ j I Date.-9/xh ....... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ... . .. . ... ............. e . -Y ................................................... has permission to perform ............... T '`±::............................... wiring in the building of hArA.- ............. / .... V ...... 0 ........ ........................................... at Ie ass. Fee .............. North - h Andover, M Lic. No. Q5.)i ........... ............ . . .......................... ...... & ........................... Check 4t CN Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. BOARD OF FIRE PREVENTION REGULATIONS Occupancy arid Fee Checked [Rev. 11/991 leave blank) 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 IN INK OR TYPE ALL INFORMATION) Date: 8 f�//,� City or Town of: i( oH` �t?CQpt t °� To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) 332 /1/l c;rlo/c ('i d,. ,2 D Owner or Tenant /j/%,f �(/p� S Telephone No. X77? 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 ❑ New Service Amps / Volts Overhead ❑ Undgrd ❑ Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: /6; it 6n, 1"P. mudeJ No. of Meters No. of Meters Cmmnletinn nfthe follnwino tahle may he waived by the Incnertnr nfWirec No. of Recessed Fixtures q No. of Ceil.-Susp. (Paddle) Fans No. of Total Transformers KVA No. of Lighting Outlets No. of Hot Tubs Generators KVA No. of Lighting Fixtures Swimming Pool Above [I In- El rnd. rnd. o. o Emergency Lighting Battery Units No. of Receptacle Outlets 5 No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches �2 No. of Gas Burners No. of Detection and InitiatingDevices No. of Ranges d No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers r Heat Pump Totals: Number Tons I KW I No. of Self -Contained Detection/Alerting Devices No. of Dishwashers l Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems: No. of Devices or Equivalent No. of WaterK`,1, Heaters No. of No. of Si s Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring* No. of Devices or Equivalent OTHER: Attach additional detail i1_desired, or as required by the Inspector of Wires. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE El BOND ❑ OTHER ❑ (Specify:) (Expiration Date) Estimated Value of Electrical Work: 1500,00 (When required by municipal policy.) Work to Start: / 5 Inspections to be requested in accordance with MEC Rule 10, and upon completion. I certify, under the pa s and penalties of perjury, that the information on this application is true and complete. FIRM NAME: /,Jug f -Ji e / LIC. NO.: -8-04/416 Licensee: �o , , >��f 1;ncP� Signature_ / _ LIC. NO.: (if applicable, enter "exe)Apt" in the licAse number line.) Bus. Tel. No.: 978 SS/ 0,2 Address: Alt. Tel. 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. N b 0 The Commonwealth of Massachusetts Deparhnent of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 lim" inass gov/dia Workers' Compensation Insurance Affidavit'. Builders/Contractors/Electricians/Plumbers AQnlicant Information Please Print_Lel=_ibly Name Address: Qq Ngn5cd� AuC Irl, AM o 1 g3 v Phone #: q7$ "5 / O-� Are you an employer? Check the appropriate boat: Type of project (required): LEI I am a employer with 4. Q I am a general contractor and 1 6. F] New construction �ployees (full and/or part time}. * have hired the sub -contractors , fisted on the attached sheet. 7. [2 -Remodeling 2. I am a sole proprietor or partner- ship and have no employees These sub -contractors have g. Q Demolition working for me in any capacity, employees and have workers' g Q Building addition (No workers' comp. insurance comp, insurance.$ 5. Q We are a corporation and its 10.Q Electrical repairs or additions required.] 