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Home My WebLink AboutMiscellaneous - 351 WILLOW STREET 4/30/2018 (6)1 ys - �rt, - -rt ,' �i�. Date ....... ..........,.:.............. TOWN OF NORTH ANDOVER PERMIT FOR WIRING Thiscertifies that .................... Q4.................................................................................... .... has permission to perform ....�1y 1.�.......�� ...1f�..�t. ^�.... wiring in the building of,,,,,,,.!. ,....,-„a�?. ........................................................ at ................`.........W,� l.inJ......... > North Andover, Mass. i Fee......... .15- ... Lic. No. I. ..:. .................................................................................... Check #� ELECTRICAL INSPECTOR 4� V 1I Co�nmonsvealllt of V.6'aa•1.46016 Offcia{ Use Only IVOccAff�� j Ermo Igo.— earbneal 4".. JArvico3 1 - l) i BOARD OF FIRE PREVENTION REGULATIONS 3 upancy and Fee Checked [Rei. }/07) (lease blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL table ,tar he haired M the his ector of Ptres WORK All work to be performed in accordance with the Massachusetts Electrical Code (VIE )• 527 CMR 12.00 (PLEASE PRINT IA'I.AIK OR TYPE ALL I.NFOR.IAATION) Date: Z City or Town of ° ° eta giTo the Inspecto • o Wit -es: By this application the undersigned ves no icWhis orhLer intention to perform the lectricaI work described below. 3 Location (Street & Number)_ � (A II b� �� c�� l Transformers K A Owner or Tenant lc 0 Telephone No. Owner's Address Is this permit in conjunction with a building per tt? Yes ❑ No Purpose of Building (�(�,�r� . (Check Appropriate. Box) ' 60 Generators ICA'A `-�-1' 1ML Utilih, Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Battery' Uniitgcencv tg ting New Service Amps / _Volts Overhead ❑ Cndgrd ❑ No. of deters Number of Feeders and Ampacit• FIRE ALARMS No, of Zones Location and Nature of Proposed Electrical Work: No. of Recessed Luminaires No. of Luminaire Outlets No. of Luminaires No. of Receptacle Outlets FOfSwitches isposers No. of Dishwashers Ino. of Dryers . No. of Water ham, Heaters No. Hydromassage Bathtubs OTHER: Completion o%the jollrnrin table ,tar he haired M the his ector of Ptres No. of Ceil.-Susp. (Paddle) Fans ° ° eta 3 Transformers K A No. of Hot Tubs Generators ICA'A Swimming Pool Abovrnd.e F1 rnd. ❑ Battery' Uniitgcencv tg ting No. of Oil Burners FIRE ALARMS No, of Zones No. of Gas Burners No. o Detection and Initiating= Devices �! No. of Air (end. Tota ne No. of Alerting Devices _31 Heat ump um er ons Totals: ° o e - ontaine DetectionlAlertin !{ Space/Area Heating KW Devices 1 ocal j unicipa t ' Connection ❑ Other fi Heating ApplianceshW Security systems:No. 0.0 of Devices or E uiivalent 0.0 Si ns BallastsDevices Data Wirin er E uivalent No. of Motors Total HP c ccommuntcahonsNV trtng: No. of Devices nr F...... •.`3..... Estimated Valu of Eleclrieal Work `Ft' Ittach additional detail ijdesu•ed. or as regrured by the Inspector of wires. 3 (When required b-% municipal polies• ) Work to Start:_ Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived p 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 c�ov,e�ra a is in force, and has exhibited proof of same to the pen -nit issuing office. CHECK ONE: INSURANCE [;? BOND ❑ OTHER ❑ (Speeifi FIRM NAME: �: ) I certify, under the pains and penalties of perjury, that lite it formation on this application is trite and complete. �;-'�# nature I.I.W.?SO Licensee: (lfapplicable. enter eremj�t tie license nianber line.) Sig LIC. NO.: Address: Bus. Tel No.%-E!8� TeL No *Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "S•` License; .fit. L c, No..: OWNER'S INSUW%NCE WAIVER: I am aware that the Licensee does not ;are the liability insurance coverage normally required by law. By my signature below. I hereby waive this requirement. 1 am the (check one) ❑ ONNmor o��mer S A Cnt. Owner/Agent Signature Telephone No. PERMIT FEE: )�� CThe Commonwealth of Massachusetts Department of IndustrialAccidents a 1 Congress Street, Suite 100 Boston, MA. 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE PILED WITH THE PERAUTTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): r ibt y S y S t em , I n c City/State/Zip: c a„n„ R M n n, 906 Phone #: Are you an employer? Check the appropriate box: 1. MfI am a employer with c;7#' employees (full and/or part-time). 2. ❑ I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ 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 proprietors with no employees. 5. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.t 6. ❑ We are a corporation and its officers have exercised their right of 'exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 7. ❑ New construction 8. ❑ Remodeling 9. ❑ Demolition 10 ❑ Building addition 11.0 Electrical repairs or additions 12. ❑ Plumbing repairs or additions 13. ❑ Roof repairs 14. E] Other:5 E ez Rv? S yS7-e, *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'do�4g all work and then hire outside contractors must submit a new affidavit indicating such $Contractors 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 workers' 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: Travel prG Casua 1 ty K Ri rp-t-.T rr) Policy # or Self -ins. Lic. #: $�F$ `� 8-0 Expiration Dater r, _ 1-6 _ 2 C) 16 Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of Investigations of the DTA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Signature: Date: Phone #: Official use only. Do not write in this area, to be completed by city or town official City or Town: ;, `, Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #• DAVCSEC-01 LOOM CERTIFICATE OF LIABILITY INSURANCE CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE DATE(MhvIDDKYWj VV„R•..•�'" 6!1$1216 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. MPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the poll cy(les} must be endorsod. If SUBROGATION IS WAIVED, subject to tiro terms and conditions of the policy, certain policies may require an endorsement. A statomont on this certificate does not confer rights to the , cortlfic_ato holder In Ileu of such endorsement(6) ; f+f I:gUCLR - •• .. t:ON^CACT • - i Saium-.Five insurance Services, LLC AAMk' 445 Main Street PHONE rFax IArc, No, c <o: (781) 933.3100 luc. N• : T81 933•9!)4i Woburn. MA 01An1 EMAIL li. Q., RCD Davco Security Systems Inc PO Box 1208 Saugus, MA 01906 ADDRess: Insurance.servicesd)saiomfive.com INSURER($) AFFORDING COVERAGE NAIC # INSURER A: Everest Insurance Company _ INSURI•R H: Travelers Cas & Surety Co of AAA ;34194 � 1 INSURER C; — INSURER D: INSURFR F: I INSURER F {� _COVERAGES CERTIFICATE NUMBER~ _ _ REVISION NUMBER: _ i 1 S TQ CLR1'iFY THAT 1 Hk'. POLICIES OF INSURANCE us,rEU BEt OW HAVE ESFsF'N ISSIJE•'J�T'0 THE tNSUR2 O NAMED AHOVE FOR THE POLICY PER.00 I ,U• )A'ED NOTWITHSTANDING ANY REQUIREMENT TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENTWITH RESPECT TO WWCH THIS j 4 1ICATL MAY nE ISSUED OR MAY PERTAIN, THE INSURANCE ArrORDCO BY THE POLICIES DESCR,OGO FIEREIN IS 8U8JECI 1'0 ALL THF- 11 -RMS ; �Gt.t„1CNS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE SEEN REDUCf-.D BY PAID Cc AIMS _f I TYPE OF INSURANCE_ _ _ INSO„VWQ _ POLICY kUMOCR t' L) Y F UT 4:XF A I X COMERCIAL GENERAL LIABILITY �_—, (MM/DDANW) (MM%DOMYYi,I —LIMITS My „ CLAIMS MALE OCC'JK :cN'L!wC)tEU/; (E un•)I i' nPl�„r5 I;:H. X I ot],,rV dF I 1 AUYUMOUILE LIABILITY B •: ' r^JrC L OwVNED X I SCtIEr JLEJ AU�IJS X • ntLC, «uT05 X • NON•OWNrD • X UMORELLA L1A6 ; •X UL;r;UH� ' q excess uAls X 161GL007281-151 CLAMS MAUI DELI RETVNI',ONS 10,000 WORKERS COMPENSATION AND EMPLOYERS' LIAHIL 11Y B ANV I N Y t�1t1JFHI�rLtk.NAk1 NbH;kX1-CU'1'IVr „ - CI H MI MIbF.H rXCLUDED? , N N I A UNatldato,Y M NH) . ..�:•.I �- an ��r.�apT ONs nn•n,v CCO02642.1 b1 US7E851801 FACH U(:C:JHHEIK:E S 1 06!1612015 06/16/2016 UVAt: TQ REST= PgrI`A: yr•S .Fa uax,rre-t-w) $ MEL) E%rr ;Any une peau-) PER804A1 & ADV !N.URY S GcNEnALA(:Gstl:;;AtE S PROW,. -S- AGG S I s ^.•_ ,••• v COMHINm s :NG r I IMI- s „Lf y „e.641'„ 11 09116120191 0 611 612 01 6 t U001LY IN.,"RY (Pct j:c-ca;n. S 1,0 1.0 ^Ut t;cri:-,OM1 Or OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Add,tlon01 RIMOrks Scbodulo, may bo Ottoohod if morn spado Is roquired) 1 CERTIFICATE HOLDER CA 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 I ACORD 25 (2014/01) The ACORD name and Togo are registered marks980 ACORD D CORPORATION. All rights reserved, 80:11LY IMICRY (Per Ma4uIl S L—Rf4r- a061161201606/1612016 06116/2016' 0 AGCRFOA?' _ S 06/16/2016 06/1612016 r t rACnA: ctoSvr 5 .:, r,.SI'ASF. rA rM=I Oyrr.a _ r = t O, ICV I tMIT 1 S 1,0 1.0 ^Ut t;cri:-,OM1 Or OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Add,tlon01 RIMOrks Scbodulo, may bo Ottoohod if morn spado Is roquired) 1 CERTIFICATE HOLDER CA 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 I ACORD 25 (2014/01) The ACORD name and Togo are registered marks980 ACORD D CORPORATION. All rights reserved, MMOR HJOF -digArs %-.11E S* F-0 L LOW I:N:G DID Mr CONTRACT.JF SU-U-k-ITY-jfSTE,MS- - I-At E B 61�06-- b 4' 23V 12 1 tl� 36MAP040'. - 5a-45 3 SSCO-000355 Frederick W Davis 6 Webb Place Saugus MA 01906 MOVIrf-I �� 04/0412017 Date ........ TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies.�. .......... ... . 44..p.` . -j- W4 �k?...... ..�.......................... has permission to perform ....... -.....................U.v.\e...z ...- ... ...... ................. wiring inthe buildingof................................................ at ........,�`.1..... ��4,1.! {.l.blj!....�....................................... . North Andover, Mass. � ELECTRICAL INSPECTOR `Check # LY e \1 Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. jbit Occupancy and Fee Checked [Rev. 1/071 (leave blank APPLICATION FOR PERMIT TO PERFORM .ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code QfEQ, 127 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: /S" /S City or Town of: NORTH ANDOVER To the Inspecto of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street &Number) 05% �7/l��+r A) _- Owner or Tenant Owner's Address '7,S 1 0 Is this permit in conjunq_wn with a building permit? Yes ❑ Purpose of Building_N %✓Sy Telephone No. No J�d (Check Appropriate Box) Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters NewServicei;00 Amps by /�nVolts Overhead ❑ Und rd g ❑ No. of Meters Number of Feeders and Ampacity / Location and Nature 4)f Proposed Electrical Work: GSttf %�QfieG/!'IC�.1 C't'✓>Ge l i 1 — Ij— � .4_ ('mlotion nffho .,. .. h., ,....;...,A 7... A— No. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑In- ❑ nd. Md. o. of Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS I No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total No. of Alerting g Devices No. of Waste Disposers Heat Pump Totals: Number Tons "" ' """""' KW "."".............. No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systemsti No. of Devices or Equivalent No. of Water KW Heaters No. of No. of Si ns Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or E uivalent OTHER: U-jAttach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical[ Work: �d , �+D0l) (When required by municipal policy.) Work to Start: / �S� Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE O RAGE: 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 ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under the ins and penalties of perjury, that the tnfor ation on this application is true and complete FIRM NAME: t QLI`712r c �t C.L LIC. NO.: Z- Licensee: l✓Q;r Signature _LTC. NO.: (If applicable, enter "exe t" i the license number li e.) �G7v'��/+�1T►'— Bus. Tel. No.; Address: S6 w E Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. Iam the (check one El owner El owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE. $1 Z� . _-p q�-+-� �r �q�y rpm- �r •��+ r� , ' � , _. Ju.IJJee�J..LiJ.4.. L�E�yr��iJ�.�-'.�I.y�.AJ.L1�1I®N.SPET .fU.`S1��ECJLJ.�J.V JC'�.fuP��JI: 1 I.ROU. 'arse -- [ ^Failed- [ j ?fie -inspection regtu ref[($50.(0) - j j inspectors' co)Innents: (Xnspectors' Signature-nonizals) Date 3. UM +"R GROUM XNSPECTION: Passed-[ j Failed— [ j Re -Inspection required ($60.00) - [ j Inspectors' comments: (inspectors} Signature - no Initials) Date D 0 O TAGS A13 TO BE FAI ND OUT AND LEFT ON SITE IF THE AREA. TO BE INSPECTED IS.WOT .ACCESSIBLE AND A RE WSPECTION OF X50.00 IS TO BE CHARGED. ..,., « .. . \I m ° . � - � � •� .� \ .© u 7 r-4 Is® � < >cot �m . of -Jy . « ! \ & . e�\ .. _�. . o« - � » � y � m� � < : ^ . r L & � t �:.Ln < < ym. • " The Commonwealth of Massachusetts ! Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print I,esibly Name (Business/Organization/Individual): Piquette & Howard Electric Service, inc. Address: 222 Plaistow Road City/State/ZI : Plaistow, NH 03865 Phone #: 603-382-3182 Are you an employer? Check the appropriate box: Type of project (required): 1. ® I am a employer with 50 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6 E] New construction 2. ❑ I am a sole proprietor or partner- listed on the attached sheet: 7. ❑ Remodeling ship and have no employees These sub-contractors have g, ❑ Demolition working for mein any capacity. [No workers' comp. insurance employees and have workers' con P• insurance.t 9. f-1 Building addition required.] 5. ❑ We are a corporation and its 10.g Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4), and we have no l 3.❑ Other employees. [No workers' comp. insurance reouired.l •Arty applicant that checks box M must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. lam an employer that isproviding workers' compensation insurance for nV employeex Below is thepollcy and job sate information. Insurance Company Name: The Travelers Indemnity Company Policy # or Self -ins. Lie. #: UB1C349231 Expiration Date: 09-01-2015 Job Site Address: 351 Willow Street City/State/Zip: North Andover, MA 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. Ido hereby certif nder thepdi cod penq es of perjury that the information provided above is true and correct Phone #: 603-382-3182 Offid l use only. Do not write in this area, to be completed by dty or town ofclaL City or Town: PermiMcense # Issuing Authority, (circle one): ). Board of Health 7. Building Department 3. City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector 6. -Other Contact Person: Phone#: PIQUE -1 OP ID: JO ..,1 CERTIFICATE OF LIABILITY INSURANCEDATE(MM/DD/YYYY) 10/08/2014 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 Foster Sullivan Insurance 163 Main St. North Andover, MA 01845 Michael J. Foster CONTANAME: Brian Clancy (AIiCN o EEll:978-686-2266 FAX No): 978-686-6410 E-MAILss: bclancy@fostersullivangroup.com INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: TRAVELERS INSURANCE CO 19046 INSURED Piquette & Howard Electric Service Inc 222 Plaistow Road Plaistow, NH 03865 INSURER B: UNDERWRITERS AT LLOYDS 15792 INSURERC: INSURER D : INSURER E: INSURER F: rnVFRArFC rr-RTIFIr:ATF NIIMRFR• REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL BR POLICY NUMBER EFF MMIDDYIYYYY POLICY EXP MMIDDIYYW LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE FxI OCCUR X..C.UCOVERAGE CO5549M436 CONTRACTUAL LIABILITY 09/01/2014 09/01/2015 EACH OCCURRENCE $ 1,000,00 MAGE TO RENTED PREMISES Ea occurrence $ 300,00 MED EXP (Any one person) $ 5,00 PERSONAL& ADV INJURY $ 1,000,00 APPLIES GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: RO LOC POLICY X PECj PRODUCTS - COMP/OP AGG $ 2,000,00 $ A AUTOMOBILE LIABILITY X ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON OWNEDPER HIREDAUTOS AUTOS 8106684M970 09/01/2014 09/01/2015 COMBINED SINGLE LIMIT 1,000,00 Ea accident $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ — ACC DDAMAGE $ A X UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE CUP6684M982 09/01/2014 09/01/2015 EACH OCCURRENCE $ 5,000,00 AGGREGATE $ 5,000,00 DED I X I RETENTION $ 10000 $ A WORKERS COMPENSATIONWC AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE YIN OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If Yes, describe under DESCRIPTION OF OPERATIONS below N / A UB1 C349231 09/01/2014 09/01/2015 STATU- OTH- X TORY LIMITS X ER E.L. EACH ACCIDENT $ 500,00 E.L. DISEASE - EA EMPLOYEE $ 500,00 E.L. DISEASE - POLICY LIMIT $ 500,00 B PROFESSIONAL LIAB S67300019 07/18/2014 07/1812015 1,000,00 1,000,00 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Town of North Andover, MA 1600 Osgood Street 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 U 19Ut5-ZU1U ACUKU cUKrUKA I wN. All rlgnts reservea. ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD Date.4/ TOWN OF NORTH ANDOVER PERMIT FOR WIRING ou'- ..... ... �....�..�... . ....... ......This certifies that ........... ........................................... 7f� ....... ................................. has permission to perform ... ......... wiring in the building of ........ -j .......... .......................................... / I'-), � /C ),) dove at................................................................................. ... ........ . North An Mass. Fee......` -;-Vo Lic. No--�VPR ............... ................. ..................... -�Czli---- T"* (0600- zb*- ELECTRICAL Check # c2 67S -/ Commonwealth of Waieachuaetts 2epartment ol3ire Services BOARD OF FIRE PREVENTION REGULATIONS Print Form Official lUUse 1Only Permit No. �_�2- Occupancy and Fee Checked [Rev. 1/071 (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: April 02, 2015 City or Town of: North Andover 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) 351 Willow Street Owner or Tenant Bake N Joy Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ Purpose of Building Industrial Manufacturing Existing Service Amps / Volts New Service Amps / Volts Number of Feeders and Ampacity No Q (Check Appropriate Box) Utility Authorization No. Overhead ❑ Undgrd ❑ Overhead ❑ Undgrd ❑ No. of Meters No. of Meters Location and Nature of Proposed Electrical Work: Engine room upgrade for new spiral freezer. Providing power for new refrigeration equipment, spiral freezer, conveyor system, and reconfiguring packaging equipment. Comoletion of the following tahle may he wnived by the tncneclor nf If;— No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above In- rnd. ❑ rnd. E]Batter o. o Emergency Lighting Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. o TDetection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices g No. of Waste Disposers Heat Pum Totals Number Tons KW No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems: No. of Devices or Eq uivalent No. of WaterKWNo. Heaters of No. of Si ns Ballasts Data Wiring: No. of Devices or E uivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: $55,000.00 (When required by municipal policy.) Work to Start: April 04, 2015 Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability 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 ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is ue and complete. FIRM NAME: Piquette & Howard Electric Service, Inc. x,C. NO.: 392 MR Licensee: Robert B. Howard Signatur LIC, NO.: (Ifapplicable, enter "exempt" in the license number line) Bus. Tel. No.: 603-382-3182 Address: 222 Plaistow Road, Plaistow, NH 03865 Alt. Tel. No.: *Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: 1 am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent rr Signature Telephone No. J PERMIT FEE: $ el- � f,;r,,S � e�e - 3 ��1 x,11 vL, ;tib (A � 1 � -1q— �s� Ala12 Date .... ........ TOWN OF NORTH ANDOVER PERMIT FOR WIRING �, This certifies that ........I.P . ....... .. . ............................................. > has permission to perform ....................... e .......... wiring in the building of . ..... at ................................................................... I.Z-,q-a .... ...................... . Orth Andover, Mass. Fee .. ............ Lic. No. .............. .......... ... 7z/ INSPECTOR Check * 2 ff 'SIU -1`+ VIA, 12 ��,'1 7 Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. Z-02--1 Occupancy and Fee Checked [Rev. 1/071 (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC 527 C vlR 12.00 (PLEASE PRINTWINK OR TYPEALL INFORMATION) Date: t/� &.5 City or Town of. NORTH ANDOVER 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) BA% Owner or Tenant S/ ai /'(ow 51- o ,g% Telephone No. Owner's Address Is this permit in conjunction with building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building AdYy ✓LS Utility Authorization No. - Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: /Ii-16AC, Completion ofthe followinz table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑In- F1o. rnd. rnd. o Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: Number " "' Tons "''" KW """..............Detection/Alerting No. of Self -Contained Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KW Heaters No. of No. of Signs 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 if desired, or as required by the Inspector of Wires. Estimated Value of Flectrical, Work: (,� (When required by municipal policy.) Work to Start: /� Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless _ the licensee provides proof of liability 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 ❑ BOND ❑ OTHER ❑ (Specify:) X certify, under the ins ��nd penalties of erjury, that th formation on this application is true and complete. j FIRM NAME:. l tan C LIC. NO.: 149/ CD 6 / Fl — Licensee: 1YI11v/ty 04 Signature LTC. NO.;� 22 (If applicable, enter "exef t" in the license num line.) Bus. Tel. No.