3. Q I am a homeowner doing all work officers have exercised their 11.Q Plumbing repairs or additions myself: [No workers' comp. right of exemption per MGL 12.E] Roof repairs insurance required.] t c. 152, § 1(4), and we have no employees. (No workers' I3.Q Other comp. insurance required.l *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 are doing a work and then hire outside contzactors 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 state whether or not those entities have employees. if the sub -contractors have employees, they must provide their warkers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lie. Expiration Date: Job Site Address: City/5tate/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 certifypunddeer thheeep'ains andpenahies of perjury that the htformation provided above is true and correct. Siettature• Date: Phone #: %7k SS/ Official use only. Do not write in this area, to be completed by city or town ofciaL City or Town: PermitlLicense # 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 #. 11338 TOWN OF NORTH ANDOVER This certifies that... PERMIT FOR PLUMBING has permission to perform........................................................................................... m ..... plumbing the buildings of....-->.?....-�...�f.. ....!�..1�.r...a...f............................. at........................... :........................................................................... . North Andover, Mass. Fee.. '�O.0. Lic. No....................................................................................................... l PLUMBING INSPECTOR Check #1 TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER [7,____ INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES a NO Di' IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Dk OTHER TYPE OF INDEMNITY Q BOND 0 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 Q AGENT 10 SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. (J Lt� h.i�,i/lP I� PLUMBER'S NAME Y c r1 0 LICENSE # 5 �, SIGNATURE MP dJ JP Q CORPORATION FJj# i PARTNERSH IP D# LLC [4 COMPANY NAME G� ��,. ,� Vat ; ADDRESS CITY �c,r � - ...-_... - _I STATE ZIP D _ TEL 3 '? 071`7 . FAX �� CELL �h� "1.6� / �� EMAIL MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY --k MA DATE[( PERMIT# JOBSITE ADDRESS j 3 A>I c. Y�Jll OWNER'S NAME P OWNER ADDRESS 3 Intra 12 �i c }2 4 k12 TEL o `I FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL © RESIDENTIAL PRINT CLEARLY NEW: E]I RENOVATION: 0 REPLACEMENT: d PLANS SUBMITTED: YES ® Nod FIXTURES -1 FLOOR- BSM 1 2 3 4 5 6 7 S 9 10 11 12 13 14 BATHTUBk CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM _ IF-- DEDICATED DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM { - ..__�( f _ _ __..I _k _J Dk DICATED WATER RECYCLE SYSTEM DISHWASHER �( . • _ ( 1 [ .�._I .-___.._.1 � � _-_-__1 ._.._.._ DRINKING FOUNTAIN FOOD DISPOSER i .. _. _._._.� -----( _.._ f _I ._ -� ._..__1 .__..__( .---._ _k ) ...___ _._._J k ....._.__7 FLOOR/ AREA DRAIN INTERCEPTOR (INTEMOR) KITCHEN SINK LAVATORY k � J 1 } k J ( J k ( 1 _. ___.f ROOF DRAIN ___J SHOWER STALL _[ .__._k ___J ___.k k SERVICE/ MOP SINK _ _ _; �k 1 _ k _. _I I k _..__ E f _ i _-_ III III TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER [7,____ INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES a NO Di' IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Dk OTHER TYPE OF INDEMNITY Q BOND 0 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 Q AGENT 10 SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. (J Lt� h.i�,i/lP I� PLUMBER'S NAME Y c r1 0 LICENSE # 5 �, SIGNATURE MP dJ JP Q CORPORATION FJj# i PARTNERSH IP D# LLC [4 COMPANY NAME G� ��,. ,� Vat ; ADDRESS CITY �c,r � - ...-_... - _I STATE ZIP D _ TEL 3 '? 071`7 . FAX �� CELL �h� "1.6� / �� EMAIL W a Lii W U- • The Commonwealth of Massachusetts F Department ofjndiustrialAccidents M}'� 1 Congress Street, Suite 100 a, •.-_ d _Boston, MA. 02114-2017 �< www mass.gov/dia OiM S��V • Workers, Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERNIITTING AUTHORITY. n ,...amu.• ....._.._ �-- - - r Name (Business/Orgaf&ation/Individual): F V i l L 1 J A Address: Neu �� iNG S� City/State/Zip: Ase you an employer? Check the appropriate box: Phone #: 1.[]i am a employer with ---L. employees (full and/or part-time). 2.00 I am a sole proprietor or partnership and have no employees Working for me in any capacity. (No workers' comp. insurance required.] 3.E] I am a homeowner doing all work myself (No workers' comp. insurance required.] t 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole is i, proprietors with no euaployees. 5 -ElI am a general contracto and T have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.t 6.[] We area corporation and its. officers have exercised their right of exemption per MGL c. 152 §1(4) and'we have iio employees: [No workers' comp. insurance required.] Type of project ()required): 7. ❑ NeVd6nstr6&1on 8. [] R.emodelliig 9. ❑ Demolition 10 ❑ Building addition 11.0 Electrical repairs or additions IZ,Q Plumbing repairs or additions 13T] Roof repairs 14.[] Other *Any applicant that checI bk 01. must also fill out the section below showing their workers' compensation policy nnformation: Homeowners who submit•this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such I Contractors that check ibis Box must attached 'an additional sheet showing the name of the sub -contractors and state whether or not (hose entities have employees. If the sub -contractors have employees, they must provide their workers' comp, policy number. X am an employer that is providing wor kers' compensation insurance for my employees. Below is the policy and jolt site information. Insurance Company N Policy # or Self -ins. LIG. Expiration Date' City/State/Zip: Job Site Address: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). by a fiAb up to 0-00 Failure to secure coverage as require egqu ed a d zvzMp penalties the form of ATOP nal Violation 1RK ORDER and a fine of no to $2050.00 a and/or one-year imprisonment, day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. X do hereby eart�gnder tliepains andpenalties ofperjury that the information provided above istrueand. correct. Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Phone Contact Person: Information and Instaructions 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 enferpri'se, and including the legal representatives of a deceased employer, or the receiver'a trustee 6fan individual, partnership, association or other legal entity, employing emplbyees.. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant ofthe 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 certificates) 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 IndustrialAccidents. 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 thai must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number: The Commonwealth. of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MA.SSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia `��,,,,.,.- '°' CERTIFICATE OF LIABILITY INSURANCE DATE ABOVE FOR THE POLICY PERIOD ANY CONTRACT OR OTHER DOCUMENT WITH 81DOtYYYY) /31 8/31/2015 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 NHeidi Skolnick NAME: Mg: Allmass Fernekees LLL' PHONE (978.. 0013 FAX (978)346 0095 IAtGN2 E>Ii? 17 East Main St ................................Y __....................... _...._.............L.i_tCSN.o1;._......................._._ E-MAILDRSS:heidi@fernins.com Merrimac MA 01860 INSURER(§) AFFORDING COVERAGE NAIC q -- - _ � INSURERA:Preferred Mutual Insurance Co. .... ...