- z 47 Address: /o8 � Z -tomr a 9�0 i4an Alt. Tel. No.: 051f *Per M.G.L c. 147, s. 57-61, security work require epartment of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent PERMIT FEE: $ Signature Telephone No. t t_e ase. vire N1 5 . ✓ t IU eYP • -1'', k' ?-0 �V-P . ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance -with the provisions of M.G.L. c. 143, § 3L, the a permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filer?' �� Q on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an 1 r electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shall be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012. ❑ Rule 8 — Permit/Date Closed: *** Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection Pass M Failed Re- Inspection Required ($.) ❑ Inspectors Comments: i? Lay Inspectors Signature: Date: SERVICE INSPECTION: Pass Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass M Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspecto s Signature: Date: ROUGH SPECTION: Pass Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Sig ture: Date: FINAL INSPECTI Pass Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: 0 DEB WEINHOLD ... TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com a << , •f The Commonwealth of MassachusettsLn - Department of IndustriqlAccidints Office of Investigations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organi'zatiorAndividual): Address: City/State/Zip: Phone #: Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. # ship and'have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3.01 am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12. FJ Roof repairs 13.❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. I Homeowners who submit this affidavit indicating they aie doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date:. Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder 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 cero under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: Phone #: Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - Contact Person: Phone Information and Instruction.s Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein., or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced -acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of lndustrnal Accidents Office of Investigations 600 Washington. Street Boston, MA. 02111 Tel. # 61.7-727-4900 ext 406 or 1.-877�,MSSAFE Revised 5-26-05 Fax # 617-727.7749 www.naass.govldla 9 -OW4"- Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ 417,565.00 m $ - $ 5,010.78 Plumbing Fee $ 626.35 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 626.35 Total fees collected $ 6,363.48 351 Willow Street South 490-14 on 12/11/2013 Butler Building for DAF Equipment 0 Date .�d 3...,' .............:. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies thatO, ►►' �?C H ! 1 has permission to perform?Q........................................................... I� c,!UL,i ...... wiring in the building of...... � � � � `� Jo at ....(?.. ........�.�............................ �........................................................ . North Andover, Mass. " Fee ... ).'T-197..... Lic. No.................. ELECTRICAL INSPECTOR (� Check # � 7 . �Q -r- t) -11 c5 oi- q 1Zl2 i�# dt Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. Ulu Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. ]/07] (leaveblank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersignedIves notice of his or her intention to perform the elec_tri�aI work described below. Location (Street & Number) I i J-)� Owner or Tenant Owner's Address Telephone No. Is this permit in conjunction with a building permit? Yes Y No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps olts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: oc�.lpl ; C�vrtm QJg!U Completion of the.following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. of Total � Transformers KVA .4-5 No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of LuminairesSwimming Pool Above ❑ In- El rnd. rnd. o. o Emergency Lighting Battery Units rQ No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices g No. of Waste Disposers Heat Pump INumber Tons KW No. of Self -Contained Totals: I Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local E] Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KW No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP TelecommunicationsWiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: �3 _5 R (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such cove a is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE [BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: LIC. NO.: Licensee: Signature LIC. NO.: (If applicable, enter "exe " in the lic se number line.) Bus. Tel. No.,� ' Q"� iOS� Address:fiA, Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, sec rity work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's a ent. Owner/Agent Signature Telephone No. PERMIT FEE: $ Py9 4 1 ® %4�o CERTIFICATE OF LIABILITY INSURANCE /DDYYYY) 771/12/15 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(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 endorsement(s). PRODUCER Richard A. Kowalsky Insurance 544 Lincoln Avenue P.O. Box 999 Saugus, MA 01906 CONTACT NAME: PHONE 781 231-2020 FAX No: (781) 231-2021 ADDRESS: el@KowalskyInsurance.com INSURENS) AFFORDING COVERAGE NAIC # INSURER A: Norfolk and Dedham Mutual INSURED B : Ronald J Mikol -INSURER INSURER C: 280 Depot Street INSURER D: Dunstable, MA 01827 INSURER E: INSURER F: $ COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICES 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. LTR TYPE OF INSURANCE ADDL INSR UB WVD POLICY NUMBER POLICY FF MIDDIY POLICY MNIDDYYYY LIMITS p; a GEN ERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE Fx_1 OOCUR A0`0. a North Andover, M?, 01845 R0401428A 6/15/14 6/15/15 EACH OCCURRENCE $ 500,000 AREITEI ESEaoccurrence $ 50,000 PREMSO MED EXP (Anyone person) $ 5,000 PERSONAL&ADV INJURY $ 500,000 GENERAL AGGREGATE $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER POLICY PRO- LOC PRODUCTS - OOMP/OPAGG $ 1,000,000 $ AUTOMOBILE LIABILITY ANY AUTO ALLOWNED SCHEDULED AUTOS AUTOS NON -OWNED HIREDAUTOS _ AUTOS a accident $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ eracadent UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION $ $ YORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTNE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) Ifyes describe under DESCRIPTION OF OPERATIONS below N / A ITORWC STATU- OTH- (y FIR E.L. EACH ACO DENT $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ 1 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101, Additional Remarks Schedule, If more space Is requil red) Electrical Wiring Job Location: 351 Willow Street South CERTIFICATE HOLDER CANCELLATION © 1988-2010 ACORD CORPORATION.UAII rights reserved. ACORD 25 (2010/05) The AC ORD name and logo are registered marks of ACORD Phone: (978) 688-9566 Fax: (978) 688-3211 E -Mail: SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of North Andover ACCORDANCE WITH THE POLICY PROVISIONS. North Andover Town Hall AUTHORIZED REPRESENTATIVE /� Attn: Electrical Inspector 120 Main Street A0`0. a North Andover, M?, 01845 RAK/E1 © 1988-2010 ACORD CORPORATION.UAII rights reserved. ACORD 25 (2010/05) The AC ORD name and logo are registered marks of ACORD Phone: (978) 688-9566 Fax: (978) 688-3211 E -Mail: V The Commonwealth of Massachusetts . - Department of Industrigl Accidiie is Office of.Investigations 660 Washington Street Boston,1t74 02111 www.mass.gov/ciia Workexrs' Compensation ][assurance Affidavit: Buffders/Contractor$XlectriciansM!iiinobers A liteantXnformation PleasePrin$Led . Name (Business/Orgauiization/Tndividual Are you ant employer? Check the appropriate box: 1. ❑ I am a erbployer with 4. 0 I am a general contractor and I mployees (fall and/or part-time).* have Hired the sub -contractors listed on the attached sheet 2• ' I am a sole proprietor or partner ship an&lave, naemploye es These sub -contractors have working for me in any capacity. workers' comp. insurance, 5. ❑ We are a corpora#on and its [Nb workers' comp. insurance officers have exercised.their required.] 3. ❑ I am a homeowner doing all work right of exemption per MGL Myself [No workers' comp. c. 152, §1(4), and wehave no employees. [No workers' insurancerequir4j comp. insurance required.] Type of project (required.): 6. ❑ New cOnstraction f 7. [] Remodeling 8. ❑ Demolition 9. ❑ Building addition ME] Electrical repairs or additions 11.❑ Plumbing,repairs or additions UP RoofrePairs 13.❑ Other kAny applicant that checks box#1 must also fill outthe section below showingtheir workers' compensationpolicy information. i Homeowners who submitthis affidavit indicating they 2're doing all work and then hire outside contractors must submit a new affidavit indicating such. TContractors that checkthis box must attached an additional sheet showing the name of tho sub. -contractors and their workers' comp. policy information. I am an employer that isproviding workers' compensation insurameformy employees Below is thepolley an4job site information. Insurance Company Policy # or Self ins. Lic. Expiration Date:, ' ! 4:0 Yl I N City/State/Zip: • ai CN �� l r lob Site Address Attach a copy o#tbe workers' corntpensatlonpolicy declaration page (showing the policy number and expiration date). Failure -to secuxe_coverage_as xeg4i edunder Section 25A ofMGL o.152 can lead to the imposition of criminal penalties o£a Ease up`to $1;500:00 andfox one�year-xmprisoiiinent as ve]l_as eiyilpenalixes-ita=the form_of a STOPWORK ORDER and afire — of -up to $250,00 a day against the violator. Be advised that a copy of this statement may be forwarded io the Offico of — -- - -- Investigations of the DTA. for insurance coverage verification. Ido lid eby ceryy uWer tlkepa;, s and, that the information provided above is tran d eorreeI rat -A• a -� -./ S Off cial use only..Do not write in this area, to he completed by city or fawn official. City or Town: Permit/License # Issuing Authority (circle One): 1. Board of Health 2. BuildingDepartment 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other J f nr►fact Per�nn: Phone M. Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every persoiz tri the service of another under any c6fract of hire,• express or implied, oral or written." An employei is defined as "an individual, partnership, association, corporation or other legal entity, ox anytwo or more of the Foregoing engaged in a j oint enteiprise, and including the legal representatives of a• deceased employer,. or tI? e receiver o - trustee of a i individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having notmore than three apartments and who xesides 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 employes." 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 bas 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 fbr the performance ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapterhave beenpresentedto the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are notrequired to carry workers' compensation, insurance. If an LLC or LLP does have employees, apolicy is required. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should ba mtomed to the city or town that the application for the pem dt or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Off'icials Please be sure that the affidavit is complete andpxinted 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 -sue to:M in the permit/license number whichwill be used as a reference number. In addition, an applicant thatmust submitmultiple permit/licame applications in any given year, need only submit one affidavit indicating current PONY information (ifnecessary) and under "lob Site Address" the applicant should write "all locations in (city or town)." copy of the affidavit that bas been officially stamped or marked by the city or town may be provided to the applicant as Froof that a valid affidavit -lion file for future permits or licenses..A new affidavit must be filled out each year_ - ere ahomeowner orcitizen xs-obtauung a-hcense_or permitriot aelafed_�y business: ox_eommercial venture -` -- (x.e. adog license orpermit to buin leaves eta.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and shquld you have any questions, Please do not hesitate to give us a call. The Department's address, telephone and fax number: Tho CQ:s ouwealthofMmsacftl oitq Depaftmt QfZndWdd .Acelde is Office ofTAY- ugaamm 6.44 Was gtm Street B oston, MA 021 X X Tei. 0 617-7.27-4900 ext 446 ox 1-877�MASS"AFE Revised 5-26-05 Fax# 617-727-7m WWW=agQvAha Date.. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .Y....!. v/e...T..:.:!../..�'�C��_ +.e.- f' ............. v has permission to perform ........... i' ..... S�� ,a_ ............................... wiring in the building of.............................. N„ G ............. ............................................. - (+ / at .. �...... � 1.. �' 3r�/1 t. n�........................... orth Andover, Mass. Fee...--..... Lic. NoZJ��% ..... 32Vl� ELEIRC LL IONSPECTOR Check # � 5 � J Commonwealth of Massachusetts Official Upse�Onl Department of Fire Services Permit No. �c Q Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS . [Rev. 9/05] (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: 9/25/14 C, City or Town of. North Andover To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. 3 Location (Street & Number) 351 Willow Street South North Andover, MA 1 Owner or Tenant Bake N Joy Telephone No. Owner's Address 351 Willow Street South North Andover, MA Is this permit in conjunction with a building permit? Yes ❑ No ® (Check Appropriate Box) Purpose of Building Commercial Utility Authorization No. 16926473 Existing Service 2500. Amps 480/277 Volts Overhead ❑ Undgrd ® No. of Meters 1 New Service 1600 Amps 480/277 Volts Overhead ❑ Undgrd ® No. of Meters I Number of Feeders and Ampacity ADDING 4 SETS OF 600KCMIL FOR ADDITIONAL 1600A SERVICE Location and Nature of Proposed Electrical Work: UPGRADING PAD MOUNT TRANSFORMER AND INSTALLING NEW SECONDARY CONDUCTORS FOR NEW 1600A SERVICE Completion of the following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans 0 No. of Transformers 0 Total KVA No. of Luminaire Outlets 0 No. of Hot Tubs 0 Generators 0 KVA No. of Luminaires Swimming Pool Above ❑In- 1:1o. rnd. rnd. o Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners 0 FIRE ALARMS I No. of Zones No. of Switches No. of Gas Burners 0 No. of Detection and 0 Initiating Devices No. of Ranges 0 No. of Air Cond. 0 Total Tons No. of Alerting Devices g No. of Waste Disposers 0 Heat Pump Totals: Number .....� . .........................Detection/Alertin Tons KW No. of Self -Contained Devices 0 No. of Dishwashers Space/Area Heating KW 0 Local ❑ Municipal ❑ Other 0 Connection No. of Dryers 0 Heating Appliances 0 KW Security Systems:* No. of Devices or Equivalent No. of Water 0 KW Heaters No. of 0 No. of Signs Ballasts Data Wiring: 0 No. of Devices or Equivalent No. Hydromassage Bathtubs 0 No. of Motors 0 Total HP Telecommunications Wiring: 0 No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: $185,000.00 (When required by municipal policy.) -Work to Start: 10/8/14 Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability 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 ® BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: Piquette and Howard Electric Service LIC. NO.: MR392 Licensee: Robert B Howard Signature LIC. NO.: (If applicable, enter "exempt" in the license number line.) Bus. Tel. No.. ---60-382-3182 Address: 222 Plaistow Rd — Plaistow NH 03865 Alt. Tel. No.: 603-382-6182 *Security System Contractor License required for this work; if applicable, enter the license number here: 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 a ent. Owner/Agent Signature Telephone No. PERMIT FEE. $ /6? Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. ACity or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. r The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, ple:,cse do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 7-2013 www.mass.gov/da 0 22MMOWELLTH OF M At HIfSEi TS: pi W61 • • -• • WARP jj ELE6Tit I C i ANS : l ISSU.ES.THE FOLLOWING -LICEN AS A.4 -EG JOURNEYMAN ELECTRIC RODERT B HOWARD 95 'CONLEYS GROVE RD- Y D t�itY STH 03038-9506z ELECtft I C I ANS: <<. ISSUES THE FOLLOWING LICENSE AS:.A f`ST-STMASTER E.LECTRi C I AN, . p.iQUI TTE HOWARD ELECTRIC SEI�VI�CrE ROBERT B HD tAiW i 4 95 CONUYS GROVE ` it URRY ,,;gH 03038-950' 39214R'' 0 1- .11`16 66888 STATE OF NEW HAMPSHIRE ELECTRICIANS BOARD NAME: RO EXPIRES: PIQUE -1 OP ID: JO ACOR�� CERTIFICATE OF LIABILITY INSURANCE �--'� DATE(M8/20 14 F10/08/20 4 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(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 endorsement(s). PRODUCER Foster Sullivan Insurance Main St. CONTANAME: CT Brian Clancy HONE (FAX a/r Ell: AiNO): 978-686-6410 North Andover, MA 01845 Michael J. Foster E-MAIL l canc fostersullivan rou ADDRESS: by@ 9 p•com INSURER(S) AFFORDING COVERAGE NAIC # 09/01/2015 INSURER A: TRAVELERS INSURANCE CO 19046 PREMISES Ea occurrence $ 300,00 INSURED Piquette & Howard Electric INSURER 8: UNDERWRITERS AT LLOYDS 15792 Service Inc GENERAL AGGREGATE $ 2,000,000 222 Plaistow Road INSURER C: INSURER D: Plaistow, NH 03865 INSURER E: LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS HIRED AUTOS NON -OWNED AUTOS L INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INTR SR L TYPE OF INSURANCE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of North Andover, MA POLICY NUMBER MM/DDY/YYYY TR POLICY EXP MM DD/YYYY LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE r—xl OCCUR X..C.0 COVERAGE C05549M436 CONTRACTUAL LIABILITY 09/01/2014 09/01/2015 EACH OCCURRENCE $ 1,000,00 PREMISES Ea occurrence $ 300,00 MED EXP (Any one person) $ 5,00 PERSONAL & ADV INJURY $ 1,000,00 APPLIES GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICYFX PRO LOC PRODUCTS - COMP/OP AGG $ 2,000,000 $ A AUTOMOBILE X LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS HIRED AUTOS NON -OWNED AUTOS L 8106684M970 09/01/2014 09/01/2015 COMBINED SINGLE LIMIT 1,000,000 Ea accident $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ PER ACCIDENT 1 $ A X UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE CUP6684M982 09/01/2014 09/01/2015 EACH OCCURRENCE $ 5,000,00 AGGREGATE $ 5,000,00 DED I X I RETENTION $ 10000 $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVEY 1 OFFICER/MEMBER EXCLUDE[ (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N/A UB1C349231 09/01/2014 09/01/2015 X WC STATU- I X OTH- TORY LIMITS ER E.L. EACH ACCIDENT $ 500,00 E.L. DISEASE - EA EMPLOYEE $ 500,00 E.L. DISEASE - POLICY LIMIT $ 500,00 B PROFESSIONAL LIAB S57300019 07/18/2014 07/18/2015 1,000,00 1,000,00 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) CERTIFICATE HOLDER CANCELLATION ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 26 (2010/05) The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of North Andover, MA ACCORDANCE WITH THE POLICY PROVISIONS. 1600 Osgood Street AUTHORIZED REPRESENTATIVE North Andover, MA 01845 ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 26 (2010/05) The ACORD name and logo are registered marks of ACORD Date ...)-+ �v 1 .�t ....... '5 ................................ TOWN OF NORTH ANDOVER PERMIT FOR WIRING .. ........ ..... ........ .... This certifies that ........ >............ has permission to perform .... Akle .................................. 7 ................................ ...................... I wiring in the building of......... .....s'...... S� ........................................................ ........... 5 Mass. ......... ..... �, `North Andover, 444.� Ike .... I -� . ....... Lic. No. Check # q�4 y a (fom.mon.wea& of Wamachaeeth Official Use Only cc�� Permit No. � 7)7Ab 2epartmen.t o f Jim Semice.4 Occupancy and Fee Checked wi BOARD OF FIRE PREVENTION REGULATIONS [Rev. ]/07] (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: J 3 -J J. City or Town of: jr-14k- 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) 551 Owner or Tenant 3-nkK,) Telephone No. IIA32E(OKY nq Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) C Purpose of Building �� , Utility Authorization No. Existing Service Amps / Volts Overhead U Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity j Location and Nature of Proposed Electrical Work: 1�p„�-a�}�l,n� pv�i^��nrA'.1D 11Mr•,✓IM cl 1�2.11'lc\i Completion of the ollowin table may be waived b the Inspector o Wires. No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA AboveIn- o. o Emergency Lighting No. of Luminaires Swimming Pool rnd. ❑ rnd. ❑ Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices �C No. of Ranges No. of Air Cond. Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Number Tons KWNo. of Self -Contained Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ElMunicipal ❑Other Connection IS No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of WaterKW No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications wirin 1. No. of Devices or E uivNent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: o (When required by municipal policy.) Work to Start: S N 16 Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such cover ge is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE [BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: DaveoS LIC. NO.: 12.K C Licensee:Signature LIC. NO.: 11521- T) (If applicable, enter "exempt" in the license number line) Bus. Tel. No. Address: _ q V -Q Jo T �Ci.CQ- S ,-mc us . ly1A \ C1 O(D Alt. Tel. No.: - - *Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's a ent. Owner/Agent Signature Telephone No. PERMIT FEE: $ ,) �01 6 V 0J Imp-) — The-Commonwealth-ofMassaehusetts- Department of Industrial Accidents Office of Investigations kip 600 Washington Street Boston, MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/ContractorsfFIectriciandPlumbers Applicant information Please Print LeMbly Maine (Business/Organizatio0ndividual): �A V e-0 �E 6VP- Address: hll�v� 3� ��f} cE aC) 8e)( 0/9 t l6vS Alf/- d / 9'0 6 phone M / S I " 62.53 - q V6 0 Are you an employer? Check the appropriate box; Type of project (required): I.X I am a employer with �S 4. ❑ I am a general contractor and I 6• E] New construction employees (full and/or parttime).* have hired the sub -contractors 2. ❑ 1 aro a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub -contractors have g, ❑ Demolition workingfor me in an capacity. � y p �� employees and have workers' con insurance.t P• 9• ❑Building addition [No workers comp. insurance required.] 5, E]We are a corporation and its 10QEleetrical repairs or additions 3. ❑ 1 am a homeowner doing all work officers have exercised their l t.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGT. 124-1 hoof repairs insurance requiied] t e. 152, §1(4), and we have no 13] Other -s€�,e s employees. [No workers' comp. insurance required.] rany applicant ibst chocks box g 1 must also fill out the section below showing their workers' compensation policy Information. r Homeowners who submit this affidavit indicating they arc doing all work and then hire outside contractors must submit a new, allidavit indicating Such. TContraetors that check this box must attached an additional sheet showing the name of the sub -contractors and state whcthcr or not those cniiiics have employees. lfthe sub -contractors have employees, they must provide their workus' comp. policy number. ram an employer that O providing workers' compensatlon insurance for my employees Below is the policy and job site information. /} Insurance Company Name: /kA V�ZG>/2S �f}S vA�iz/ �U�eETz/ �—O• Policy # or Self -ins. Lie. P: E 85/ feel Expiration Bate: Job Site Address: 35/ 0WOU) S% Se)U7 ff City/Stafe/Zip: ±%Q• AN1>O V -r Q 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 MOL 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 'W'ORK 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. 1' do hereby cert under the pat aLLndpenaldes ofperjury that lite information provided above is true and co erect Qionnimp.- 9/- Xm - Ll .7 O'ffieial use only. Do not write in this area, to be completed by city or town ofctat 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 #• ?IMA'I:ION .01 DAVCSEC-01 LCARUSO CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDD/YYYY) 11/24/2014 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Salem Five Insurance Services, LLC 445 Main Street(AC, Woburn, MA 01801 PHONE (781) 933-3100 AIc Ne; (781) 933-9048 AC No Ext ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # 06/16/2014 INSURER A: Everest Insurance Company EACH OCCURRENCE $ 1,000,000 INSUREDINSURERB:Travelers Cas & Surety CO Of AM 31194 INSURER C: Davco Security Systems Inc PERSONAL & ADV INJURY $ 1,000,000 PO BOX 1208 INSURER D: INSURER E: Saugus, MA 01906 INSURER F: AUTOMOBILE LIABILITY ANY AUTO ALL OWNED X SCHEDULED AUTOS AUTOS NON-OWNFD X HIRED AUTOS X AUTOS CnVFRAGFS CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IIJSR LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER POLICY EFF MMIDDlYYI'Y POLICY EXP MMIDDYYY /Y LIMITS A X _ COMMERCIAL GENERAL LIABILITY CLAIMS -MADE a OCCUR 51GL007281-141 06/16/2014 06/16/2015 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED PREMISES Ea occurrence $ 1,000,000 MED EXP (Any one person) $ 10,000 PERSONAL & ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY a PRO- JECT LOC OTHER: GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMPIOPAGG $ 1,000,000 $ B AUTOMOBILE LIABILITY ANY AUTO ALL OWNED X SCHEDULED AUTOS AUTOS NON-OWNFD X HIRED AUTOS X AUTOS BA7E868021 06/16/2014 06/16/2015 COMBINED SINGLE LIMIT $ 1,000,000 Ea accident BODILY INJURY (Per person) $ BODILY INJURY (Per acddent) $ PROPERTY DAMAGE $ Per accident A X UMBRELLA LIAR EXCESS LIAB X OCCUR CLAIMS -MADE 51CC002642-141 06/16/2014 06/16/2015 EACH OCCURRENCE $ 5,000,000 AGGREGATE $ 5,000,000 DED RETENTION S $ B _ WORKERS COMPENSATIONX AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y� OFFICERIMEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below NI A UB7E851801 06/16/2014 06/16/2015 PER OTH- STATUTE ER E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE - POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS i VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) C 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 - n � , ,aoo-cve4A%,%Jrrtv U%Jrcrvrv{I,vly. rAu rlynta reserveu. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD r� North Andover MIMAP January 28, 2016 Andover svo Q MVPC Be J Interstates — I — sR Roads t7, Easements ( 1 Parcels 1" = 155 ft •�° 025.0-0082 .qf @T50 Horizontal Datum: MA Slateplane Coordinate System, Datum NA083, Meters Data Sources: The data for this map was produced by Merrimack NORTF/ Valley Planning Commission (MVPC) using data provided by the Town of Of ,1`90 '6. 'q1,O North Andover. Additional data provided by the Executive Office of e� •e O Environmental Affairs/MassGIS. The information depicted on this map is L for planning purposes only. It may not be adequate for legal boundary to definition or regulatory interpretation. THE TOWN OF NORTH ANDOVER MAKES NO WARRANTIES, EXPRESSED OR IMPLIED, CONCERNING ry THE ACCURACY, COMPLETENESS, RELIABILITY, OR SUITABILITY t i OF THESE DATA. THE TOWN OF NORTH ANDOVER DOES NOT c9 �P • ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF THIS INFORMATION Peter C. SteianLw,* Archkec4 p. c. Inspector of Buildings Town of North Andover 1600 Osgood Street Building 20, Suite 2035 North Andover, MA 01845 RE: Inspection Final Affidavit To the Building Inspector: I certify that I, or my authorized representative, have inspected the work associated with Permit No. 1097-15 dated l5 ; Bake'n Jo.. Foods, located at 351 Willow St. South, North Andover, MA 01845 and that to the est of my knowledge and belief, the work has been done in accordance with the Permit and the plans approved by the Building Department and with the provisions of the Massachusetts State Building Code and all other pertinent laws and ordinances. Peter C. Stefanini cwIRLE Architect — Mass. Reg. No. 7460 y Expiration date: 08/31/16 l L Hon; • et' piaarch@comcast.net To e M MAILLOUX BROTHERS B CONSTRUCTION CO., INC. • S-.�� GENERAL CONTRACTORS Russell J. Mailloux, Vice Pres. Project Manager russ@mbcbuilders.com 55 Chase Street Methuen, MA • 01844 197S -6S6 - FAX. 978-683-3452 20 pond street hopkinton, ma 01748 p. 508 435 7272 Peter C. Stefanini, Architect, P.c. Building Department Town of North Andover 400 Osgood Street North Andover, MA 01845 RE: Inspection Final Affidavit To the Building Inspector: I certify that I, have observed the work associated with Permit No. _474_, located at Bake'n Joy Foods,.651 Willow Street South?North Andover, periodically and that to the best of my knowledge and belief, the work has been done in accordance with the Permit and the plans approved by the Building Department and with the provisions of the Massachusetts State Building Code and all other pertinent laws and ordinances. Peter C Stefanini Architect — Mass. Reg. No. 7460 Peter C. Stefanini, Architect, p.c. Company 20 Pond Street, Hopkinton, MA 01748 Address 20 POND STREET, HOPKINTON, MA 01748 TEL. (508) 435-5710 - FAX (508) 435-7273 Date..`J? .`:2 j.:/U..... "`° '• "� TOWN OF NORTH ANDOVER p PERMIT FOR WIRING This certifies that ................... ..../ .................................................................. has permission to perform ....� �` `t ................................................................... wiring in the building of p .. =.�...... lel/r�...�-.-�.:. ... .Zor� Andover, Mass.at . INSPECTOft Check # 16, 926 Commonwealth of MaAaac4udettd Official Use Only Apartmenl o/—}ire Seruicee Permit No. Ory y BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked �. [Rev. 1/07] 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: (Xl2el U City or Town of. 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) 3cS'/ if! /�04, J7 s��( Owner or Tenant y /r, Telephone No. Owner's Address 50.^ Is this permit in conjunction with a building permit? Yes 0' No ❑ (Check Appropriate Box) Purpose of Building ,�o+�,� y Utility Authorization No. , Existing Service Amps / Volts New Service Amps / Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Overhead ❑ Undgrd ❑ Overhead ❑ Undgrd ❑ Comnletinn nftho fnllnu,i o f„xl No. of Meters No. of Meters '0.04,v/ No. of Recessed Luminaires g2 -----,----.. ... No. of Ceil: Susp. (Paddle) Fans .•.••••.. ...... .,.. ......cuu inc .no cuwu YY[rG'J'. No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑In- ❑ rnd. grnd. o. of Emergeli'll!!y Eiglifing 22ILea Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones WOV, No. of Switches 20 No. of Gas Burners No. of Detection and Initiatin Devices No. of Ranges No. of Air Cond. Tonsotal "rtetin lerting Devices 2d No. of Waste Disposers Heat Pump umber ons e - ontafineTotals: n/Alertin Devices No. of Dishwashers Space/Area Heating KW Municipal❑Other ConnectionNo. of Dryers Heating Appliances KW stems:* No. of WaterNo. KW No. of No. of of Devices or E uivalent Heaters Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors ommunications Wiring: 2—.02f Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: 77. tfA& (When required by municipal policy.) Work to Start:- 3 ZZI10 Inspections to be requested in accordance with MEC Rule 10, and upon completion. POI 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 coverW is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ND ❑ OTHER ❑ (Specify:) I certify, under the pains andpenaltie erjury,trthat the information on this application is true and complete. FIRM NAME: Pwf Gafi n e LIC. NO.: IX Y00 4 Licensee: 7 011WJ� Signature LIC. NO.:ZJZ7Cf (If applicable, e�t�r " empl, i theIic se umb line. Bus. Tel. No.:% %jOdYi Address: �/Td/AV 7, �//�-4 7/d��ii.� /ice ald'G l *Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Alt L o No. �/ ' D ` 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 check one requirement. I am the Owner/Agent ( owner F-1owner's agent. Signature Telephone No. PERMIT FEE: $ �i /SOS f�lwi--?- C",2�- J-- i /,- l o p ---z7 U�z-- 0 Fi February 25, 2010 Commonwealth of Massachusetts Board of State Examiners of Plumbers and Gasfitters 239 Causeway St., Suite 400 Boston, MA 02114 Dear Sirs, Le Bay State Gas A NiSounce Company 55 Marston Street P.O. Box 869 Lawrence, MA 01841-2312 (978) 687.1105 Fax: (978) 688.1875 � NNSRS OF p4G ceA' 8 ECR o RUL S�o� .0 REGULATIONS N FQ CHECKED gy 2/ Z C13 DATE 3 /� v U- 0 o FOR 7'H --BOARD 6'bO LAN EXAMINER�y�� This letter is to confirm that Bay State Gas Company, the serving gas supplier, can provide 7,821 scfh at 5 psig delivery pressure at Bake N Joy Foods' new Boston Coffee Cake Division located at 351 Willow St. in North Andover, MA. Sincerely, trraTrainA� Field Engineer Bay State Gas Company a 96ub Date ....... ............ 1,1,-2.. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ...........J .. v... .......?'G i?/.. /.......55��......... has permission to perform........ Qc.h;P. fj. r(?� . s %..... ...... wiring in the building of .....��%>>� �..� x ........................................ at ..... S l �« . Q. ..... 5 � ...... Soul .� orth Andover, Mass. .............. .... .... Ile Fee . /,57�-�....... Lic. No. Z �SY.frSl�..........,% .� . .......��...A2- � ! ...................... . ELEC'I�ICAL INSPECTOR r' j Check # �� / 4F M Cfornm.onwealtle olec/hl Ylajdachu6et — 2epartm.ent of77ire Serviced BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. I� �`S— Occupancy and.Fee Checked ;ev. 1/07] (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: t 0. { . 2D1 D City or Town of: o norvA To the Inspector of Wires: By this application the undersigned gives notice of his or her intentioto perform the electrical work described below. Location (Street & Number) S , LzILLc,u.--�, S'Q. ` C MNA Owner or Tenant : Owner's Address Telephone No. Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building �GP�� Utility Authorization No. Existing Service New Service Amps / Volts Amps / Volts Overhead ❑ Undgrd ❑ Overhead ❑ Undgrd ❑ No. of Meters No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical bVork: �aU� P��1=SS S�s'1�1�n ComnleNnn nfthe following table may be waived by the Inspector of ffires. 1 1 Attach aacationat aetau ry aesu-ea, car as regeureu uy 1 to rrxoNcuv. 0j .. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability 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 Q BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on thls application is true and complete. FIRM NAIVIE: �o - LIC. Na: 1c%\ --,)L Licensee: ��. oyaf4 \ll Signature LIC. NO.: LA�j (If applicable, enter "exempt" in the license number line.) 1311s.Te1.No.:`1sl 133 ��IlsO Address: 4 1-(�V)V) plcioo 1 41 UAM Oft(o Alt. Tel. No.: S00. 147:L 13 ala *Per M.G.L. c. 147, s. 57-6 I, security work'reduires Department of Public Safety "S" License: Lic. No. �`n 4z7�) OWNER'S INSURANCE WAIVER: I am aware that the Licensee sloes 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 a-ent. Owner/Agent Signature — Telephone No. PERMIT FEE: -- - o. of Total No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans Transformers KA No. of Luminaire Outlets No. of Hot Tubs Generators KV A No. of Luminaires AboveIn- Swimming Pool rnd. ❑ rnd. ❑ No. of Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE AI.,ARMS No. of Zones o. of Detection and No. of Switches No. of Gas Burners Initiatin Devices No. of Ranges Total No. of Air Cond. Tons No. of Alerting Devices Heatl.Pums '1 ons No. of Self- ontained No. of VVaste, Disposers _Ngm.ber ..,...K� Detection/Alerting Devices No. of Dishwashers Space/Area Pleating KW Municipal Local ❑ Connection ❑ Other No. of Dryers Pleating Appliances IOW Security ystems: No. of Devices or Equivalent No. of WaterKWNo. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent Telecommunications Wiring: No. Hydromassage Bathtubs No. of Motors Total HP No. of Devices or Equivalent OTHER: 1 1 Attach aacationat aetau ry aesu-ea, car as regeureu uy 1 to rrxoNcuv. 0j .. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability 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 Q BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on thls application is true and complete. FIRM NAIVIE: �o - LIC. Na: 1c%\ --,)L Licensee: ��. oyaf4 \ll Signature LIC. NO.: LA�j (If applicable, enter "exempt" in the license number line.) 1311s.Te1.No.:`1sl 133 ��IlsO Address: 4 1-(�V)V) plcioo 1 41 UAM Oft(o Alt. Tel. No.: S00. 147:L 13 ala *Per M.G.L. c. 147, s. 57-6 I, security work'reduires Department of Public Safety "S" License: Lic. No. �`n 4z7�) OWNER'S INSURANCE WAIVER: I am aware that the Licensee sloes 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 a-ent. Owner/Agent Signature — Telephone No. PERMIT FEE: Architecture, Engineering & Construction for the Food & Beverage Industry ASSOCIATES CERTIFICATE OF SUBSTANTIAL COMPLETION alz€1 oy 351 Willow Street Sout North�d ower, 1rfiA$I8 Project No. 20289 28 May 2010 To: Muffin Realty Trust Contract for: 12,920 sf Bakery fit -up of existing building Construction Manager: CMC Associates, Inc. Contract Date: 19 January 2010 Project or Designated portion shall include: The entire bakery area as defined by the drawings & contract. The work performed under this contract has been received and is deemed to be substantially complete. The date of Substantial Completion is, therefore; established for the portion noted above as: 28 May 2010 which is also the date of commencement of warranties required in the contract documents, excerpts as stated below. The definition of the Date of Substantial Completion of the Work or designated portion noted above is the Date determined by the Architect when construction is adequately complete, in accordance with the Contract Documents, so the Owner may occupy or utilize the work or portion noted above for its intended purpose, as detailed in the Contract Documents. A list of items to be completed or corrected (Punch List), prepared by the Contractor and amended by the Architect and Owner, is currently being published. The failure to include any items on this list does not alter the requirements of the Contract Documents. The date of the commencement of warranties for items included in the Punch List will be the date of final payment unless agreed to, in writing, by the Owner and the Contractor. CMC Associates, Inc. 2b Mb1 lot a The contractor agrees to complete or correct the Work on the Punch List within 60 days of the above Date of Substantial Completion. CMC Associates, Inc. By�� The Owner accepts the Work or portion noted above as substantially complete as determined by the Architect and will assume full possession thereof at 12:00:00 PM on 05.28.10 Muffin Realty Trust By:)� D (Note - Owner's and contractor's legal and insurance Z64nsel should determine and review insurance requirements and coverage; contractor shall secure consent of surety company, if any.) The Owner accepts full responsibility for security, maintenance, all utility costs, damage to Work, and insurance coverages necessary for the complete protection of all risks associated with the Project and its occupancy, except as noted below. Two Batterymarch Park, One Pine Hill Drive. ■ Quincy, MA 02169 ■ 617.328.7899 ■ Fax 617.328.1779 www.cmcassociates.com Commonwealth of Massachusetts OFFICE OF CONSUMER AFFAIRS DIVISION OF PROFESSIONAL LICENSURE Board of State Examiners of Plumbers and Gasfitters 239 Causeway Street, Suite 400 Boston, Massachusetts 02114 SPECIAL PERMISSION GAS REQUEST APPLICATION FORM $86.00 application fee per job — Check payable to Commonwealth of Massachusetts (1) TYPE OF REQUEST CHECK APPROPRIATE BOX [See General Note number 41 Booster Cogeneration _ Dual Fuel _ Elevated ✓ Kiln Gas Utilization Equipment over 12,500,000 BTU; Water Tube Boiler over 10,000 Itis. steam/hr tz► ArrucAn I Name: MTE Engineering , Tel: 781-329-7700 Fax: 781-326-6037 Address: PO Box 263 Cityrrown: Westwood State: MAI Zip: 02090 A copy of this request, to include all documentation was given to the Plumbing/Gas Fitting Inspector on (mm/dd/yyyy) I hereby certify that the information entered on this application request, to include supporting documentation, is true and accurate and is in compliance with Chapter 1 Ge I Laws and 248 CMR Massachusetts State Fuel Gas Code as amended. Senior Mechanical Engineer Authog6rd jgdatUe Title/Position Email: Tmason.mteeng@verizon.net Date: 02/22/2010 (mm/dd/yyyy) (3) bLKVING GA5 5UPPLILK INFORMATION N/A Natural Gas: Bay State Gas Co. N/A Propane Gas:. A signature is not required if a letter from the Gas Supplier is attached. 17 14 1 /i INFORMATION Authorized Signature Authorized Signature Information requested is not known at this time, a contractor is yet to be hired. Name: LC Mechanical Tel: 508 328-4192 Fax: Address: PO Box 275 City/Town: Fall River State: MA Zip: 02724 BOARD OF STATE EXAMINERS OF PLUMBERS AND GAS FITTERS BOARD OF STATE EXAMINERS OF PLUMBERS AND GAS FITTERS (5) FIRE DEPARTMENT (Required for Dual Fuel Only) A signature is not required ff a letter from the Fire Department is attached Fire Department Notified of this request on _.„µM; (mm/dd/yyyy) Authorized Signature ALLATION INFORMATION Use Occupancy: Commercial , Industrialy✓ Institutional._ Residential_". Other Company/Name: Bake'N Joy Muffin Realty Trust Tel Installation Address 351 Willow Street South_ - "._ City/Town N Andover Equipment to be installed: (2) 800 MBH Water Heaters (1) 750 MBH RTU Roof Top Unit (2) 343 MBH Revent Ovens (1) 240 MBH RTU (3) 120 MBH Unit Heaters (1) 480 MBH MUA Make up -air unit (1) 150 MBH Unit Heater (1) 555 MBH Pan Washer (1) 3000 MBH Tunnel Oven All equipment is listed as input valves. Length of piping from the point of delivery to the most remote appliance/equipment is::. feet. The total connected load is 7,821,000 M ,.w. BTU Pipe Size: Low pressure 8 Elevated pressure 4.E�a_... ' Supplier will provide 5w,= pounds / , inches w.c. gas pressure and 7821 cfh at the meter outlet. Reasons for this request: To reduce the piping size from 8" to 4". (7) FOR OFFICE USE ONLY Request for Special Permission is hereby granted xdenied Date 3!`6 lla (mm/dd/yyyy) Reason(s) for denial: Authorized Sign ure TELEPHONE: 617 727-9952 FACSIMILE: 617 727-6095 WEB:www.mass.gov/dpi/boards/pl — - / " Date.. :�� ...... Y .......... 0 �y r iTOWN OF NORTHAER 00� PERMIT FOR GAS INSZLLATION .......... This certifies that ....................... . .... ..... has permission for gas. installation ... . . . . . . . ... . in the buildings of .2!- at �orth Andover, Mass. Fee/2�'. Lic. No.1/�C,S7. ............. GAS IN' ACTOR Check # VJ-0-61 Ti 9 1") MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS FITTING (Type or print) Date Z11a, '7 NORTH ANDOVER, /MASSACHUSETTS Building Locations S f W 1 L L 0 G-�- S� �%� h Permit # Owner's Name Amount $ 9 AW e ,(� + 7 0 �4 AtlrF �;, A* /Y ZY r C's IL ❑ T New Renovation ❑ Replacement � Plans Submitted (Print or type)C�� A �� `r�-L Check one: Certificate Installing Company Name ❑ Corp. Address Dv o2 S Partner. L=on Vim- � rd � •Z� 2 � usmess a ep one _ a ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter LAVUZ4 4 INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes 0/ No E] If you have checked yes, please indioate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity Bond Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 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 Agent Owner Agent __...., .................. —&— — u,iu,u,auvu i 114Vc Suomin:eu kor enterea) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter the General Laws. !APPROVED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter lumber 0 Gas Fitter icense Number —11ra—steT Journeyman a z F o x a w W oz p z o F w x z U w x z W , x C C4 w w F^ w E" x e4 a W Q z�z C z a O v x C x LT.BASEM � 3 o Cal .� O U O z > A a F O SUB-BASEM ENT ENT 1ST. FLOOR oZ 2 N D. F L O O R 3RD. FLOOR 4TH. FLOOR 5TH. FLOOR 6TH. FLOOR 7TH. FLOOR S.TH. FLOOR (Print or type)C�� A �� `r�-L Check one: Certificate Installing Company Name ❑ Corp. Address Dv o2 S Partner. L=on Vim- � rd � •Z� 2 � usmess a ep one _ a ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter LAVUZ4 4 INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes 0/ No E] If you have checked yes, please indioate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity Bond Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 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 Agent Owner Agent __...., .................. —&— — u,iu,u,auvu i 114Vc Suomin:eu kor enterea) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter the General Laws. !APPROVED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter lumber 0 Gas Fitter icense Number —11ra—steT Journeyman f The Commonwealth of Massachusetts Department of Industrial Accidents Office of Lnvestigations UT 600 Washington Street Boston, ALL 02111 www -mass govldia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LeQ><bly Name (Business/Organizafion/Individual): Address: City/State/Zip: Phone #: Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* 2. ❑ have hired the sub -contractors 1 am a sole proprietor or partner- listed on the attached sheet x ship and have no employees These sub -contractors have working for me in any capacity. [No workers' comp. insurance workers' comp. insurance. 5. ❑ We are a corporation and its required.] 3. ❑ I am a homeowner doing all work officers 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' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12.❑ Roof repairs 13. ❑ Other « ,� t, ur Mesecnan Dean shop= ub h v: o i ers' conisation police information. t Homeowners who submit this affidavit indicating they are doing all work and thea hire outside contractors must submit a new affidavit indicating such. lContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Si ature: Date.: Phone #: FOfficial use only. Do not write in this area, to be completed by city or town officiaL City or Town: Issuing Authority (circle one): L Board of Health 2. Building Department 3 6. Other Contact Person: Permit/License # City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector Phone #: Y Information as d Instructions i Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation orother legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of coxnpliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being ; ✓quested, not the Department of Industrial Accidents. Should you have any questions regardintg the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investibations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax :# 617-72.7-7749 wvrvu,.mass .- t?ov/dia cl].. Date . 1 TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION Thi§ -certifies that........................................................................!M�t�.s....�'.•. has permission for gas installation 1._0 �r-� in the buildings of ... 1. ..........N........ J a . ..................................................... at...........��...........�-'!..!�,.�.... ...................... North Andover, Mass. Fee:!��! Lic. No.... .......................................................................... �� GAS INSPECTOR Check # Iry - MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY _ �6,-' �1 nc�+Ct� .. .. ._ MA DATE-- o "� ..:,..PERMIT # JOBSITEADDRESS �� 60 �` OWNER'S NAME(\ S1C3 GOWNER ADDRESS TEL '.FAX TYPE OR OCCUPANCY TYPE COMMERCIAL : EDUCATIONAL ` .. RESIDENTIAL . PRINT CLEARLY NEW: RENOVATION:...' REPLACEMENT: ,._.' PLANS SUBMITTED: YES' , NO . APPLIANCES Z FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER - COOK STOVE l_.. . DIRECT VENT HEATER :' , • _ DRYER FIREPLACE FRYOLATOR ........ __.. FURNACE , GENERATOR ... __._ _.._ _... GRILLE-------` �._ ' .. r ..... _ INFRARED HEATER - " - '.y._. ' LABORATORY COCKS '~ - ._- ... MAKEUP AIR UNIT OVEN - - ; .. POOL HEATER V- ROOM/ SPACE HEATER � ROOF TOP UNIT TEST UNIT HEA l�R 1 UNVENTED ROOM HEATER WATER 4EATEF, -. _ ._ ,` _ _ _ _ OTHR.I.._....._.�.-_........_......_.:._...._._......_t ~ .,«ataswt.w:.�d.a:}.bexivnavcmavu,s+e:a..mwaea:sray..hiv. tss:. •..;. .. ..,'....: � '.:.. ••. - - _ INSURANCE COVERAGE I have a current Liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES X NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY X._j OTHER TYPE INDEMNITY L3 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 J)g AGENT -1 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 accurateto the best of my knowledge and that all plumbing work and Installations performed under the permit issued for this application will be In oompli ce wi II Pertinent prov lon of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. n PLUMBER-GASFITTER NAME ! Richard Ebacher LICENSE #? Y,920,.�w SIGNATURE .LICENSE MP[_-) MGF JP L,,„� JGF LPGI i w+ CORPORATION L#; 1659;�x PARTNERSHIP>�,#Z }i LLC IJ#i _.n •tip _ ADDRESS ',�40Portsmout�, hose,,,�_.._�____w�....�..<..�...3 COMPANY NAME:t�h�(g.�g�...�____�. CITY ['"Amesbury STATE SMA 1ZIP01913 FAX'9783884208 ' CELU 978-815-8m ;EMAIL; ree.-.9—ow .,_._�.�._._4....„..µ.,.... __,. _,,........w......... _ <. ,..�< _ , ' Iry - + The Commonwealth of Massachusetts F Department of IndustrialAceidents I Congress Street, Suite 100 - Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Name (Business/Organization/Individual): be C, 4-e � 0" �►L �/ Address: Z -f 0 t,- !% 0,�l 7- Piz City/State/Zip: 07-F1 G Iql3 Phone #: 9 IC— v� a 49 �- Are you a employer? Check the appropriate box: 1. am a employer with ! employees (full and/or part-time).* 2. ❑ I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. Q 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 proprietors with no employees. 5. I ant a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.$ 6. Q We are a corporation and its officers have exercised their right of exemption per MGL c. 152, §1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 7. New construction 8. emodeling 9. ❑ Demolition 10 Q Building addition 11. ❑ Electrical repairs or additions 12.0 Plumbing repairs or additions 13. E] Roof repairs 14.0 Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating suck #Contractors 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-coniraciors have employees,'tliey must provide their workers' 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: f C Policy # or Self -ins. Lie. #: ;�a C, Expiration Date: c /s Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi Yy under the pains and penalties�of perjury that toe informadgn provided above is true and correct. -04,,// /./��, I �-� S /Date: Phone #: Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): ; 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall. enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should'enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary). and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The 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-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia v 'IRAT EBACH-1 OP ID: MS J'Ar!V.�I►<�W CERTIFICATE OF LIABILITY INSURANCE DATE TE (MM/ DD/YYYY) 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 Phone: 978-388-2354 Gould Insurance Agency, Inc. 7 Market Square Fax: 978-388-6678 Amesbury, MA 01913-2494 CONTACT Matt Sherrill PHONE. FAX, ac Nc : 978�88v' 578 ADDRESS:matts@gouldinsurance.com INSURER(S) AFFORDING COVERAGE NAIC 8 GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS MADE a OCCUR INSURER A:Arbella Protection Insurance 41360 INSURED Ebacher Plmb.& Heating, Inc. Richard Ebacher INSURERS: INSURER C: P.O.Box 548 40 Portsmouth Rd. Amesbury, MA 01913 INSURER D: INSURER E: INSURER F : a.on, rrwia I r. rmumor_rt: KtVI51UN NUMBER' inIJ IJ IV l•Crc l lr'T Intel Int VULK:ItS Ur 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 POLICY NUMBER POLICY EF MMIDD F MMIDD LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS MADE a OCCUR 8500031450 07/06/2014 07/06/2015. EACH OCCURRENCE $ 1,000,00 DAMAGE TO PREMISES Ea occurrence) $ 100,00 MED EXP (Any one person) $ 5,00 PERSONAL&ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: POLICYX PRO.JECT El LOC PRODUCTS - COMPIOP AGG $ 2,000,00 S A AUTOMOBILE X LIABILITYeB ANY AUTO AALL UTOOS OWNED X SCHEDULED AUTOS HIREDAUTOS X NON -OWNED AUTOSPe°amdent 1020001776 07/06/2014 07/06/2015 INED INGLE LIMIT 1,000,00( BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ E $ INC $ A X UMBRELLALJAB EXCESS LU1B X OCCUR OCCUR MADE N / A 600031451 07/06/2014 07/06/2016 EACH OCCURRENCE $ 5,000,00 AGGREGATE $ 5,000,00 DED I X I RETENTIONS 10,000 WORKERS COMPENSATION AND EMPLOYERS' UABIUTY IN JPARTNER/EXANY PROPRIETORECUTIVE Y❑ OFFICERIMEMBER EXCLUDED? (Mandatory 1n NH) $ WC S_RYTATU TH ITS E.L. EACH ACCIDENT y E.L. DISEASE - EA EMPLOYE $ A If yes, describe under DESCRIPTION OF OPERATIONS below Property Section 8500031450 07/06/2014 07/06/2015 E.L. DISEASE -POLICY LIMIT 1 $ Stored 350,00 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, H mora space Is required) Plumbing & Heating operations Town of North Andover Bldg 20, Suite 2035 1600 Osgood St N. Andover, MA 01845 ACORD 25 (2010/05) NORTHAN 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 ©1988-2010 ACORD The ACORD name and logo are registered marks of ACORD All rights reserved. '�CQ.RI�► CERTIFICATE OF LIABILITY INSURANCEDATE(MMIDDNYYY) 12/04/14 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 Aon Risk Services. Inc of Florida CONTACT NAME: Aon Risk Services, Inc of Florida 1001 Brickell Bay Drive, Suite #1100 Miami, FL 331314937 PRO -NE FAX AIC No Ext): 800-743-8130 A/C. /C No): 800-522-7514 COMMERCIAL GENERAL LIABILITY CLAIMS MADE OCCUR M L ADDRESS: ADP.COI.Center@_)Aon.com INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: New Hampshire Ins Co 23841 INSURED ADP TotalSource CO XXI, Inc. INSURER B : INSURER C 10200 Sunset Drive Miami, FL 33173 INSURER D : ALTERNATE EMPLOYER Ebacher Plumbing & Heating Inc 40 Portsmouth Rd INSURER E : Amesbury, MA 01913 INSURER F 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. LIMITS SHOWN ARE AS REQUESTED. INSP LTR TYPE OF INSURANCE ADDL INSR SUBR WVD POLICYNUMBER POLICY EFF MMIDO POLICY EXP MMIDD LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS MADE OCCUR EACH OCCURRENCE $ DAMAGE TO RENTED PREMISES occurrence E MED EXP oneperson) $ PERSONAL 6 ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: POLICY ❑ PROJECT ❑ LOC GENERAL AGGREGATE $ PRODUCTS-COMP/OPAGG $ E OTHER AUTOMOBILE LIABILITY a accident $ BODILY INJURY Per eraon $ ANY AUTO ALL OWNED SCHEDULED BODILY INJURY PeraoddeM $ AUTOS AUTOS NON -OWNED accident $ HIRED AUTOS AUTOS(Per $ UMBRELLA UA13 d OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS UA13 CLAIMS -MADE DEC I I RETENTION $ A WORKERS COMPENSATIONX AND EMPLOYERS'LIABILITY YIN ANY PROPRIETOR/PARTNERIEXECUTIVE OFFICER/MEMBER EXCLUDED? NIA WC 094184567 MA 07/01/14 07/01/15 PER OTH- STATUTE ER E.L. EACH ACCIDENT $ 2,000,000 E.L. DISEASE - EA EMPLOYEE S 2,000,000 (Mandatory in NH) Ir �, eescr@e antler E.L. DISEASE - POLICY LIMIT $ 2,000,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached N more space is required) AS workstte employees working for the above named clent.company, paid under ADP TOTALSOURCE, INC: s payroll, are covered under the above stated policy. The above named went is an aitemate employer under this policy. GERTIFIGATE HOLDER CANCF:I 1 ATInN Town of North Andover SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 1600 Osgood Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Building 20, Suite 2035 North Andover, MA 18450 ACCORDANCE WITH THE POLICY PROVISIONS. AUT HORtZED REPRESENTATIVE W IUBB-ZoT4 ACORD CORPORATION. All rights reserved. ACORD 26 (2014/01) The ACORD name and logo are registered marks of ACORD Date ... 1.1 < TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ...'C...'! `C�" �G� C �1 ........... ....... .;...... ............ .................. .............. has permission to perform ................ -.... C?L Q ... plumbingin the buildings of:........ ``�-........r ....SV at ........ ./ North Andover, Mass. Fee....��.v...: ...... Lic. No. ��.4�................................................................................... PLUMBING INSPECTOR Check # 33-29 Z i�� y MASSACHUSETTS UNIFORM APPLICATION FOR A PEVMITTO PIERFOfMA PLUMBING WORK CITY' ' ..- MA DATEI4aj PERMIT# JOBSlTE ADDRESS .....,.. ,.._. , 5 OWNE R'S NAMEI 7 j .Yl. , , - OWNERADDRESS, TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL fg EDUCATIONAL Cl RE,SIDE NTIALQ PRINT 0LeARLY NEtN; t2 Nt3VATION: REPLACEMQNT: PLANSSUBMITTED: Ye$o. NO FIXTUtiES IFLOOR*+ BSM' t 2 3- A 5 r a a �n moomm va so m warke s' Com The Commonwealth of 1{ assachusetts Department of Industrial Accidents Office of Imvestigations 600 ffrashington ,street Boston, M,4 02111 www. mass.gov/dia satnon Insurance nce Affidavit: Builders/Contra ctors/Electricians/P lumbers Name (BusinesslOrganization/Individual): Address: city/state/VD:, Are yor- an employer? Check the appropriate box:. 1. Q I am a employer with _ employees (full and/or part-time). i` 2. Q I am a sole proprietor or partner= ship and have no employees working for me in any, capacity. [No workers' compo insurance required]. 3. Q I am a homeowner doing all work myself. [No workers' compo insurance required.) or I have hired the contractor listed on the attached sheet Phone M 4. Q I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have' workers' compo insurance. t 5. [] We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' coMpo insurance required.] Type of project (required): 6. Q New construction 7. Q Remodeling 8. Q Demolition 9. Q Building addition 10.Q Electrical repairs or additions ll.[] Plumbing repairs or additions 12.Q Roofrepairs 13.Q0ther Any ap;!licant that checes box #1 must also fill out the section below showing their worlcers' compensation policy information. t HomeoN:mers who submit this affidavit indicating they are doing all work and then hire -outside contractors must submit anew affidavit indicating such. iContractors 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 workers' compo policy number. i am an: employer that is providing workers ` compensadon insurance for my employees. Below is the policy acid job site information. . Insurance Company Name: Policy 4 oe Self=ins. Lie: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing tlie policy number and expiration date). Failure to secure .overage as required under Section 25A of MGL c. 152 can lead to the impo ition 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 coveraire verification. 1 do hereby certi/Y under the pains and penalties of perjury that the information provided above is true and correct. 9ignature: 1l _ Date: '? fs ,bone: EBACH-1 OP ID: MS may. CERTIFICATE OF LIABILITY INSURANCE TE DD/YYYY) (MM/ DATE(MMI2014 TYPE OF INSURANCEMn_ 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 endomement(s). PRODUCER Phone: 978-388-2354 Gould Insurance Agency, Inc. 7 Market Square Fax: 978-388-6578 Amesbury, MA 01913-2494 CONTACT AME CT Matt Sherrill PAICN No. Ext .978-388-2354 AAMC No): 978-388-5578 E-MAIL ADDRESS: maM@gouldinsurance.com INSURE S) AFFORDING COVERAGE NAIC A INSURER A:Arbella Protection Insurance 41360 INSURED Ebacher Plmb.& Heating, Inc. Richard Ebacher INSURERS: INSURERC: P.O.Box 548 40 Portsmouth Rd. Amesbury, MA 01913 INSURER D. INSURER E: INSURER F: GENLAGGREGATELIMIT APPLIES PER POLICY X PRO Loc THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCEMn_ POLICY NUMBER POLICY EFF MMID POLICY EXP MMID LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE a OCCUR 8500031450 07/06/2014 07/06/2015 EACH OCCURRENCE $ 1,000,000, PREMISES Ea occurrence) E 100,00 MED EXP (Any one person) $ 5,00 PERSONAL &ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GENLAGGREGATELIMIT APPLIES PER POLICY X PRO Loc PRODUCTS -COMPIOPAGG $ 2,000,00 S AI AUTOMOBILE LIABILITY AUTO ALL OWNED SCHEDULED AUTOS X AUTOS X HIRED AUTOS X AUTO -OWNED 1020001776 07/06/2014 07/06/2015 COMBINED SINGLE LIMIT Ea accident S 1,000,000 BODILY INJURY (Per person) E BODILY INJURY (Per accident) $ (Pracci AMAGE $ INC $ A X UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE 600031451 07106/2014 07/06/2015 EACH OCCURRENCE $ 5,000,0 AGGREGATE $ 5,000,00 DED I X I RETENTIONS 10,000 $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR(PARTNERIEXECUTIVEE. OFFICERIMEMBEREXCLUDED? ❑ (Mandatory In NH) K es, describe under DESCRIPTION OF OPERATIONS below NIA WC STATU TH- Y PER L. EACH ACCIDENT $ E.L_ DISEASE - EA EMPLOYE $ E.L. DISEASE - POLICY LIMIT $ A Property Section 8500031450 07/06/2014 07/06/2015 Stored 350,00 DESCRIPTION OF OPERATIONS! LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, H more space Is required) Plumbing & Heating operations NORTHAN Town of North Andover Bldg 20, Suite 2035 1600 Osgood St N. 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 ly ©1988-2010 ACORD CORPORATION_ All rinhte raear .A ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD r CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 12/04/14 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 Aon Risk Services, Inc of Florida 1001 Bddcell Bay Drive. Suite #11 DO Miami, FL 331314937 CONTACT NAME: Aon Risk Services, Inc of Florida PHONE I FAX Ext): 800-743-8130 JAJC, No): 800-522-7514 M% AUTHORIZED REPRESENTATIVE z ,No, ADDRESS: ADP.COI.Cerder Aon.com INSURER(S) AFFORDING COVERAGE NAIC II MED EXP one n $ INSURER A: New Hampshire Ins Co 23841 INSURED ADP TotalSource CO XXI, Inc. INSURERS: 10200 Sunset Dive Miami, FL 33173 INSURER C: INSURER 0: ALTERNATE EMPLOYER Ebacher Plumbing & Heating Inc 40 Portsmouth Rd INSURER E : Amesbury, MA 01913 INSURER F 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. LIMITS SHOWN ARE AS REQUESTED. INSF TYPE OF INSURANCE NSR WYD POLICY NUMBER POLICY EFF POLICY EXP LIMITS LTR MM/DD M/DD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE COMMERCIAL GENERAL LIABILITY CLAIMS MADE OCCUR THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN NortBuilding d er.SuiA North Andover, MA 18450 18 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE z EACH OCCURRENCE S DAMAGE TO RENTED PREMISES occurrenceE MED EXP one n $ PERSONAL 8 ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: POLICY ❑ PROJECT ❑ LOC GENERAL AGGREGATE $ PRODUCTS - COMP/Op AGG $ OTHER $ AUTOMOBILE LIABILITY COMBINED a accident $ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIREDAUTOS AUTOS BODILY INJURY Perperson) $ BODILY INJURY Peraoddent $ (PeraccidentDAMAG $ a UMBRELLA UAB OCCUR EACH OCCURRENCE $ EXCESS UA8 I I CLAIMS -MADE AGGREGATE $ DEC I I RETENTION $ A WORKERS COMPENSATION AND EMPLOYERS' LIABJUTYX ANY PROPRIETOR/PARTNER/IXECUTIVE YIN OFFICERIMEMBER EXCLUDED? 