__ INSURED Hot & Cold Plumbing � Heating LLC. ..... ......_. INSURER B ................._......_._._..,__...................:....______...,.........._.._._....._..................._................................_..._................._...._...3 - O Eric Watson INSURER C 19 Hathorne Street INSURER D: .......... _.__. -- _ .... ....._ _..�.. _ _. H8verhi 11 MA 01835 INSURER E. _—......................... ......_. _._ __...._....... ....... ...i Idents I BODILY.. ....._ —............_.�._.....__._...__..-. INJURY (Per person) $ INSURER F: nr_VI0IVIV IVVry16CK: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ABOVE FOR THE POLICY PERIOD ANY CONTRACT OR OTHER DOCUMENT WITH CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED RESPECT TO WHICH THIS 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. LTR TYPE OF INSURANCE PMOL�pY EFF POM ERP; POLICY NUMBER 6DY LIMITS COMMERCIAL GENERAL LIABILITY ? I A CLAIMS•MAOE EACH OCCURRENCE $ 11000,000 AMAGE TO RN7ED _. ' i...... --- ? i...........I : OCCUR ( € PREM�SES {Ea oc�o *ence) ) S 50,000 __ ;HOP 0100705252 3J1/2025 3J1/20I6 MED EXP (A ) $ 10,000 (Any one person ............. ------- ------ ( GEN'L AGGREGATE LIMIT APPLIES PER ` PERSONAL & ADV INJURY $ 11000.0_00 k` GENERAL AGGREGATE $ 2,000,000 I PRO• ( POL fCV ; ,......................._..__ ...., JECT (, LOC 'OTHER: _—_...................... i PRODUCTS-COMP/OPAGG $ 2, 000, 000 ...__..........................._.______._..........__ ....................... IS AUTOMOBILE LIABILITY MBILIMIT7 NED SINGLE$ ..._....I ANY AUTO ! ALL OWNED SCHEDULED Idents I BODILY.. ....._ —............_.�._.....__._...__..-. INJURY (Per person) $ ....... AUTOS AUTOS ? ! BODILY INJURY (Per 1 $ ....... i _ HIRED AUTOS ;AUTOS NON -OWNED 1 .... accident) PTY DAMAGE _— 15ROER S $ ' UMBRELLA UAB � p OCCUR I I 1 EXCESS iE {_ACH OCCURRENCE $ ...._ LIAB - j CLAIMS -MADE _.. i AGGREGATE $ I DED RETENTIO» .................( r_...._ _._.__.. _.. � $ WORKERS COMPENSATION PER UTH AND EMPLOYERS'LtABiLITY Y/N1 I STATttJTE .. ER ANY PROPRIE70PIPARTNERIEXFCUTIVE OFPCER/MEMBER EXCLUDED? E 1. EACH ACCIDENT $ (Mandatory NH) _ E.L. DISEASE EA yes. If es. describe under b !DESCRIPTION - EMPLOYE15 $ ............................. . _.. . _ ... ..........___........... _.... ....__.____._.,.,._...... OF OPERATIONS below i E.L. DISEASE - POLICY LIMIT $ i f r } DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached H more space Is required) /'�G�4t Cl/+ATC uf�f f1t•f1 Town of North Andover 1600 Osgood St North Andover, MA 01845 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Heidi Skolnick/£AURA 4-r 1i I& 1ZVOO-ZU14,At;UKU cuH:PORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD INS025 (201401) _-_-__-___--_-`` ----_ ' ---' � .`~~-~__�' � J- -' ~-� � Date .................. E 3 ........... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that .................. .... . ........ has permission for gas installation inthe buildings of ........`A. ...... ........................................................... at ... 3:Z?l ...... ' North Andover, Mass. Fee �� ....... Lic. No. ...... ................................................................... GASINSPECTOR Check # MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK F CITY I N. Andover MA DATE 7/31/2014 PERMIT # JOBSITE ADDRESS 337 Marble Ridge Rd OWNER'S NAME G„_.... OWNER ADDRESS I Same TE�_ JFAX TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL ® RESIDENTIAL❑ PRINT CLEARLY NEWU RENOVATION: ❑ REPLACEMENT: ® PLANS SUBMITTED: YES❑ NOE] APPLIANCES 7 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER i BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR r FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER --------------------------------- Replace 1 Gas Meters x and Associated Pi i I INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES []NO ❑ I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ❑ OTHER TYPE INDEMNITY ❑ 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 ❑ 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 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 co liance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME Joseph Marino LICENSE # 8736 SIGNATURE MP ❑ MGF 0 JP ❑ JGF ❑ LPGI ® CORPORATIONE]# 3285C PARTNE HIP®# LLC ❑#� COMPANY NAME: RH White Construction Co ADDRESS 141 Central St CITY I Auburn STATE MA ZIP 01501 �DTEL 508 832-3295 �� FAX 508-926-4347 CELL 508-832-4614 EMAIL JMarino@RHWhite.com ROUGH GAS INSPECTION NOTES I THIS PAGE FOR INSPECTOR USE ONLY I FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE; $ PERMIT # PLAN REVIEW NOTES I �C ® (MM/DD�YYYY CERTIFICATE OF LIABILITY INSURANCE rag. 1 of �[TAT /29/2013I THIS 0ERTiFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERIN-ICATE 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 holderis an ADDITIONAL INSURED, the Policy(ies)mu6t 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 notconFerrights to the Certificate holder In lieu of such endorsement(s). willi4 04 MaeaachuaHtte, Inc. C/o 26 CQntury Blvd. P. 0. Box 305191 XRMI%ville, TN 37230-5191 R. X. White Construotion Company, Inc. 41 Central Street P. 0. Box 257 Auburn, MA 01501 a i,36M INSURERA:The Charter Oak Fixe Ineuranag INSURER 9:Tr1LVQ1AVS Property Casualty Co INSURER C:NatiOnal Union Piro Ineurancm INSURERD;Traveyers Indmmnity Company INSURER E: NAIO rt ny 25615-001 oi' Am 25674-009 y o£ 7,9445-001 25658-D01 �....,.r.��� L r_K1U-IUA1r INUML5hK:20267680 REVISION NUMBBR; THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD IN171CA7ED. 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. TYPE or- IN A[GEN ERALLIABILITY IMFRCIAL GENERAL LIAAII.ITY CLAIMS -MADE OCCUR PER; B AUTOMOBILE LIABILITY X ANYAUTO AUTOS NED AUT08ULEI X HIRtrDAUTDs X NN-OWNED AUTOS X Comp Defl I Y Coll Ped -EXsdgAs H �s�eI� DED I F. RETENTIONS =0,000 D WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN D ANY PROPRIEToR(PARTNERlEXECUTIVEf ;1 N(A OFFICERIMEM9ER EXCLUDED? MvandatoN In NH) Ue'�nel+ i IUN Uh UPURATIONS below rE xvidence of Inourance VTC20co 97789949-13 19/3./2013 19/1/2014 977R955A.-7.3 4/1/2013 19/1/2014 BE8766140 9/1/207,3 19/1/2014 LIMITS EACH OCCURRENCE O RENTED 3(Eaocemonccl -, �;E 300,QOC MEDESLP(AnYone arson S 10,0QC PERSONAL INJURY $ 2 QD-0, 000 GENERAL AGGREGATE $ 41000,000 PRODUCTS-COMP/OP AGO, ', 000500 NN acel16Dj INGLELIMIT $ S 2,000,00(l BODILY INJURY(Perperson) $ BODILY INJURY(Persooldent) $ VTRRUB 8205A185-13 19/1/207.3 19/1/203,4 S 3.A VTC2RUB A2071A-13 9/1,/2013 9/1/2019 E.L. E.L. DISEASE -EA EMPLOYE. E.L. DISEASE- POLICY LIMIT epeeo 1,000,000 1,000,000 1,000,000 SHOULD ANY OF TWE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, AUTHORISED REPRESENTATIVE Coll,*4197604 TP1:1694012 Cert::20287680 ©1988-2010ACORD CORPORATION. All rights reserved. CORD 25 (2010/05) The ACORD name and logo are registered ,narks of ACORD Date. NORTH TOWN OF NOS HANDOVER PERMIT FOR PLUMBING This certifies that ..........................'................. . has permission to perform -�? ^. —r `....' ..- .............. . plumbing in the buildings of ....... ..................... at. `--' . ..... � ............. ; North 'Andover, Mass. Fee&(`? .77. Lic. No . 'a�% + 0 GZ.� P 11 G INSPECTOR Check !