0 N / A WC 094184567 MA 07/01/14 07/01/15 STATUTE ER E.L. EACH ACCIDENT E 2,000,000 fMy�dcribeundaa E.L.DISEASE- EAEMPLOYE $ 2,000,000 E.L. DISEASE - POLICY LIMIT $ 2,000,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached ff more space is required) Ali worksite employees working for the above named client company, paid under ADP TOTALSOURCE, INC.'s payroll, are covered under the above stated policy. The above named dient is an alternate employer under this policy. VI\ISI IVA.G ■,VGVGR cAur-cr r AT! IM Town or North Andover SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 1800 Osgood Street 35 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN NortBuilding d er.SuiA North Andover, MA 18450 18 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE z v iatsrj-LUT4 AGUKU t;UKNUKATION. All rights reserved. ACORD 26 (2014/01) The ACORD name and logo are registered marks of ACORD Date ... . a�.Irf TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that....V--, A � (-� /1�(. L bAt- i"T } I .................................................. . 1 has permission to perform.1. .... tn...... ..�..N.'�[...'� plumbing in the buildings of........ - ................................ ............................. at ........ .(2. ........�-,:P .A,0`^1....� ........ North Andover, Mass. Fee. .F� . Lic. No. Al ) .:�.... l.............................................................. �CA� PLUMBING INSPECTOR Check # 5-7572-L 15 C* v-�- \2-�73�lq TYPE OR OCCUPANCY TYPE COMMERCIALS EDUCATIONAL 0RM108N 1. PRINT TIALO OLEARLY NEW. R -0 -,o 'PLAN 'SOOMI D. YE$XNO0q 4NOVATION. REPLACEMENT, TTE "' ft:{ , . 1BSM1 1 1 i 1 3 7 low mm xm mm DUN nw, Vzx- rm'"l-m-ft Aw �*W*wswwx ow swig so no "Am, - Am low 4"m Aw IN AMA 1�1 rA j leers' Compensation ; alit Infof'111M1011 600 Washington Street Boston, HA 0-111/ )tt lip it). ntttss.gO Pldia Insurance Affidavit: Bt.filders/Confradors/ElectriciaifS [fill bci's Muse Print Lc ibl, Nor.tb Shore Mechanical Contractors, Inc. 1C (Businn ess/0I-gaizaIion/lntlivid Ila ll: _ ACddi-css: /Clivv/state/zi 6 Garden Street, Suite 2 Danvers, MA 01923 P11o11c H. 978-774-9800 Are you in employer? Check lite ltppropriate box: 'I. ll a 9cllel'31 CUII[1'tloor tllld I . � 1 cull a rny",luycr wills -- _ s6 - . E]I do enlp)(iyces (full and/lar hart tinlc).* lliIVC Ilil'Cd 1110 Sllh-C-01111110111'S listed -in the attached shve.'t. ❑ I and a SoIC proprietor or pclrUiet These sub-convactors have ship and have no Cnlpinyees working for rale in any cal)acily. [No workers' coillp, irlsu1-811U s regtl i red.j 3. H I ani a honleowner doing all wort: myself. (No workers' comp. insurance required.] 1` employees acid have workers' comp. insurance. 5. ❑ Y,'e arc a corporation and its officers have exercised their right of exemption per MR, c. 152, §](4), and we have no employees. [No workers' coma. insurance required.] Type of project (required): 6. ❑ New C0 11SIRICllUn 7. n Remodeling S. ❑ Demolition 9. ❑ Building Addition 10.0 Electrical repairs or additions I l.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other Any applicant that checks box #i must also fill Out the section below showing their workers' compensation policy infonma(ion. 1-lomcowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new afridavit indicating such. Contractors that check this box must attached ao additional sheet showing the name of the sub -contractors and state whether or not those entities have mployees- If the sub -contractors have employees, lhcy must provide their workers' comp. policy number. am an employer that is provh1itrg workers' compersrrtion insurance for my employees Below is fire policy and joh site { fortuatiou.. ABC KA Workers Comp. Group/TD Insurance, Inc. lsurance Company Name: olicy # or Self -ins, Lic, #: ABCMA005016- Expiration Date: 1/01/& >b Site Address:_ � �� fir`/0'IV _s-' City/State/Zip: �ytir� �,lklrt, 4"4, ttach a copy of* the workers' compensation policy declaration page (showing the policy number and expiration date). inure to secufe coverage as required under Section 25A of MGL c. 152 can lead to the illlposition of criminal penalties of a ie up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine up to $250,00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of vestigations of the DIA for ilisurance coverage verification. to hereby certifjl antler the pain rural penalties ofperjury that the information provided above is Prue and correct. t� /✓� _ data' rzvzh ata one 9: 70-7F— -77V — 721:�-t Official use only. Do loot 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 a. Plumbing Inspector 6. Other Contact Person: Phone #: 0155 'r I I T i i :ii' : •�f ' h1 '•' ,'ii�.�: 'i LL� � p �.' Li i!•�'� it ,. • �.: �"� ' L •J '--�' `LO Ac ZL�: 11 ,. W;;,f '1 . :. WIX W Ow a " W ; W. w . 1h W w Q}.. p0 > a m. A LLL f''' � o J O o' LLI � A ZQ w e W 3: LLJ .-� F a h- aN ma - a a = rti LL �a U) LL1 3: LU m Wo = J = 2(l) cn 3 LU ' z w . z. NT -.7-- rn Im ice: ":1;� L+ •i T i i :ii' : •�f ' h1 '•' ,'ii�.�: 'i LL� � p �.' Li i!•�'� it ,. • �.: �"� ' L •J '--�' `LO rr, l rel: ZL�: 11 tnLu Z WIX W Ow a " W ; W. w . p p0 > a m. A F QO z ._ o J a LL F- 2 Q w e W 3: LLJ .-� ma - ' :. :. o�: e U) ry = 2(l) cn 3 LU ' z w . z. '.aiij�iifilS'':•: a. i :ii' : •�f ' h1 r li co in WIX W a W ; W. . LL. �:dr— uj N • >Z It! -= m Z A r CD G H LL �LLI� = 2(l) cn 3 LU w . z. -.7-- rn Im AV i kx- C nr 1, r7 Date .1.2-1�149....... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ... , CI^Cy .... - Ck .. . ... ...... ........ ..... ..... ... ........ .... ..... has permission to perform J � ot-)0- d.a ................................ ...... ........ .... Y\ � Lk ?�- � - ...................... plumbing in the buildings of........ 9 ... . at ........... ....... S."i . .............. North Andover, Mass. .... .. .. .... ....... ........ ...... ............ ..... Fee& . ...... Lic. No.11. . ................... ....... I PLUMBING INSPECTOR Check* ]3 � I I .t R P TYPE OR PRINT CLEARLY A PERMIT CITY o MA DATE "L PERMIT JOi3SITEAOpRESS OWNER'S NAME' OWNER ADDRESS TEL FAX OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL O NEW:0 RENOVATION. 91 REPLACEMENT:0 PLANS SUBMITTED. YES 0 NOO I NAWKMi 4 t LUUK- 8SM 1 1 1 2 1 3. 4 1 5 1 6 1 7 1 8 1 9 j 10 1 11 12 13 14 I have a current Ilabil Insurance,policy or its substantia) equivalent which meets the requirements of MGL Ch.142. YESQ9 NO IF YOU CHECKED YES, PLEASE INDICATETHE TYPE OF COVERAGE BY CHECKINO THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY P; OTHER TYPE OF INDEMNITYBOND OWNER'S INSURANCE WAIVO.- I am aware that the licensee does rat 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 and that all plumbing work and Installations perforated under the permit issued for &s applloation will n comp!` nce wilts all Re t provision a he Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 4�r l J 1 PLUMBER'S NAME Richard Ebacher LICENSE# SIGNATURE Mpo JP0 CORPORATION 0#=PARTNERSHIP #=LLC{# COMPANY NAME Ebacher Pig & Htg. Inc ADDRESS 40 Portsmouth Road. P.O. Box 548 \� CITY Amesbury,STATE F MA ZIP: 01913 TEL FAX 978-388-4208 CELL 978-815 1315 ; EMAIL r.ebacher@ebachercompany.com Cytec Pc. -�., � /!��o� G�✓�4 �: 5 �J �q-�-e ti J o�j awI8�1 V I L CORL�� CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIYYYY) 12/04/14 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(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 endorsement(s). PRODUCER Aon Risk Services, Inc of Florida 1001 Brickell Bay Drive, Suite #1100 Miami, FL 33131-4937 CONTACT NAME: Aon Risk Services, Inc of Florida PHONE FAX A/C No Ext): 800-743-8130 A/C No): 800-522-7514 EMAIL ADDRESS: ADP.Col.Center@Aon.com INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: New Hampshire Ins Co 23841 �la�tac�at INSURED ADP TotalSource CO XXI, Inc. INSURER B: INSURER C: 10200 Sunset Drive Miami, FL 33173 INSURER D: ALTERNATE EMPLOYER Ebacher Plumbing & Heating Inc 40 Portsmouth Rd INSURER E : INSURER F Amesbury, MA 01913 COVERAGES CERTIFICATE NUMBER: 951052 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LIMITS SHOWN ARE AS REQUESTED. INSR LTR TYPE OF INSURANCE ADDL INSR SUBR WVD POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MMIDD LIMITS AUTHORIZED REPRESENTATIVE COMMERCIAL GENERAL LIABILITY �an,r„��C'e��cc�s;=l�nao �la�tac�at EACH OCCURRENCE $ DAMAGET CLAIMS -MADE ❑ OCCUR PREM SES Ea occurtDence $ MED EXP (Any oneperson) $ PERSONAL & ADV INJURY $ L AGGREGATLIMIT APPLIES PER: EPOLICY GENERAL AGGREGATE $ M'' 0PROJECTEILOC PRODUCTS - COMP/OP AGG $ $ THER CO D SINGLE LIMIT AUTOMOBILE LIABILITY =n') Ea a$ BODILY INJURY Perperson) $ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS BOD LEY Per accident $ NON -OWNED OPE Y G HIRED AUTOS AUTOS FUMBRELLA Per accident $ LIAB OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS UAB CLAIMS -MADE DEC I I RETENTION $ A WORKERS COMPENSATIONX AND EMPLOYERS* LIABILITY YIN WC 094184567 MA 07/01/14 07/01/15 PER OTH- STATUTE ER E.L. EACH ACCIDENT $ 2,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? N / A E.L. DISEASE - EA EMPLOYEE $ 2,000,000 (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 2,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) All worksite employees working for the above named client company, paid under ADP TOTALSOURCE, INC.'s payroll, are covered under the above stated policy. The above named dient is an alternate employer under this policy. , CERTIFICATE HOLDER CANCELLATION Town of North Andover SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 1600 Osgood Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Building 20, Suite 2035 ACCORDANCE WITH THE POLICY PROVISIONS. North Andover, MA 18450 AUTHORIZED REPRESENTATIVE �an,r„��C'e��cc�s;=l�nao �la�tac�at ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 26 (2014101) The ACORD name and logo are registered marks of ACORD EBACH-1 OP ID: MS A��R�'1 CERTIFICATE OF LIABILITY INSURANCE DA12/05/201TE Y) 12/05/2014 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(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 endorsement(s). PRODUCER Phone: 978-388-2354 Gould Insurance Agency, Inc. 7 Market Square Fax: 978-388-5578 Amesbury, MA 01913-2494 CONTACT Matt Sherrill PHONE FAX A/C xt No E : 978-388-2354 AIC Ne ; 978-388-5578 E-MAIL ADDRESS: matts@gouldinsurance.com INSURER(S) AFFORDING COVERAGE NAIC # INSURER A:Arbella Protection Insurance 41360 INSURED Ebacher Plmb.& Heating, Inc. Richard Ebacher P.O.Box 548 40 Portsmouth Rd. Amesbury, MA 01913 INSURER B: INSURERC: INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILICY LTR TYPE OF INSURANCE POLICY NUMBER EFF MMILDIDIIYYYY MCY EXP M/DD/YYYY LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE FKOCCUR 8500031450 07/06/2014 07/06/2015 EACH OCCURRENCE $ 1,000,00 DAMAGE TO PREMISES Ea occurrence $ 100,00 MED EXP (Any one person) $ 5,00 PERSONAL&ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: JECT POLICY X PRO- LOC PRODUCTS- COMP/OP AGG $ 2,000,00 $ A AUTOMOBILE X LIABILITY ANY AUTO ALL OWNEDX SCHEDULED AUTOS AUTOS HIREDAUTOS X NONAUTO-OWNED(P.rracddentDAMAGE 1020001776 07/06/2014 - 07/06/2015 COMBINED(Ea denSINGLE LIMIT $ 1,000,00 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ $ INC A X UMBRELLA LIAB EXCESS LIAR X OCCUR CLAIMS -MADE 4600031451 07/06/2014 07/06/2015 EACH OCCURRENCE $ 5,000,00 AGGREGATE $ 5,000,00 DED X RETENTION $ 10,000 $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE❑ OFFICER/MEMBER EXCLUC (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A WCSAOTH- TORY LIMIT ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYE $ E.L. DISEASE - POLICY LIMIT 1 $ A Property Section 8500031450 07/06/2014 07/06/2015 Stored 350,00 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Plumbing & Heating operations NORTHAN Town of North Andover Bldg 20, Suite 2035 1600 Osgood St N. 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 @ 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD r'he Commonwealth of Massacliuseiis - Departrnent o, f Xndushigl Accidents Office o, fInvestigaieons 600 Washington Sheet Boston, HA 02111 www.massgovldia worker$' Compensatioubsurance Affidavit: Builders/Contracfox�/�X Plim eianrint xnb 1, Pie:a�e Print �e�.. - Name (Business/OrganiLationftd'vidual): City/StatelZip: Are you an employer? Check the appropriate box: 1. �ZjI am a employer with ' —© 4• ❑ I am a general contractor and I havebiredthe sub -contractors a employees (full and/or pe}. 2. ❑ I am a sole proprietor orpartn.er listed on the attached sheet. These sub -contractors have ship an&have no employeesworkers' working forme is any capacity. comp. insurance. 5. ❑ We are a corporation and its [No workers' comp. bsurauce officers have exercised their required.] 3. El X am a homeowner doing all work right of exemptionpor MGL c. 152, §1(4), and we have no Myself. [Ib workers comp. insurancoregaked.] employees. jib workers' comp. insurance required.] Type of project (required): 6. New construction f 7. Remodeling S. [l Demolition r 9. Building addition 10.QElectrical rep*s or additions 11.❑ Plumbing, repairs or additions 12.[] Roofrepairs 13.[] Other F] Mny applicant that checks box6l must also fill ouitha section below showing their workers' compensatioupolicy information. y� i -Homeowners who submit thus affidavit indicatingthey Re doing allworlc and then hire outside contractors must submit a new afixdavit indicating such. TContractors that cheekthis box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. Policy information. X am. an employer that isproviding workers' compensation insurance for my employees:.Be%w is thepolley and job site informatdon. / 'n — 1, V Insurance Company policy # or Set- ius. Lic. # : 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). Failure to secure coverage as requiredunder Section 25.A. of MGL c. 152 can lead to the imposition of criminal penalises of a fi a up to $1,50 0.00 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 dap against the violator. Be advised that a copy of this statement may be farwarded to the Office of Investigations of the DI& for insurance coverage verification. ^ X do bere%y cerfl-rY under the pains and penalties ofperrury that tit information provided alcove is true and correct Phone 4. F Oficial use only..Do not write in tins area, to lie completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. CWITowa Clerk 4. Electrical inspector 5. PlumbingInspector 6.Other - Phone #: -- Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,• express orimpiied, oral orwxittenr ' An employer is defused as "an individual, partnership, association,coxpoxati0 or other legal entity, or anyiwa ormo o of the foregoing engaged in a joint enterprise, and including the legal representatives of a•deceased employer, or the receiver or trustee of an individual, partnership, asso ciation or other legal entity; employing employees. however the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwellinghouse 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 Ideal 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 pro duced.acceptable evidence of compliance with, the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political sub div cions shalt enter into any contract fbr the p erfoxmance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have, b e an pros onto d 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 certificates) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are notrequired to cavy workers' compensation insurance, if au LLC or LLP does have employees, apolicyisrequired. Be advised that this affidavit maybe submitted to the Department of Iudustrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be refuxnedto the city or town that the application for thopermit or license is being requested, not the Department of v Industrial Accidents. Should you have any questions regarding the law or ifyou 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 andprinted legibly. The Departmenthas 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 xegarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given, year, need only submit one affidavit indicating current policy information (ifnecessary) and under "Jab Site Address" the applicant shouldwrite "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. Anew affi'tdavit must be typed out each year. Where ahome owner or citizen is obtaining a license ox permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do nothesitateto give us a call. The Department's address, telephone aad fax number: ThoCQMM0nWf,1ajt.h Of l q,(,hvset Depat eul QfhidwWal A raoidents• Ojwce dwesugaa( W 604 WasWugtm oett B ostQn, 021 X 1 Tel -9 617-72,7-4900 at 406 or 1-877,:MS.AM Revised 5-26-05 Fax 61T727 -7m WWW—Mma sov/iiia 4'�QROTEOT,Q,P � 'tier. 7173' EBACHER EBACHER Plumbing & Heating Inc., fire Protection DickEbaCher President/Owner T 978.388.4086 F 978.388.4208 r.ebacher@ebachercompany.com P.O. Box 548 40 Portsmouth Rd Amesbury, MA 01913 MA Master Lic.8926 NH Master Lic.1235 C, Wp4kler Conkrac;or #000463 Date .1s' .......... 10914 Fee ...................... Lic. No.. ry-z b..... PLUMBING INSPECTOR Check # lass. Date ...... �.`�..-l..Y. TOWN OF NOIRTM ANDOVER This certifies t at ®...................!`...:....... has permissio for gas ' stallation in the buildingi�..... Le ...... at ..... 3.�..�.1........... 2 .41u �....5. ..... Fee Lic. No. � gi .......... b �`....................................... .......'......!.s .......................... ...., North Andover, Mass. .. ....................... .................................................................................. GASINSPECTOR Check #0- 973%"l e, C Date .. ..1 . ...... ....... t TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ........ l-P.�...e„IL.,..........'..".5................................................. has permission for gas installation . V?-...... U.� �' ................................ in the buildings of ...... �c.R......N�....?..,-::................................................ at ..... -��.�� .... `. �'`....:' . ................ . North Andover, Mass. Fee.125..'�! Lic. No. I W.�......... GASINSPECTOR Check # L Z G t C Tel Fr) A7ll te- 1i MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK -� CITY ,ff, �,V�,Y,,[ MA DATE `�/ � � � PERMIT # U � JOBSITE ADDRESS —0,6-1 /Jp��f✓tyll^OWNER'S NAME GOWNER ADDRESS TEL FAX TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL CLEARLY NEW:: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO'k APPLIANCES -1 FLOORS— 1 2 3 4 5 6 7 8 9 10 11 12 13 14 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 I SPACE HEATER ROOF TOP UNIT _.. TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch.142 YES X'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. C HECK 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 anda rate to the best of my k wledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance -wit all Pertinent pro sion o h Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME Peter G. Viens LICENSE # 12116 SIGNATURE MP 0< MGF JP JGF LPGI CORPORATION# 3631 C PARTNERSHIP # LLC #. COMPANY NAME: Merrimack Valley Corporation ADDRESS 15 Aegean Drive, Unit #3 CITY Methuen STATE MA ZIP 01844 TEL 978-689-0224 FAX 978-689-2206 CELL 978-807-2819 EMAIL pviens@mvalleycorp.com (2� Tel Fr) A7ll te- 1i Gi+ F O z F U W a z J d z .. k--z4f t', } C ❑ a z z O r ❑ W � ~ W O w O CL Uw # z CL. V) U) w >WW Z Q a LU a w C4 w Q w N a V zz a a a x � F � Qw iii T'l w t.. w w F O z z 0 F U W 0. z V) d v a J The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, Mass. 02111 www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant taformation Please Print Legibly Name (Business/Organization/individual) : Address: %� /� i9� ��F �/ -27$' 1 City/State/Zip:/�%%r��,� ship and have no employees ,.��%,� �j�j r Phone#: Are you an employer? Check the appropriate box: 1. I am an employer with _; 4. IJ I 1 employees (full and/or part time).* am a general contractor and I have hired the sub -contractors 2. :1 1 am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance. $ required] 3. 1 I 1 am a homeowner doing all work 5.❑ We are a corporation and its officers have exercised their myself [No workers' comp. right of exemption penis MGL insurance required] t c. 152, § 1(4), and we have no employees. [no workers' comp. insurance required.] Type of project (required): 6. 0 New construction 7. C Remodeling 8. L Demolition 9. LJ Building addition 10. 0 Electrical repairs or additions 11. 0 Plumbing repairs or additions 12.NRoof repairs��G� 13. � Other Any applicant that checks box #1 must also fill out the sects n blow showing their workers' compensation pohcy tnformat,on. tHomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contactors that check this box must attach 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 roust provide their workers' 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:--Z�4%6 Policy # or Self -ins. Lic. #: ,Qjj�(,,��A� �� v ,/ I ,Expiration Job Site Address:_ ��/ //Q9� j City/State/Zit):- kation 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 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 $250.00 a day against violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for coverage verification. 1 do herby cerdydndepthe Print Name: c ofRerjury thpt the information provided above is true and correct A/ t! 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): i.Board of Heath 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact person: Phone #: Aw This certifies that . ...... . e. l" ! e i e� ......... has permission for gas installation .`?! .`.., i � ....... . � in the buildings of .! .. !..� �.-- ..................... at ...-S �.. V-?��.�. .S�""- .... North Andover, Mass. /'�[ . Fee. 16� —... Lic. No. .��. . !-V ................. ... �, t - G�j,�.� ��) GAS INSPECTOR Check # 2 3 8753 tC 034— ISI o.j -7kji3 GOWNER TYPE OR PRINT CLEARLY MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY /��f�l� !yc d J MA. DATE PERMIT #/� I JOBSITE ADDRESS S/ OWNER'S NAME ADDRESS: ; TEL: FAX: OCCUPANCY TYPE: COMMERCIAL EDUCATIONAL ❑ RESIDENTIAL. ❑ NEW: ❑ RENOVATION: U/- REPLACEMENT: ❑ PLANS SUBMITTED: YES /NO ❑ FIXLITRES I FLOOR— Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR _._. GRILLE LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM I SPACE HEATER ROOF TOP UNIT TEsi UNIT HEATER UNVENTED ROOM HEATER WATER HEATER INSURANCE COVERAGE I have a current liabililyInsurance 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. 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 hereby certify that all of the details and information I have submitted (or entered) regarding this application Knowledge and that all plumbing work and installations performed under the permit issued for this applicati, provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. / PLUMBERIGASATTER NAME: Jose h .. M_.Wh the LICENSE #L-9.6.6-4.,-.1 SIGN COMPANY NAME: I North Shore... mechanical Contractors-, Inc......._ ADDRES : CITY: I Danvers...... ....... .. STATE: a] ZIP: 0192.._..._._.._.. TEL: ._97$.-.77-4.-9800 CELL: sf2 _._._.... __. EMAIL: ie and accurate to the best of my be in compliance with all Pertinent FAX: 1978-77 Co MASTER ❑ JOURNEYMAN ❑ LP INSTALLER 0 CORPORATION ® # 1441 PARTNERSHIP ❑ #0 LLC ❑ #0 t !� Office of Investigations 600 FVashington Street AIA 01111 iv It, w.nuis's.gov/dia Workers' Compensation Insurance Affidavit: Buildei-s/Coiitl'actot's/Electi-iclatls/Pltttlibei-s Applicant Information Please Print Legibly Ni nic North Shore Mechanical Contractors, Inc. Address: 6 Garden Street, Suite 2 -_ City/State//,ip: Danvers, MA 01923 P110I1C i#: 978-774-9800 Are you :u1 employer? Check the appropriate hnx: 1. I� 1 11111 a cinpluyer will) 36 4. -11 21111 a gCller,91 C0111r,1001- iIlld I "ll.)lovees (full and/ul parl-tillic). have hired (lie suh-c.mill'iclor.s _. ❑ I ,1111 a .i(tl(; lir(ilil'Ii;I(il' or pi'1llili;l'- listed un the altached slice(. 511111 ,Illd have. no (:Illployees 1 -hese stlb-contraclors have working for me in any capacily. employees and have workers' [No workers' comp. insul-ance comp. insurance.$ required.] 5. ❑ .".'c arc a corporation and its 3. ❑ I am a homeowner doing all wuri: officers have exercised their nlyself. [No workers' comp. right of exemption per MGL, insurance required] 1 c. 152, §1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (require(f): 6. ❑ New C(ul.slructiun 7. ❑ l?enuldeling S. ❑ Dunoliti011 d. ❑ L3trilding addition I f 1.❑ E!ectnc2tl relr,irs cr additiur is I i.❑ Plumbing repairs or additions 12.0 Roof repairs 13.❑ Other Any applicant that checks box #1 must also Fill out (he section below slowing their workers' compensation policy intbrmation. t 1-10"leowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 'Coll tractors that check this box must attached all additional sheet showing the name of file s u b-co,l tractors and state whether or not those emit,es llave employees. If the sub-comraclors have employees, they must provide their workers' comp. policy number. I am an elnpluyer that is provirliltl; workers' compensation insurance for my elnpli pe(m Below is the police fl/1-1/job site to fornratlon. Insurance Company Name: ABC MA Workers Comp. Group/TD Insurance, Inc. Policy # or Self -Ins. Lic. 4: ABCMA005016— `/ Expiration Date: 110.11154 .lob Site Address:_ .357` �a /( elV :59—_-570d%141 City/State/Zip: ,, �/�/ 8� /i't'j% 0 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 [lie 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 )f up to $250.00 a day against the violator. Be advised that a copy of this statement play be forwarded to the Office of 'nvestigations of the DIA for insurance coverage verification. elo hereby certify under the pains and penalties of perjury that the information provided above is true and correct lionature f �,A�- li�-=-L a, ,,_._ -__7 I/—j . 'hone. 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. Cit ,/Town Clerk 6. Other Contact Person: 4. Electrical Inspector 5. Plumbing Inspector Phone #: COMMONWEALTH OF MASSACHUSETTS SHEET METAL WORKERS AS A MASTER -UNRESTRICTED ISSUES THE ABOVE LICENSE TO: JOSEPH M WHITNEY 26 GREENLEAF DR DANVERS MA 01923-1528 10503 08/28/12 4185 COMMONWEALTH OF MASSACHUSETTS PLUMBERS AND GASFITTERS-° REGISTERED AS A PLUMBING CORP ISSUES THE ABOVE LICENSE TO: JOSEPH M WHITNEY NORTH SHORE MECHANICAL CONTRAC Mb 6 GARDEN ST �/.;c STE 2 "'N DANVERS MA 01923-1431' 1441 05/01/14 143105 y COMMONWEALTH OF MASSACHUSETTS � �°I0 •° ° :e••.o PLUMBERS ANL vASFITI'ERS LICENSED AS A Mi ;)TER PLUMBER ISSUES THE ABOVE LICENSE TO: CT J 26 DANVERS GREENLEAF DR MA 0, ;•23— 1528 COMMONWEALTH OF MASSACHUSETTS y PLUMBERS AND GASFITTERS LICENSED AS A JOURNEYMAN PLUME'---- ISSUES THE ABOVE LICENSE TO: JOSEPH M WHITNEY 26 GREENLEAF DR U3 DANVERS MA 01923-1528 18587 05/01/14 156979 • COMMONWEALTH OF MASSACHUSETTS • • •o •umm :••-.s SHEET METAL WORKERS AS A BUSINESS ISSUES THE ABOVE LICENSE TO: JOSEPH M WHITNEY NORTH SHORE MECHANIC",L CONTRAC 0 G 61 GARDEN ST SUITE 2 DANVERS MA OIY23-0000 354 05/09/13 98"c - 10 a I Lq- 2 n, -5 This certifies that .�( SP.p .... ........... has permission to perform.1 . ..... cjf ..� ... !4 plumbing in the buildings of...... ....................... ..�i ..... .................... North Andover, Mass. Lo Fee IPj. t -:f .. Lic. No.%AP ..... ......M............................................................... Date ?,)-z, .I. .. I 7 -� .......... ...... I ........ TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING Check � , `D 2--'S - PLUMBING INSPECTOR MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK "� v'�- j MA DATE --1 PERMIT # - CITY __ JOBSITE ADDRESS S-%_- _--�'✓//i PVJW/ OWNER'S NAME �i2 i N P OWNER ADDRESS L ifA_ ,j►/ _- - TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: ❑ PLANS SUBMITTED: YES NO!i FIXTURES 1 FLOOR- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB "� CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM rBSM DEDICATED GAS/OIL/SAND SYSTEM _ _ ._ , —� 1 _�_ _- '•_ _ i� _, -- - DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM - - - ? � I ' DEDICATED WATER RECYCLE SYSTEM DISHWASHER1 DRINKING FOUNTAINEli FOOD DISPOSER'FLOOR / AREA DRAIN i�._ i . . '^ 1_INTERCEPTOR (INTERIOR) 1 _ KITCHEN SINK _ - LAVATORY _ ._. _ r _ _ ROOF DRAIN SHOWER STALL �,_ _ r ��' IM_ SERVICE / MOP SINK _- _J - Tom'. - TOILET - URINAL';,_ WASHING MACHINE CONNECTION L�i' _ WATER HEATER ALL TYPES WATER PIPING i OTHER 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 i LIABILITY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY ❑ 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 © 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 ompliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. W-�' PLUMBER'S NAME I Joseph M. Whitney LICENSE # 9664 SIGNATU MP(] JPD CORPORATION # 1441 PARTNERSHIP LJ#L�LLC 0,# � COMPANY NAME I North Shore Mechanical Contractors ADDRESS 16 Garden Street, Suite 2 {� CITY Danvers STATE MA ZIP 01923 TEL 978.774.98001\9 FAX 1978.774.9898 CELLEMAIL -'7JW -- -,-- - vp v t/ 1 7 •P. w � LfjjfLC Vl arc rcoec�uu.vn�. _ 1 600 Washington Street r Boston, HA 011// •�' 1411'tt 11TCI5'S'.b (ll �CftfJ Workers, Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers `A Cant Inforilla ion I'lease !Tint Legibly Nt1t11C(fiusiness/grganization/lntiividuall: North Shore Mechanical Contractors, Inc_ Address: 6 Garden Street, quite 2 C'j(y/Si,j(e/Zip: Danvers, MA 01923 P1jolie #: 978-774-9800 Are you an employer? Check Ilse appropriate box: 1 ;111) a rrlipluyer will+ 36 4. ❑ I am a gencral colltraclor and 1 havc hirci) Ihc. strb-cunlrticlnrs elllployces (full anc Of llall-ttnle). ?, ❑ I [till a sole propriclor or prrrtner- shill ,fled have. 110 elilployees working for nle in any capacity. [No workers' camp, insurance required.] 3. iJ I ani a homeowner doing all wort: myself (No workers' comp. insurance required] t lis[ed on the altached shcel. These sub -contractors have employees arid havc workers' comp. insurance., 5. ❑ Yrle are a corporation and its officers have exercised their right of exemption per MGL. c. 152, § ] (4), and we have no employees. [No workers' comp. insurance required.] Type of project (r•equirc(l): (,. ❑ New conslruclk111 7. ❑ Remodel lb S. ❑ Demolition 9. [] Building addition 10.❑ Electrical repairs or additions I ].❑ Plumbing repairs or additions I2.❑ Roof'repair•s 13.❑ Other Any applicant that checks box 41 must also fill out die section below showing their workers' compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. Contractors that check this box must altachcd an additional sheet showing the name of d+e sub -contractors and state whether or not those entities have mployees. if the sub -contractors have employees, they must provide their workers' comp. policy number. am an eniployer that is provitlinn workers' c•impenstrtlon insurance fir my entpk(llees. Belon., Ls the polio! (!till fob site {fitrnurtiat. lsurance Company Nanle: ABC MA Workers Comp. Group/TD Insurance, Inc. olicy # or Self -ins. Lie. #: ABCMA005016— /.3 Expiration Date: 1 /01/6z )b Site Address: 51 <,oa7-14 all //caw sT City/State/Zip: IV&P-A) Z&t ,Ie,64jta � ttach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date), iilure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a le up to $1,500,00 and/or one-year imprisonment, as well as civil penalties in the form of STOP WORK ORDER and a fine .up to $250,00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of vestigations of the DIA far insurance coverage verification, to hereby certify raider the paitg and penalties of perjury that the information provider! above is true and correct ature: / Z/2- // 3 one 4: 19,79— 77Y~�� - Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: a15yr T Cj) WE sin. Buis < Lu use w Lu ME -LU.- Z.O Wt.) ..w um U)LU z <f- UL), LL w < z (,) 0 > 0 z LL Ln T m 0 on 0 w M LL T Cj) WE sin. Buis < Lu use w ME -LU.- Jk ..w (n LU Z sin. Buis U, 04 (n LU Z cm U < z (,) < LL Ow 73 L>Ll U4LLJ 1Z I.- (n �d 0 on 0 Lu lz ZO • w z H Q< LL o Vi F- 2 < LL. ul e Lux in3 w co .0 > 0 LLI 00 F -Lu L LL- CD LLII-- il Q. < L4 W Min cn 3: C5 A4. w U . IEN U4LLJ 1Z I.- (n �d 0 z w o LL. co .0 > 0 F -Lu LL- CD LLII-- il = < L4 W Min cn 3: Lu w Z. 0 Oct,10, 2014 8:29AM Town of North Andover Town of North Andover BUILDING DEPARTMENT No. 3298 P. 1/1 CONTRACTOR AFTER HOURS REQUEST FORM CONTRACTORS NAME: �M&m 1C— ' e ADDRESS: ��(�S'l bL.7 �D • _ CITY/ TOWN: AAAM Q STATE: J ZIP: BUS. PHONE: (k� ? 3 0 oA— CELL: ,(IP -6.3) 919 — 0W3 MA. LIC #: MASTERS: `�`� 3�"Z JOURNEYMANS: Z \\ °�c� E PERMIT # k 2-'9 6!!� N -GRID SR## & ja Z /3 REOUESTED DATE: %/ J®% TIME: �Gm JOBLOCWILLOW S1 OWNER: PHONE: (�� yg37 'WORKERS CELL: (9`%9 oho EYGIC- lcxcy - Pfo eie4iC REASON FOR REQUESTED INSPECTION AND JOS DETAILS: sh U"Wil / sWW NORTH ANDOVER SUPERVISOR SIGNATURE: Contractors requesting INSPECTIONAL SERVICES due to weekend or after hour operations such as service related planned updates or special situations, will be required to provide a four hour minimum charge of $150.00 paid to the Town of North Andover at that time. Community Development Division,1600 Osgood Street, North Andover, Massachusetts 01845 Phone 976.680.9545 fax 978.688.9542 Web www.townofoorthandover.com j- 0' 4J CD C\J _ -4t U ei'T "I . I _1 CD o I av Mf Jam. y 0 �r 54: tin t Al 4-f i rm XN CD Xp. _Ln a) ru CD `i. Ln ti ru Yt ca kz, Ln Ln kl L rm d) 44 CW2 rLi _ �.o cy- Jai. j, ui LD Co .. M� " , 1 11- U) 41 ol 4� L13 ru Ak j- Date ....1.....��.... �...�,�... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies thatN.l d� ' has permission to perform,! ...A A.,' v\.... P �--PS wiring in the building of.........� � c -a J V ........................................................... ..................... at �i........W '��o ,� �-i— `................................................................... North Andover, Mass. V ELECTRI/CAL INSPECTO Fee`.._"' Lic. No. `.............� ....... Check # Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. (b/�'�� Occupancy and Fee Checked [Rev. 1/071 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC 527 MR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: j ; City or Town of. NORTH ANDOVER To the Inspector o Wires: By this application the undersigned gives notice of his or her intention to perform he electrical work described below. Location (Street & Number) Owner or Tenant A A k2 - Al- r� �/ Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes � No ❑ (Check Appropriate Box) Purpose of Building_ �� t eP 5 Utility Authorization No. Existing Service Amps / Volts New Service Amps / Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: I-OP�� Overhead ❑ Undgrd ❑ No. of Meters Overhead ❑ Undgrd ❑ No. of Meters ewt� I 6 � 1/1c' sis �e P 4 I � y,e(' Qod Completion of the following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Above In- Swimming Pool rnd. ❑ rnd. ❑ o. o Emergency Lighting Batter Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiatin Devices No. of Ranges g No. of Air Cond. Total Tonscz No. of Alerting Devices No. of Waste Disposers Heat Pum Number Tons KW ........................ No. of Self -Contained Totals: Detection/Alertin Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers y Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KW No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total I Telecommunications Wiring: No. of Devices or E uivalent [OTHER, Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: . (When required by municipal policy.) Work to Start: AAP Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless'— the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such covers e is in force, and has exhibited proof of same to the permit issuing office." CHECK ONE: INSURANCE [BOND ❑ OTHER ❑ (Specify:) I certify, under therains and penalties of per'ury, that the information on this application is true and complete. FIRM NAME: ,� ✓ LIC. NO.: QQ(of(�A- Licensee: DrA,-e C,5iAoe Signature LIC. NO.: `�Q -4 (If applicable, enter "exempt"in the license number lin .) Bus. Tel. No. - 9,,z'fZ- QX -n ltf.IX- Address: {�Aata(� �c�� Alt. Tel. No.: 4ot' �o41-�a( *Per M.G.L c. 147, s. 57-61, security work requires Department of P�Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one)❑ owner ❑ owner's a ent. Owner/Agent �- Signature Telephone No. PERMIT FEE: $ io�J o �� t,1 � V -e A � vyn.A l - Commonwealth of Massachusetts Official Use Only Department of Fire Services Permitl Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (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: j a 0 City or Town of: NORTH ANDOVER To the Inspector Of Wires: By this application the undersigned gives notice of his or her intention to performhe electrical work described below. Location (Street &Number) 3/}; ��(}1 „j �,�r SbU Owner or Tenant Owner's Address „1 Is this permit in conjunction with g building permit? Yes Lv Purpose of Building No. No ❑ (Check Appropriate Box) Utility Authorization No. Existing Service Amps / Volts Overhead ❑ New Service Amps / Volts Overhead ❑ Number of Feeders and Ampacity �— Location and Nature of Proposed Electrical Work: e- W 11� C `i u�" S,i�P� 1 i � ��) I a n ��" �` ��i�roil % J Com letion of the 2 Undgrd ❑ No. of Meters Undgrd ❑ No. of Meters _ AI—ViCP'r- wingt(G n � : Jk' VeC- Q_0 0 'lam i win table ma be waived b the Ins ector o Wires. ' u Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: AM Inspections to be requested in accordance with MEC Rule 10, and upon completion. � INSURANCE COVERAGE: Unless waived by, the owner, no permit for the performance of electrical work may issue unles the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such Covera e is in force, and has exhibited proof of same to the permit issuing office. + CHECK ONE: INSURANCE [1�BOND ❑ OTHER ❑ (Specify:) I certify, under therains and penalties of per'ury, that the information on this application is true and complete. FIRM NAME: ,c� C fe LIC. NO.: QQ(J�� Licensee: 0Giy-e ('Gt/�Cl� Signature T. LIC. NO.:�— (If applicable, enter "exempt" in the license number lin .) Bus. Tel. No.: K;Z- iZ— &05 'CXf,lc Address: �G aW 1 �� w�( Alt. Tel. No.: 4(J -foul-Qa('� *Per M.G.L c. 147, s. 57-61, security work requires Department of Pub is Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one ❑ owner ❑ owner's agent. Owner/Agent PERMIT FEE: $ )dS~ Signature 1 1 Telephone No. o60 No. of Total No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires SwimmingPool Above ❑ In- ❑ rnd. rnd. No_.of Units Emergency Lighting Batter Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones a No. and No. of Switches No. of Gas Burners Initiatin Devices Inof itiating No. of Ranges No. of Air Cond. TotaTons No. of Alerting Devices cz Heat Pump Number Tons KW No, of Self -Contained No. of Waste Disposers P Totals: Detection/AlertingDevices No. of Dishwashers S ace/Area Heating KW P g Local ❑ Municipal F1 Other Connection No. of Dryers Y Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KW No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP _ Telecommunications Wiring: No. of Devices or Equivalent OTHER: u Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: AM Inspections to be requested in accordance with MEC Rule 10, and upon completion. � INSURANCE COVERAGE: Unless waived by, the owner, no permit for the performance of electrical work may issue unles the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such Covera e is in force, and has exhibited proof of same to the permit issuing office. + CHECK ONE: INSURANCE [1�BOND ❑ OTHER ❑ (Specify:) I certify, under therains and penalties of per'ury, that the information on this application is true and complete. FIRM NAME: ,c� C fe LIC. NO.: QQ(J�� Licensee: 0Giy-e ('Gt/�Cl� Signature T. LIC. NO.:�— (If applicable, enter "exempt" in the license number lin .) Bus. Tel. No.: K;Z- iZ— &05 'CXf,lc Address: �G aW 1 �� w�( Alt. Tel. No.: 4(J -foul-Qa('� *Per M.G.L c. 147, s. 57-61, security work requires Department of Pub is Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one ❑ owner ❑ owner's agent. Owner/Agent PERMIT FEE: $ )dS~ Signature 1 1 Telephone No. o60 LIP Date .. :�... v ........... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that �..±v`.P �t`� e T Q'..p d^' ��,--t--L `j...............................................p.......................................... has permission to perform ..... !.. ..... V v\ L^ .......................................................... wiring in the building of....... ..................................... at ........ 1.. I l l Q M�.... .......................... ..,North Andover, Mass. Fee. 2 Lic. No... '4... /"a ............ ....................... ........... 2CTRICAL INSPE Check # 16,732- �J r^ a Commonwealth of MassachusettsO cial Use O Department of Fire Services Permit No. BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/o7j (leand Fee lank)Checked ° (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 W INK OR TYPE ALL INFORMATION) Date: q NO City or Town of. NORTH ANDOVER 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) 3 � '/V I �IO�J 644t Telephone No. q ]�_ 6%i _ hkk Owner or Tenant Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No 9 (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service / Overhead ❑ Undgrd ❑ New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Amps Volts No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: �tr; tL cy R� CP�b�`t oy' M� , _ o Completion ofthe following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- ❑ rnd. rnd. o. o Emergency Lighting Batter Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiatin Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices g No. of Waste Disposers Heat Pump Totals: Number Tons ...""""""""'""'...."""."'""""' KW No. of Self -Contained Detection/AlertingDevices No. of Dishwashers Space/Area Heating KW Municipal Local ❑ Connection [_1 Other No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water Heaters KW No. of No. of Signs Ballasts Data Wiring: y No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: t j No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Q , _ Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such cov age is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify, under thepains and penalt'es of perjury, that the information on this application is true and complete. FIRM NAME:. �IA��PI Pi� a'�t �/ 4D �Crt`•Q� �. �, C� LIC. NO.: Licensee: Signature LIC. NO.: (If applicable, enter "exempt"'i,n the license amber line.) Bus. Tel. No.