/ 7638 ■r MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO. DO PLUMBING (Print or Type) j t � OA4 NNc� off. , Mass. Date 1 20�01_Permit# 2��3Y Building Location 331 V' 1 ir-we rd rr �� I�fA Owner's Name I SOV I- ^ I , New ❑ Renovation ❑ Replacement ❑ FEATURES W Type of Occupancy Plans Submitted Yes ❑ No ❑ Installing Company Name �U6�Te��l9w�b\f1Q—�e�'an. AddressyO (�M 2\$ Check one: S( Corporation ❑ Partnership Certificate Business Telephone R l@,—_�i ❑ Firm/Co. _ Name of Licensed Plumber 44-�"`A7"s 1 INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch 142. Yes A No ❑ If you have checked yes, please indicate the type of coverage by checking the appropriate box. A liability insurance policy*l Other type of indemnity ❑ Bond ❑ OWNERS 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 ❑ I herebycertify 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 installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. By ''C ` igna ure OT Licenseau er Title Type of License: Master X Journ man ❑ City/Town License Number m�`�`011 ■■■■■■■■■■■■■■■■■■■■■■■■■■■ [Won W-0101; .. - ■■■0010001 ■■■■■■■■■■■■■■■■■■ 11 Installing Company Name �U6�Te��l9w�b\f1Q—�e�'an. AddressyO (�M 2\$ Check one: S( Corporation ❑ Partnership Certificate Business Telephone R l@,—_�i ❑ Firm/Co. _ Name of Licensed Plumber 44-�"`A7"s 1 INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch 142. Yes A No ❑ If you have checked yes, please indicate the type of coverage by checking the appropriate box. A liability insurance policy*l Other type of indemnity ❑ Bond ❑ OWNERS 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 ❑ I herebycertify 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 installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. By ''C ` igna ure OT Licenseau er Title Type of License: Master X Journ man ❑ City/Town License Number m�`�`011 This certifies that ....... Ki ........................... has permission for gas installation' -:4 in the buildings of .......... at .... ........ -,North Andover, Mass. .... FelOP?'. Lic. No.... -Pop .. ................ GAS INSP CTOR Check # �Ile 6305 Date .... T TOWN OF NORTH ANDOVER PERMIT FOR -GAS -INSTALLATION This certifies that ....... Ki ........................... has permission for gas installation' -:4 in the buildings of .......... at .... ........ -,North Andover, Mass. .... FelOP?'. Lic. No.... -Pop .. ................ GAS INSP CTOR Check # �Ile 6305 8p MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) Mass. Date 20 Oi Permit# Building Location ���liq�,(�3�C�PT Owner's Namef'as t Type of Occupancy New ❑ Renovation ❑ Replacement Plans Submitted Yes ❑ No ❑ Installing Company Name V n _P1i0V11\0'yNA CIO Address �© a \g �MT-\ 0 Check one: Certificate I( Corporation ❑ Partnership Business Telephone �' ❑ Firm/Co. _ Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch 142. Yes X No ❑ If you have checked yes, please indicate the type of coverage by checking the appropriate box. A liability insurance policy Other type of indemnity ❑ Bond ❑ OWNERS 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 ❑ 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 installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. By Type of License ❑ Plumber Title ❑ Gasfitter 9iigna_tt7r&9f L cen d PGas I mber or Fitter 199. Master �* _k r'ih rrnmin n 'Anurnevman License Number ` e cA • • Installing Company Name V n _P1i0V11\0'yNA CIO Address �© a \g �MT-\ 0 Check one: Certificate I( Corporation ❑ Partnership Business Telephone �' ❑ Firm/Co. _ Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch 142. Yes X No ❑ If you have checked yes, please indicate the type of coverage by checking the appropriate box. A liability insurance policy Other type of indemnity ❑ Bond ❑ OWNERS 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 ❑ 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 installations performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. By Type of License ❑ Plumber Title ❑ Gasfitter 9iigna_tt7r&9f L cen d PGas I mber or Fitter 199. Master �* _k r'ih rrnmin n 'Anurnevman License Number ` e cA Date..7,/' ............ . TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION a O This certifies that f4-. <` r'! � 1'6 1 _ ' / ! 1 / f ` o has permission for gas installation . :A ................. � in the buildings of . r A..; .............................!11�. at5...'. ! .-.t!, :: : !.r.<. Y:........, North Andover, Mass. Fee./° ..... Lic. .......................... GASINSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: File Installing Company Name METROPOLITAN PLUMBING& HEATING Check one: Certificate Address Norwood Commerce Ctr , Bldg. 21 ® Corporation ErR11con Street NORWOOD MA 02062 ❑ Partnership Business Telephone 151 f) 16WI 779 ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter 4v/ z,z"7/ / INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes IN No D If you have checked Les, please indicate the type coverage by checking the appropriate box. A liability insurance policy E1 Other type of indemnity ❑ Bond D 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: OwnerD Agent ❑ Signature of Owner or Owner's Agent I hereby certify that all of the details and information I have submitted for entered) in above application are true and accurate to the best of my knowledge -and -that all-plumbing-wo-k nd'7nstallations performed under the permit issued for this application will be in compliance with all per�ttinent'provif ions of 'he['Ma tsachusetts Mate Gas Code and Chapter 142 of the General Laws. r l5 t? ti ,; u_ �� T e of License: r l 61994 {w ` Plumber Signature of Licensed Plumber or Gas Fitter }� Title ! ;; Jf 3 Gasfitter I ' -" i Master License Number Iq w`J City/Town _� Journeyman APPROVED (OFFICE US - _ONLY E N N ¢ W N Y Z ¢ N N ¢ N ¢ O N = W W J N ¢O Wcc H U in f' S N O L Q ¢ ¢ O . N t9 w ._ `y LU Q .O �_ CL p 19 Ir - _ N W W N W Z U Q = . ¢ ¢ _Z 0 ¢ W ~ o.>_ W V W = H ¢ N f. W X 4 .W .. 4 C �. >- N Z p E O t~A S ¢' x O t9 Y a .a .o 4 c9 C U c> c a F- O I SUB—BSMT. BASEMENT IST FLOOR _ 2ND FLOOR 3RD FLOOR 4THFLOOR I STH FLOOR 6TH FLOOR 7TH FLOOR 8TH FLOOR Installing Company Name METROPOLITAN PLUMBING& HEATING Check one: Certificate Address Norwood Commerce Ctr , Bldg. 21 ® Corporation ErR11con Street NORWOOD MA 02062 ❑ Partnership Business Telephone 151 f) 16WI 779 ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter 4v/ z,z"7/ / INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes IN No D If you have checked Les, please indicate the type coverage by checking the appropriate box. A liability insurance policy E1 Other type of indemnity ❑ Bond D 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: OwnerD Agent ❑ Signature of Owner or Owner's Agent I hereby certify that all of the details and information I have submitted for entered) in above application are true and accurate to the best of my knowledge -and -that all-plumbing-wo-k nd'7nstallations performed under the permit issued for this application will be in compliance with all per�ttinent'provif ions of 'he['Ma tsachusetts Mate Gas Code and Chapter 142 of the General Laws. r l5 t? ti ,; u_ �� T e of License: r l 61994 {w ` Plumber Signature of Licensed Plumber or Gas Fitter }� Title ! ;; Jf 3 Gasfitter I ' -" i Master License Number Iq w`J City/Town _� Journeyman APPROVED (OFFICE US - _ONLY E J z 0 W N w U W 0 a O W J W W W LL 0 z P t - b'., N Q O O 0 O h' f" O w Z wa rc O LL. z _O U J a CL a O z 0 _J M O LL 0 w a r w w O z J Jk 0 r W Z N W i O a J z 0 W N w U W 0 a O W J W W W LL 0 z P t - b'., N Q O O 0 O h' f" O w Z wa rc O LL. z _O U J a CL a O z 0 _J M O LL 0 w a r w w O z J