• Address: � eillh��l� �i�,�61), I ( wI4 q Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance cover normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner Owner's agent. Owner/Agent Signature - Telephone No. M- 6g;-1100 PERMIT FEE: $ ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed C on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an [� electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the "t notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shall -be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012. ❑ Rule 8—Permit/Date Closed:** Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection Pass IN Failed IN Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass IN Failed Re- Inspection Required ($.) ❑ Inspectors omments: Inspectors Signatu e: Date: FINAL INSPECTION: Pass IN Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com 0 The Commonwealth of Massachusetts Department of IndustriqlAccWnls Office of Investigations 600 Washington Street Boston, MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): UrogA pi/ IC/66t LLC Address: Lk�r\ City/State/Zip: NlA64A\1 m A MYA Phone #: Are you an employer? Check the appropriate box: 1I am a employer with 4. El am a general contractor and I _� employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet ship and'have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, §1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. F1 Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12. ❑ Roof repairs 13.[�VOther 01 �-e *Any applicant that checks box A must also fill out the section below showing their workers' compensation policy information. i Homeowners who submit this affidavit indicating they aie doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' c mpensation insurance for my employees. Below is thepolicy and job site information. ---n— Insurance Company Name: Policy # or Self -ins. Lie. #: U 13 Expiration Date: Job Site Address: W' �11AG W St4�� City/State/Zip: N mL ,Nklmr� i�,A c�6q5 Attach a copy of the workers' compensation policy declaration page (showing the 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 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. Ido hereby cepu der th"ams and penalties ofperjury that the information provided above is true and correct. 332- Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - Contact Person: Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced -acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or' -permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth ofMassacl_zvsetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA. 02111 TeX. # 61,7-72.7-4900 ext 406 or 1-877rMASSAFE Revised 5-26-05 Fax # 617-727-'7749 __WWW-Mass.8QV1dla 1* 0 2L� 7 Date...... ....................... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ........... 9,4wo ...... 1.?K ...... :YYS. has permission to perform ........ ........ >................... wiring in the building of ....... .................................... at ......... ...... ....... ............. , North Andover, Mass. fzisc ................ Fee..�� ... .... Lic. No... .... .. . I LI S E R f2i1c Check # COmmonwea& o/cc/ /taddachuoettd 2epartm.ent of Jiro S®rV4Ce6 BOARD OF FIRE PREVENTION REGULATIONS 02-y7 Official Use Only Permit No. Occupancy and.Fee Checked (Rev. 1/071 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 PR)7VT IN INK OR TYPEALL INFORMATION) Date: %-22--2=o% t City or Town of: _004,�Aq -er 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) Owner or Tenant Telephone No, Owner's Address Is this permit in conjunction with n building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building CO3MM:2r .;e,4 Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nnture of Proposed Electrical Work: L7 /eceeph-te, a, -{A 4[ r *f4 1GM a te,,— nfrbn fnttnwino rnhle may be waived by the Inspector of Wire-, Alta ch additional detail rfdearrer, o, crs,equ y p Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unlcs: 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 9 BOND f-1OTHER 171 (Specify:) I certify, under the pains rind penalties ofperjury, that the information on this application is trite and complete. FIRM NAME: � LIC. NO.: )�,\�jC Licensee: yC�.4 oy fit, �{ �S Signature LIC. NO.: 501 (If applicable, enter "exempt" in the license number line.) Bus. Tel. No.:1)"i —211 'AcKeo Address: 4 ti hh Pl,-AOn 'S(u aUS t m 0190(x_ Alt. Tel. No. nCa• �a-• 1'A air *Per M.G.L. c. 147, s. 57-61, security wor requires Department of Public Safety "S" License: Lic. No. �c7�h 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 [1 owner's agent. Owner/Agent PERNIIT FEE: sZSs� Signature Telephone No. No. of TotalNo. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators PVA No. of Luminaires Aliove n- Swimming Pool nd. ❑ rad. ❑tte o. o Emergency Lighting BaUnits No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Detection and No. of Switches No. of Gas Burners Initintin Devices _ No. of Ranges Total No. of Air Cond. Tons No, of Alerting g Devices No. of Waste. Disposers eaC Pump umber ons Totals: - - ... o. o Self -Contained Detection/Alertin Devices No. of Dishwashers Space/Area Heating KW IYlunicipal ❑ Other Local ❑ Connection Heating Appliances KW pp ystems:" No, Devices or Equivalent No. of Dryers of No. o iter IOW Heaters o. o No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent 'Te ecammunicntions 't-Viring: No. Hydromassage Bathtubs No. of Motors Total FIP No. of Devices or Equivalent OTHER: I ;red h the Ins ecior of PVire.i Alta ch additional detail rfdearrer, o, crs,equ y p Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unlcs: 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 9 BOND f-1OTHER 171 (Specify:) I certify, under the pains rind penalties ofperjury, that the information on this application is trite and complete. FIRM NAME: � LIC. NO.: )�,\�jC Licensee: yC�.4 oy fit, �{ �S Signature LIC. NO.: 501 (If applicable, enter "exempt" in the license number line.) Bus. Tel. No.:1)"i —211 'AcKeo Address: 4 ti hh Pl,-AOn 'S(u aUS t m 0190(x_ Alt. Tel. No. nCa• �a-• 1'A air *Per M.G.L. c. 147, s. 57-61, security wor requires Department of Public Safety "S" License: Lic. No. �c7�h 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 [1 owner's agent. Owner/Agent PERNIIT FEE: sZSs� Signature Telephone No. Date... .141 .............. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that 4 � I � t' I -e eA� 2 ` C", iy gu - ................................`..._....................................................................................... JJ has permission to perform �." �"��^+�.. ` '�^ m- 'VA's- �4 e)� .......................... �.................................................... wiring in the building of..... �L2 40. ..".......................................... at ........2........ ` .. i Mass. J ��.......�,�:!......'...........G�:...................�!`, North Andover, Fee...' ............... Lic. No. �I��... . ........... .d. .. /r�.......... E gCbUC PECTOR + Check.. 2 2 7 C +%�.� �l IZ 2 c�. — -ler �'1►2 �j. 1. Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No.� BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked Ulu . [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: 4-11-14 City or Town of. North Andover 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) 351 Willow Street Owner or Tenant Bake `n Joy Foods Telephone No. Owner's Address 351 Willow Street North Andover Is this permit in conjunction with a building permit? Yes No X (Check Appropriate Box) 3 Purpose of Building Office & Manufacturing Utility Authorization No. Existing Service Amps Volts Overhead Undgrd No. of Meters New Service Amps Volts Overhead Undgrd No. of Meters --7 Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Install a Pringle switch on the main breaker for the building Completion of the. following table may be waived by the Inspector of Wires. No. of Recessed Fixtures 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 ❑ In- ❑ o. of Emergency Lighting rnd. grnd. Battery Units No. of Receptacle Outlets No. of Oi�Bfirners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Number. .......................................... ..............Tons KW No. of Self -Contained Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems: No. of Devices or Equivalent No. of Water KW No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: one hand dryer Attach additional detail if 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 x BOND ❑ OTHER ❑ (Specify:) 3-21-15 (Expiration Date) Estimated Value of Electrical Work: Work to Start: 5-10-14 Inspections to be requested in accordance with MEC Rule 10, and upon completion. I certify, under the pains and penalties of perjury, that the information on this application is true and eo nplete. FIRM NAME: Stilian Electric, Inc 108 Tenney St. Georgetown, MA 018 3 LIC. NO.: Al 1067 Licensee: Karl Gonsiorowski Signature LIC. NO.: E31598 (If applicable, enter "exempt" in the license number line) Bus. Tel. No.: 978-352-9994 Address: 108 Tenney Street Georgetown, NIA 01833 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. Owner/Agent Signature Telephone No. PERMIT FEE: 125 A . Division of Professional Licensure: License Search The Official Website of the Office of Consumer Affairs and Business Regulation (OCABR) Division of Professional Licensure Mass.Gov Home State Agencies A -Z Topics Home > Division of Professional Licensure > Check A Professional License By the Division of Professional Licensure LICENSEE Name:JAMES N. STILIAN Business: STILIAN ELECTRIC INC GEORGETOWN, MA ..This Licensee has additional Licenses, click here to view them.** Licensing Board: ELECTRICIANS License Type: MASTER ELECTRICIAN TYPE CLASS: A License Number: 11067 Status: CURRENT Expiration Date: 7/31/2016 Issue Date: 8/1/1985 Exam Date: 8/1/1985 School: This web site displays disciplinary actions dating back to 1993. This license has had no disciplinary actions taken during this time. The page above has been generated by the Division of Professional Licensure web server on Monday, April 14, 2014 at 2:20:54 PM. © 2007-2011 Commonwealth of Massachusetts Page 1 of 1 Mass.Gov ONLINE SERVICES Check a License Locate a Licensed Professional Online Address Change Contact the Agency More... REFERENCES & RELATED INFO Disclaimer Regarding Website License Searches Glossary of License Status Codes More... Site Policies Contact Us http://license.reg.state.ma.us/publiclpubLicenseQ.asp?board code=EL&type_class= A&li... 4/14/2014 `Division of Professional Licensure: License Search - v The Official Website of the Office of Consumer Affairs and Business Regulation (OCABR) Division of Professional Licensure Mass.Gov Home State Agencies A -Z Topics Home > Division of Professional Licensure > Check A Professional License By the Division of Professional Licensure LICENSEE Name:KARL A. GONSIOROWSKI HAMILTON, MA Licensing Board: ELECTRICIANS License Type: JOURNEYMAN ELECTRICIAN TYPE CLASS: E License Number: 31598 Status: CURRENT Expiration Date: 7/31/2016 Issue Date: 1/25/1988 Exam Date: 12/5/1987 School: This web site displays disciplinary actions dating back to 1993. This license has had no disciplinary actions taken during this time. The page above has been generated by the Division of Professional Licensure web server on Monday, April 14, 2014 at 2:21:17 PM. © 2007-2011 Commonwealth of Massachusetts Page 1 of 1 Mass.Gov ONLINE SERVICES Check a License Locate a Licensed Professional Online Address Change Contact the Agency More... REFERENCES & RELATED INFO Disclaimer Regarding Website License Searches Glossary of License Status Codes More... Site Policies Contact Us http://license.reg. state.ma.us/publiclpubLicenseQ.asp?board_code=EL&type class=_E&li... 4/14/2014 Murphy, Peter From: Karl Gonsiorowski <KGonsiorowski@stilian.com> Sent: Tuesday, May 06, 2014 9:11 AM To: Murphy, Peter Subject: RE: CONTRACTOR REQUEST FORM Attachments: Karl Gonsiorowski.vcf Good Morning Peter, For the shut down at Bake `n Joy Foods at 351 Willow Street, our Electrician is Bill Flaherty. His cell number is 508-328- 7006. The work Request number for this is 16759424_ Thank you, Ica 01Gonsirtrr�r , �T From: Murphy, Peter[mailto:pmurphy@townofnorthandover.coml Sent: Thursday, April 10, 2014 12:07 PM To: Karl Gonsiorowski Subject: CONTRACTOR REQUEST FORM Please note the Massachusetts Secretary of State's office has determined that most emails to and from municipal offices and officials are public records. For more information please refer to: http://www.sec.state.ma,us/pre/preidx.htm Please consider the environment before printing this email. 1 Murphy, Peter 1 Full Name: Karl Gonsiorowski Last Name: Gonsiorowski First Name: Karl Job Title: Estimator/Project Manager Company: Stilian Electric Business Address: 108 Tenney Street Georgetown, MA 01833 Business: Mobile: Business Fax: E-mail: E-mail Display As: Web Page: 978-992-4154 (978) 230-1001 (978) 352-9998 KarlG@stilian.com Karl Gonsiorowski (KarlG@stilian.com) www.stilian.com 10 TOWN OF NORTH ANDOVER This certifies that ....... )voa4-6 .... &.:wwq has permission to perform .s.. .......I I 4.A) X .. ......... plumbing in the buildings of .............. ............................. I at . .....1:.%A0.4-1/ .4'r ......................... ..... ... ........................ . . North AnMass. Fee..k ... 4 ....... Lic. No. .................................................... tq, ............................. PLUMBING INSPECTOR Check # PERMIT FOR PLUMBING r— MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY Nv7f "_''"�MA DATE PERMIT PERMIT# JOBSITE ADDRESS V7-14 IV/ //o OWNER'S NAME P OWNER ADDRESS L__ �I/ y� TEL -- FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES [I NO FIXTURES 7 FLOOR- BSM 1 2 3 4 5 6 7_ 8 9 10 11 12 13 14 _ ____ _- BATHTUB - I. � ° _ r _ CROSS CONNECTION DEVICE ;_ —1'LL ",-- ' ;� DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM _ DEDICATED WATER RECYCLE SYSTEM Y DISHWASHER DRINKING FOUNTAIN t _r FOOD DISPOSER hl FLOOR I AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINKI._r LAVATORY i . 1 --j — - - ROOF DRAIN ;, ;- ' w' - .- - __-L } SHOWER STALL SERVICE I MOP SINK TOILET URINAL WASHING MACHINE CONNECTION _ , ! _ -x- WATER HEATER ALL TYPES � — =L—j_ � • ��' — i NATER PIPING I�.m "I tl_ �I_ � '__j OTHER iyl CAl _ I , INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES 0 NO Q IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Q 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 Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT1 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 pliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. and that all plumbing work and installations performed under the permit issued for this application will be iT"A- PLUMBER'S NAME Joseph M. Whitney LICENSE # 9664GNATUR MP07 JP D CORPORATION Ej# 1441 PARTNERSHIP #� LLC D# COMPANY NAME I North Shore Mechanical ContractorsI ADDRESSF6 Garden Street, Suite 2 CITY Danvers STATE MA ZIP01923 TEL 978.774.9800 �� _ - _ FAX j 978.774.9898 CELL ltrN,1413'L�f�, EMAIL e'9 ice' r— i] VffILC Vf tIL 1'CJLLSIILLV rI J. 600 [Fashington Street �� flostoll, HA 11? / 1 J ,fir, iff If? IV. 11 HISS. go v1dia ;i iters' Cornpensatioil hisur•ance Affidavit: Builders/Contractors/Electricians/fl ttmbN cant Information Please !Tint Legibl, C (BLIS iness/urbanization/ln(lividual): North Shore Mechanical. Contractors, Inc_ Address: /City/State/zi 6 Garden Street, Suite 2 Danvers, MA 01923 Phone #: 978-774-9800 Are you an employer? Check the a117ropriatc htlx: I � I tuts a rnll•,loycr will) 36 4. [] i am a general cantractor a11cl I . •._ _ _ . . employee !full and/ar part time).* have hil-Od the suh-cuntr<Ictnrs 2. ❑ I am a sole propriclor or pajall;r listed on the attached sheet. ship ,Incl have. no employees i hese suh-contractors have employees and have workers' working; for me in any capacity. comp. insurance, [No workers' ci,mp. insurtult:c Vz1 5. ❑ ,.c are a corporation and its req t.r i red.j 3. U I am a homeowner doing all w01'k officers have exercised their right Of exemptionperMCH.,myself. JNo workers' comp. c. 152, §](4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): t;. ❑ Ncw CO3I1SIRIC6011 7. ❑ Remodeling 8. ❑ Dunolitit,rl tl. [] Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other Any applicant that checks box #r must also fill Out the section below showing their workers' compensation policy information. Hollicowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. Cor:tr•actors that check this box must altachcd an additional sheet showing the name of the sub-contructurs and state whether or not those entities have mpinyees. If the suh•contraclors have employees, they must provide their workers' consp. policy number. 11111 1111 elnrploj+er flint is providing workers' conlpensadoil irtstlrallce far my elnpltgees. Beloly is fire police acrd joh site r fornxnion.. ABC KA Workers Camp. Group/TD Insurance, Inc. tsurance Company Name; olicy # or Self -ins, Lic. #: ABCMA005016/3 Expiration Date: 1/01/`(5 — &C1 tb Site Address:_ a////0w sT City/State/Zip: IV04-7,0 ft�jkKd- Mich a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). iilure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a �e up to $1,500.x0 and/or one-year' imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a line up to $250,00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of vestigations of the DIA for insurance coverage verification. to hereby certifjJ ander the pain a1u1 penalties ofperjury that the inforlrnation provider! above is true and correct. Z _ --1 Date: f z/Zl1 5 one #: 77Fr 77 °lam Official use only. Do not write in this area, to be completed by city or tolvrr official City or Town: Permit/License # Issuing Authority (circle one): 1, Board of Health 2. Building Department 3, City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: cpl3y.- -0 ::Af9. Lf Z., M Z' mt- zo qb A -M: W M C) c M .2 M M CA m M M ):11M 0 M > cl- -_, >;a > M as >1 En z M • Mrn cn ing m z 0 m oap 0 > -i -q 3: MM Ul Ul INz z 0 M X -h. --i '00 < ro-O 0 • F- z > I-F Q M M I WO o m Z*In cn • co C) Z> rn MCn > WA rn� z C5 M cn;u N o Z 47; 10 U) cn m ;din co r;3. • LTJ, ro ::Af9. j.. Lf Z., M Z' mt- zo W M C) c M .2 M M CA m M M ):11M 0 M > M -_, >;a > M as >1 En z -RI r m z 0 m oap 0 > > C- Ul Ul INz z 0 m '00 < ro-O 0 • F- 0 c(n Mza. M M I WO o U) Cl) > cn • C) Z> rn MCn > z C5 U) cn N rimTT cn j.. Z., M W M C) c M .2 M M CA M M im= M -_, >;a P -4r --i M as >1 En z > m z 0 m oap 0 > Ul Cj z z 0 E: r-> 56 m mt- In 0 c(n Mza. M > o U) Cl) z Cl) cn • Z., M W M C) c M .2 M CA M im= >* P -4r --i M as >1 En z m z 0 m oap 0 > E: r-> r. H 0 c(n Mza. C') (D M U) Cl) r i'4 • 1° / gE wow w 1,�E GJ ol lo o am � H � o E E-1 q6o� 105o A W 8ER"a�'a4&. aim $ $ P J N _- E. °o'.°- E✓m o 50 i.6q za 6E z¢�`ugp gupoeun z E au di rn U~ n - rn :: Ewsp swd sWso o,^s"8 aw :.a« ewd 88 F'i — n a 00 Z W O LO m N aa" 1° / gE wow w 1,�E GJ / / 3 0. 9 z y zar PasS Andover By - (Raine 125) a .O+ 7 O d lo o am � H � o E q6o� 105o r tl _- E. F 5 < E✓m _ / / 3 0. 9 z y zar PasS Andover By - (Raine 125) a .O+ 7 O d v m v � CD n N DO m r^ m a a T 01 d 3 x fD o T ° m 7 N N O v 7 N OO? CD N N 07 00 00 0 N Ni D i fD 7 7 Bn 6F,Nv C y N to V N LD W M < T fD 7 H .y 7 n 4AP Date ... F/ ........... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .... ......................... ... Z1 -ll-.!................... ............................................ ...... has permission to perform ....... Cd ..... wiring in the building of.... . I.t .... 6.9— .. ................... 7 ..................................................... at ......./l.%'~'........Yorth Andover, Mass. ....................................................... . L Feef ............ Lic. No- 5f ... ....... .. ... .... ELECTRICAL INSPECTOR Check #c-Ya757 Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. .D BOARD OF FIRE PREVENTION REGULATIONS Occupancy and 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 r (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 8-15-13 City or Town of: North Andover 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) 351 Willow St. South Owner or Tenant Bake `n Joy Foods Telephone No. Owner's Address 351 Willow Street South` Is this permit in conjunction with a building permit? X Yes No (Check Appropriate Box) Purpose of Building Manufacturing Utility Authorization No. Existing Service Amps Volts Overhead Undgrd No. of Meters New Service Amps Volts Overhead X Undgrd No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Addition to the building. Adding second floor space. Completion of the o ing table may be waived by the Inspector of Wires. No. of Recessed Fixtures 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 ❑ In ❑rBattery rnd. rnd. o. o mergency ig tmg Units No. of Receptacle Outlets No. of Oil Burners RT ALARMS I No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Number I Tons I TRW No. of Self -Contained Totals: I Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems: No. of Devices or Equivalent No. of Water KW No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: one hand dryer Attach additional detail if 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 x BOND ❑ OTHER ❑ (Specify:) 3-21-14 ' Estimated Value of Electrical Work: $55,000 (Expiration Date) Work to Start: 8-20-13 Inspections to be requested in accordance with MEC Rule 10, and upon completion. I certify, under thepains andpenalties ofperjury, that the information on this application is true and completes r FIRM NAME: Stilian Electric, Inc 108 Tenney St. Georgetown, MA 01833 LIC. NO.: AI 1067 Licensee: Karl Gonsiorowski Signature LIC. NO.: E31598 (If applicable, enter "exempt" in the license number line) Bus. Tel. No.: 978-352-9994 Address: 108 Tenney Street Georgetown, MA 01833 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. Owner/Agent Signature Telephone No. PERMIT FEE• 3 aq 62 v TH PAelve — 0 4"2-� 4� r�cujol- Town of North Andover Your permit has been s t back to you for the following reasons: 1) Check amount incorrect' `2"d 2) No copy of current license 3) Insurance Binder not on file or expired 4) No Workers' Compensation Insurance Affadavit Form Please call with any questions 978-688-9545. Workers' Compensation Form and Schedule of Fees can be found on the Town of North Andover Website under Building Department. �ej � cj I VV) ckl v -m �.ecewse✓j, ��,�� J VV-) � ltok� k -5 This certifies thaN t ��.(�. ' " �, ? , (�r" has permission to perform s P!�. tic (e/�. , . , ... , . . plumbing in the buildings of . I c,�,. , .' , ��, ............ . at ... ......... North Andover, Mass. Fee/,?0../.�ULic. No.�Lp ... ................... ... PLUMBING INSPECTOR Check # oZ1_ -6e V\N- -]lit �1-� y MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY MA DATEPERMIT # JOBSITE ADDRESS J Gt/l taw 5-9 Qv OWNER'S NAME�q -.� �ti POWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ❑ RESIDENTIAL ❑ PRINT CLEARLY NEW: ❑ RENOVATION: REPLACEMENT: ❑ PLANS SUBMITTED: YES�N0 FIXTURES Z FLOOR— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN Q 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 Z' INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES Q;'O'N0 ❑ IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Q/ 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 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 compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME I Joseph M. Whitney LICENSE # j SI MP ❑ JP ❑ CORPORATION ❑ # 1441 PARTNERSHIP#0 LLC ❑# COMPANY NAME I North Shore Mechanical Contractors ADDRESS 6 Garden Street, SuitK2 CITY Fpanvers STATEF—'MA-1 ZIP 101923 TEL 978.774.9800 FAX 1978.774.9898 1 CELL EMAIL i Office o f In vestigations 600 Fl ashington St/ Bo.yfon, AM 02111 �el wiviV.nt(iss'. n,i111%la Workers' Compensation Insurance Affidavit: Buil(lers/Contractors/Elect►-icians/Plumbers Applicant Information Please Print Legibly Nan1C (Business/0rbanizaticm/Individtlall: North Shore Mechanical Contractors, Inc. Adds-eSs: 6 Garden Street, Suite 2 City/State/Lip: Danvers, MA 01923 P11011c #: 978-774-9800 Are you .tn employer? Check the appropriate hox: I. 1 ;1111 a rnl!-t!uyrr Mill 36 4. ❑ I and a gcnet,al contractor and I c11)p!ovees (full and/or earl-tilnc).* have hired ille slll)-C.11l11r:IClnl:s 2 . I all] a $O1c IirlilirlCliir or p�trtilUl"- listed un the allached slic"cl. shill ;Illd 11L.Ive 110 Clllployces I llese sllb-contraclors have working for 111e in any capacity. employees and have workers' [No workers' comp. illsural,ce comp. insurance.$ required.] I 1.0 vzrle are a corporation and its 3.LjI aill a hoilleo'w•ner doiiig a!I wo1'1c officers have e;;ercised their myself. [No workers' comp. right of exemption per MG1, insurance required.] t c. 152, §](4), and we have no employees. [No workers' comp. insurance required.] i.ype of project (required).- New required):New cunslruc'liun 7. ❑ Rrnlodeling S. ❑ Demolition 9. ❑ Building addition I rl.❑ Electrical repair, or addition$ 1 I.❑ Plumbing repairs or additions 13.0 Roof repairs 13. F] Other *Any applicant that checks box #1 must also fill out U)c section below showing their workers' compensation policy information. t Mon)eowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 'Contractors that check this box must attached an additional sheet showing the name of die sub -contractors and state whether or not those entities have employees. If the sub -contractors have en)ployces, U)ey must provide their workers' comp. policy number. I art an employer that is provitlurg markers' coiupensation insurance for my clnpltwees. Beloit,is the polio, ton/ job site information. insurance Company Nanle: ABC MA Workers Comp. Group/TD Insurance, Inc. Dolicy # or Self -ills. Lic. #: ABCMA005016— /j Expiration Date: 11011154 ob Site Address:_ ;3!57/ Z /; //C -,v t-'7—�!1✓7/Y City/State/Zip: /(f \ftach a copy of the workers' compensation policy declaration page (showing the policy number and expirat on date). ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a lie up to $1,500.00 and/or one -y ear. iIll p"isonment, as well as civil penalties in the form of STOP WORK ORDER and a fine f up to $250.00 a day against the violator. Be advised that a copy of this statement nlay be forwarded to the. Office of )vestigations of the DIA for insurance coverage verification. do hereby certifj) under t/re pains andpenalties ofperjury that the information provided above is true and correct. nature' /:-.),�.c.�---•- 'Z"/0 � �j� Date /-z �/ 3 lone #: 97�-' 77L/f i Official use only. Po not write in this area, to be completed by city or toren official. City or Town: Permit/License # issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5, Plumbing Inspector 6. Other Contact Person: Phone #: o a o G a llil6 2I/60/90 h52 0000-2Z610 dW S213AN170 CD Z 31InS IS N3Cl8V9 9 AVdIN03 I'VOINVH33W 3HOHS FliaOt4 A3NIIHM W Hd3SOr 01 3SN3011 3A09V 3H1 S3f1SS1 ss3NlSns v sd Sa3MNOM 1V13W 133HS • e•'•' a o.. e s • S113snH3vssvw d0 H.LIV3MNOWWOO a 6L6991 hi/IO/SO L8581 825i-22610 VW S213ANt/0 b0 AV31N3389 9Z A3NIIHM W Hd3S0f 01 3SN3011 3A09V 3H1 S3f1SS1 =_ Wn"ld NdWA3Nano V SV C13SN3011 S831113SbJ aNy Sa39Wnld ....•• • S113SnH3vsSVVV d0 Hlltl3MNOWW00 9L69SI bT/IO/SO h996 i a a38Wnld 'W d Sb 03SN3011 Sa3.UlJSt/0'INV Sa38Wnld • ...,•11, S113SnHOVSSVIN d0 HllV3MNOWW00 SZST -s7.: 0 t/W S83ANVa HG AV31N33N9 9Z r_l �l7 A3NIIHM W Hd3SOf Ol 3SN3011 3A09V 3H1 S3(1SS1 e •-._._,SOTfihi hi/i0/SO I�hi TS4I-�Z6T0 VW Sd3ANb0 �i 2 31S 1S N308t19 9 M';3V I1NO3 -Id3INVH33W 380HS H1210N A3NIIHM W Hd3SOr :01 3SN30113AO9V 3H1 S3(1SS1 d800 JNlawnld v St/ 03a31sI938' S�13111dSt/J 0Nb' S838.Wnld. e...o• • `K o.. e e 0 sii3SnHonsvo d0 H-LIV3MNOWW00 r SETO Zi/8Z/80 £OSOT 92ST-22610 VW S83ANVO 80 JV31N3389 92 w; c; A3NIIHM W Hd3SDf :01 3SN3011 3AO9V 3H1 S3f1SS1 03101HIMNn-H3.1SM b Sb e •. a Sa3)INOM 1t/13W 133HS e S113SnHovss im d0 HIIV3MNOWWOO Date .... 7....�..7....�...-. TOWN OF NORTH ANDOVER PERMIT FOR WIRING. This certifies that ...1 �?.ftT S/$ /�� .� has permission to perform %.' ....................................... wiring in the building of........6.�7.....'..........-..T........................................... at ._q ..... � < c�G(rl.... STS' S��North Andover, Mass. ............................................... Fee../.Z,.�,?C... �U� Lic. No.#0V .. 1 . LECMCAL INSPECTORI- Check # .+ - �. Commonwealth of Massachusetts oiticial Use Unly l `Z.z, a l�s Permit No. �. Department of Fire Services -----_..__......._.__... _. qZE'} =3. Occupancy and Fee Checked Maui`` BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1 11991 (leave bliuik APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR i2.00 (PLE4SE PRhVT LV LVK OR T.YPI% AT.1'. TVTY) A 4TION) Date: City or Town of: t �l . t �e:rZ • TO the h7spector of.lfh-es: By this application the undersigned gives notice oifliis or her intention to perfirrm the electrical 111011 descr ed below, Location (Street &Number) 3rj( �r It1l0 ��i'ee{- glCl" leo Owner or Tenant -N ��py Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ New Service Amps 1 Volts Overhead ❑ Undgrd tl Number of Feeders and Ampacity Location and Nature of Pro osed (Electrical Work: 1 N-) N.0.) No, of Meters No. of l=leters M Lvw vUL'1'aUl — I Complelion o/'tire followh+ v table may be ivaived by the Inspector of Wires. No. of Recessed Fixtures No. of Ceil: Susp. (Paddle) Farts otal No. s 7 VA Trartsfat•mers KVA No. of Lighting Outlets No. of Mot Tubs Generators KVA No. of Lighting Fixtures Above In- Swirrnntittg fool `tad. yrnd. Fn'Battery q), o .Emergency ..3g r mg Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of )et Initiatin Dngectand evices No. of Ranges No. of Air Cond. 'Total Tons No, of Alerting Devices No. of Waste Disposers Heat Pump Number Tons KVi' No. of Self -Contained Totals: Detection/Alerting Devices No. of Dishwashers Space/Area heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Beating Appliances }{W Security Systems: No. of Devices or Equivalent No. of WaterNo. KW of No. of Data Wiring:Heaters Sims Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No, of Motors Total III I'elecotntnurtications Wiring: No. of Devices or Equivalent OTII ER: :Ittcrch addirionat detail (fderired,, orarreq++iced by the Lrspeerar of il'ir s. INSURANCE COVERAGE: I.friless 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 IX BOND ❑ OTHER ❑ (Specify:) //��'�'�,•� Estimated Value of Electrical Work: �p,VtJV -When required by municipal policy.) - (Expiration Date) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. I certify, under the pains antipenalties of perjttjy, that the information/on this application is trite and complete. FIRM NA.Iv'I.E: Environmental Systems, Inc. r f! ^• � LIC. NO.: Al 7482 Licensee: Steven bion Si LIT, NO.: 17_4 (Ifapplicable, eater"exempt" in the license number line.) _B_us, 82A ....__..._ Tel. No.: -.(-508)226-6006_ Address: 6 HoW.rCU nd Drive, Attleboro MA 02703 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 tine (check one) ❑ owner ❑ owner's agent. Owner/Agent PERAHT FEE, $ Signature Telephone No. The Commonwealth of Massachusetts Print. Form Department of Industrial Accidents Office of Investigations 'r 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Environmental Systems, Inc. Address: 6 Howard Ireland Drive /State/Zim Attleboro, MA 02703-4612 Phone #: (508)226-6006 Are you an employer? Check the appropriate box: 1. FZ1 I am a employer with 100 4. ❑ I am a general contractor and I employees (full and/or part-time).* 2. ❑ I am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ 1 am a homeowner doing all work myself. [No workers' comp. insurance required.] t have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.+ 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, §1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 1 l .❑ Plumbing repairs or additions 12.❑ Roof repairs 13. RV OtherHVAC + Controls *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy infonnation. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors 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 workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Associated Employers Insurance Company Insurance Company Name: Policy # or Self -ins. Lic. #:MCC2000218012013 Job Site Address:351 Willow Street South Expiration Date: 12/31/2013 City/State/Zip:North Andover MA Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a �. fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: 7-8-13 (508)226-6006 Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: 023 Date.I1.�.?.�' �1........... TOWN OF NORTH ANDOVER PERMIT FOR MECHANICAL INSTALLATION y,. p This certifies that .t"'.... ... r........... 5 has permission for mechanical installation �J V A.4 ................. in the buildings of . -D6 .. .^' at L':'� North Andover, Mass. Fee 7 i,�u t l Lic. No. J'. ��? .... .Il.. '..................... , I '\1 � �` ( ! 77/! ,[6 GAS INSPECTOR WHITE: Applicant ,rCANARY: Building Dept. PINK: Treasurer 4 Date: 7/15/13 Estimated Job Cost: $ 21692 Commonwealth of Massachusetts Plans Submitted: YES ❑ NO ❑ Business License # 436 Business Information: Name: Environmental Systems, Inc. Street: 6 Howard Ireland Drive City/Town: Attleboro Telephone: (508)226-6006 Sheet Metal Permit Permit # v- a Permit Fee: $ 2_�A n Plans Reviewed: YES NO Applicant License # 4) � Property Owner/Job Location Information: Name/ Job #:Bake'N Joy (9603) Q' 14`x` j ZC00zr jU.V -- Street: 351 Willow Street South f Z.X' ZZO City/Town: North Andover Telephone: ! Photo I.D. required / Copy of Photo I.D. Attached: Yes ® NO ❑ Staff Initial J-1 / M-1- unrestricted license J-2 / M-2- restricted to dwellings 3 -stories or less and commercial up to 10,000 sq. ft. / 2 -stories or less Residential: 1-2 family Multi -family Condo/Townhouses Other Commercial: Office ® Retail ❑ Industrial ❑ Educational ❑ Institutional ❑ Other ❑ Square Footage: under 10,000 sq. ft. ® over 10,000 sq. ft. ❑ Number of Stories: Linear Footage of Duct: 820 Sheet metal work to be completed: New Work: ® Renovation: HVAC: ® Metal Watershed Roofing: ❑ Kitchen Exhaust System: ❑ Metal Chimney / Vents: ❑ Air Balancing: Provide detailed description of work to be done: Install four (4) new standard efficiency packaged rooftop units with air distribution provided by complete supply ductwork systems terminating in registers, grilles and diffusers. Install one (1) new roof moutned exhaust fan and two (2) inline exhaust fans with complete exhaust ductwork system. 1I&3� 13 2e4 lrna'.L INSURANCE COVERAGE 1 have a current liabilitv insurance policy or its equivalent which rneets tlhe roquironaents of MG.L. Ch. 112 Yes [�] No If you have checked Yes, indicate the type of coverage by cl1ecking fila appropriate box below: r A liability insurance: policy !_`j Other type of indemnity [ ] Menti U OWNER'S INSURANCE Vti+.rlIVER: I am :rvaare that the licensee does not have the insurance coverage required by Chapter 112 of the Massachusetts General Laws, and that rely siynafure oil tills permit application waives this requirement. Check One Only _ r cam`_..: xx.y.:!, _._. _._._ Owtior Q/ Agent Signature:. of Owner or Ownpi•s Agent i By checking this boXF11 I hereby certify that all of the details and information I have submitted for entered) regarding this application are true and accurate to the hest of my knowledge and that all sheet metal work and installations performed under the permit issued for this application will be in compliarar;e with all pertinent provision of the Massachusetts Building trod© and Chapter 112 of the General taws. Duct inspection re:()ttlred prior to insulation installation: YES ---- .............. NC3 �'t•t>f;f•ess �af;�,irr;t:.iiufls Date Comment 1)ot.e By --- Title Cily1 f own Peichhit If Fel, $ .._._._. Inspector Signature of Poirnit Approval ''iI—K ,osaw ttion f,:QIII t1"ti tat:S Type of 1_icanse: tvtaster 1 Avlaster-Res tricted I_jJourneyperson ElJourneyperson-Rosh icted l_ Signature; of Licensee; License Number: ` a P Check at vLlww.n)�ass,( ovitipl Client#: 10383 ENVIRSYS ACORDTM CERTIFICATE OF LIABILITY INSURANCE DATE 7108/201133 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(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 endorsement(s). PRODUCER Starkweather &ShepleyPHONE PO Box 549 Providence, RI 02901-0549 401 435-3600 NAMIE: Sandy Benigno 401 435-3600 FAX 40-431-9678 A/C No, Ext): AIC, No ADDRESS: sbenigno@starshep.com INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: CNA Insurance 03972 INSURED Environmental Systems, Inc. 6 Howard Ireland Drive INSURER B: Associated Employers Ins CO/AIM INSURER C: Houston Casualty Co MED EXP (Any one person) $ 5,000 Attleboro, MA 02703-0037 INSURER D: GENERAL AGGREGATE $2,000,000 INSURER E: INSURER F: $ COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL INSR SUBR WVD POLICY NUMBER POLICY EFF MM/DDIYYYY POLICY EXP MM/DD/YYYY LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE � OCCUR 5088186127 12/31/2012 12/31/2013 EACH OCCURRENCE $1000000 PREMISES Ea occurr0ence $100,000 MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY X PRO X LOC JECT PRODUCTS - COMP/OP AGG $2,000,000 $ A AUTOMOBILE JXANY LIABILITY AUTO ALL OWNED SCHEDULED AUTOS AUTOS HIRED AUTOS XNON-OWNED AUTOS 5088690077 12/31/2012 12/31/201 3 COEaMBINED accident SINGLE LIMIT $ 1,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ Per accident A X UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE 5088690080 12/31/2012 12/31/2013 EACH OCCURRENCE s5,000,000 AGGREGATE s5,000,000 DED I X RETENTION $10,000 $ B WORKERS COMPENSATION Y / N AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICERIMEMBER EXCLUDED? � (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below _R N / A MCC2000218012013 1/01/2013 01/0112014X WC STATU- OTH- E.L. EACH ACCIDENT $1,000,000 E.L. DISEASE - EA EMPLOYEE $1,000,000 E.L. DISEASE - POLICY LIMIT $1,000,000 C Professional Liab H71319057 1/01/2013 01/01/2014 _ $2,000,000 $5,000 Ded. DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) RE: HVAC/Control Work Town of North Andover SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 120 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. North Andover, MA 01845 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD #S474152/M437647 MBB The Commonwealth of Massachusetts Print Form Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Environmental Systems, Inc. Address: 6 Howard Ireland Drive /State/Zip: Attleboro, MA 02703-4612 Phone #: (508)226-6006 Are you an employer? Check the appropriate box: 1. ❑✓ I am a employer with 100 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.+ required.] 5. ❑ We are a corporation and its 3. ❑ I am a homeowner doing all work officers have exercised their myself. [No workers' comp. right of exemption per MGL insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑✓ OtherHVAC Controls *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 all work and then hire outside contractors must submit a new affidavit indicating such. *Contractors 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 workers' 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: Associated Employers Insurance Co Policy # or Self -ins. Lic. #:MCC200021801211 Expiration Date: 12/31.2013 Job Site Address:351 Willow Street South City/State/Zip:Attleboro, MA 02703 Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. July 15, 2013 (508 Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: JAMES S BALDASARO ENVIRONMENTAL SYSTEMS INC (SM) 6 HOWARD IRELAND DR ATTLEBORO MA 02703 JUN 19 2013 BY--------------- Fold, Then Detach Along All Perforations Date .. l ?— TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ..�iltz'................ . has permission to perform.. �j ..... wiring in the building of Y............ at.. 3 /.. �G/.4..�0.4 Ste. Fee. S . d �'. Lic. No. C �. C,heck # S' 1 11242 ........ , orth Andover, Mass. ELECTRICAL INSPECTO 61 r Commonwealth of kamacAwa& Official Use Only Au,p pavtmzd of -%. Serviced Permit No. I Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accardance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK ORT PE dLL Ili 0 TION) Date: 11-9-1-D.— City 1-9-1Z— City or Town of: jl +�^i/ 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) Owner or Tenant tn<n V -r — Owner's Address Is this permit in conjunction with a building permit? Purpose of Building Existing Service Amps / Volts New Service Amps / Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work:, Telephone No l f� -LO -3 -I +14 Yes ❑ No � (Check Appropriate Box) Utility Authorization No. Overhead ❑ Undgrd ❑ No. of Meters Overhead ❑ Undgrd ❑ No. of Meters C-k-jY-L Completion o the ollowin table may be waived b the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- ❑ rnd. rnd. o. o Emergency Lighting Batter Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Number Tons KW ""'' No. of Self -Contained Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Connection Municipal El Other No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water, No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: 6 Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of E'l'ectrical Work (When required by municipal policy.) Work to Start: 11 `IS I t";'- Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability 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 ;K BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the i rmation on this application is true and complete. FIRM NAME: t o �^ f -Z- r t LIC. NO.: C " Z/5, Licensee: Ii%lq rIc >� —E-> YC± Z�"V Signature LIC. NO.: L/s- (If applicable, enter "exemp " in the license nu er line.- Bus. Tel. No.:&13 i13 -6 Jc/ 'S -9V % Address: 2�Alt. Tel. No.: *Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "S" Li e: Lic. No. Uv % 5_:;? OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/AgentT Signature Telephone No. PERMIT FEE. $