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PAMELA PIERCE 1-10!112"a 8377
PAUL M PIERCE
094 WAVEPLEY RD.
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PERMIT FOR GAS INSTALLATION
This certifies that .... "*"*"*"*"*"**'*"**"*'**"****"*"""', ....... , ........
has permission for gas installa ion ...
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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
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CITY, '1 (�pl)pUQ f A DATE 411/14 PERMIT # l It
JOBSITE ADDRESS OWNER'S NAME
GOWNER ADDRESS I Same TE FAXi�
TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL ® RESIDENTIALE]
PRINT
CLEARLY NEW: ❑ RENOVATION: REPLACEMENT: ® PLANS SUBMITTED: YES® NDE]
APPLIANCES 7 FLOORS--• BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER YL
COOK STOVE
DIRECT VENT HEATER
DRYER '
FIREPLACE
FRYOLATOR
FURNACE
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LABORATORY COCKS
MAKEUP AIR UNIT
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ROOM / SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
OTHER
Re lace Gas Meter x
and Piping as Needed
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INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES NO
I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY E] OTHER TYPE INDEMNITY ® BOND
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER ® AGENT
SIGNATURE OF OWNER OR AGENT
I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be o pliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. YN, 14
PLUMBER-GASFITTER NAME Joseph Marino LICENSE # 8736 181MATURE
MP 0 MGF ® JP ® JGF LPGI ® CORPORATION # 3285C PART SHIP ®# LLC ®#
COMPANY NAME: RH White Construction Co ADDRESS 41 Central St
CITY I Auburn STATE = ZIPI 01501 ITEL (508) 832-3295
FAX 508 926 4347 CELL 508-832614 EMAILJMarino@RHWhite.com
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04/03/2014 14:04 5088326751 RH WHITE CONSTRUCT PAGE 02/02
''� �® CERTIFICATE OF LIABILITY I S
t U� %, N C E DATE (MMID2 0131
�\A'\ rage 1 of �, OB/29/2013
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.
A
B
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IMPORTANT: If the Certificate holder is on ADDITIONAL INSURED, the p0licy(ies)must be endorsed. If SUI3ROGATION IS WAIVED, subject to
the terms and conditions of the policy, certaln policies may require an endorsement. A statement on this certificate does not confer rlghts to the
Certificate holder in lieu Of such endorsement(s).
willia of Maeedelhusette, Inc.
C/o 26 cortvey Blvd.
P. 0. Box 305191
NRMhville, TN 37230-5191
R. B. White Constraotion Company, Inc.
41 Central, 6treet
P. 0. Box 257
Auburn, MA 01501
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INBURERA:The chArtes Oak Fire IneuranCO Company 25615-001
INSURERe:Traval*r a Property Casualty Company of Am 25674-003
INSURERC: Nelti0)*Al Union Piro Insuranco Company of 7.9445-001
INSURERD; Travelers Indm=ity Company 25658-DO1
INSURER F,;
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSUR
INQICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER I
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBE
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
TYPE OF INSURANCE
DDI
SUB
POLICY NUMBER
GENERALLIABILITY
MED EXP(Any one person $
in &90
PERSONAL&ADV INJURY $
VTC20C0 977RB948-13
X
COMMERCIAL GENERALLIABII.ITY
CLAIMS -MADE OCCUR
PRODUCTS-COMP/OP AGO $
AX000 000
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EACH OCCURRENCE $
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AGGREGATE $
AUTOMOBILE
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1,000,000
E.L.DIAEA9E-FAEMPI,OYEE $
DIBEASE-POLICY LIMIT S
VTJCAP 977K955A-13
X
ANY AUTO
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AUT08 AUT08ULED
HIREDAUTOS X NON -OWNED
X
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UMBRELLALIAB 7C OCCUR
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BE8766140
DED I X IRETENTIDNS 10,000
WORXERS COMPENSATION
v'i�tRV$ B205A185-13
AND EMPLOYERS'LIABILITY YIN
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x/1/2013 9/1/2014
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/1./2013 9/1/2014
/1/2013 19/1/2014
speco
NUMBER;
'D NAMED ABOVE FOR THE POLICY PERIOD
)OCUMENT WITH RESPECT TO WHICH THIS
HEREIN IS SUBJECT TO ALL THE TERMS,
LIMITS
EACM OCCURRENCE $
2,000,000
INA
V I31Eeoeeuron-5 _�
-
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MED EXP(Any one person $
in &90
PERSONAL&ADV INJURY $
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PRODUCTS-COMP/OP AGO $
AX000 000
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BODILY INJURY(Per person) $
BODILY INJURY(Peraccident)
arnccldent Is
S
EACH OCCURRENCE $
.5-1-0 0 0, OOO
AGGREGATE $
5,000,000
X0
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E.L. EACH ACCIDENT $
1,000,000
E.L.DIAEA9E-FAEMPI,OYEE $
DIBEASE-POLICY LIMIT S
1,000,000
11000,000
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 REPRESENTATNE
C*11:4197604 TPI:1694012 Cert:20287680 ®1988-2010ACORD CORPORATION. All rights
ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD
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TYPE OR
PRINT
CLEARLY
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY MA DATE 4/1/14 PERMIT#
JOB SITE ADDRESS{ ftn1 {7jyt OWNER'S NAME N
OWNER ADDRESS Same TEL JFAX�
OCCUPANCYTYPE COMMERCIAL® EDUCATIONAL ® RESIDENTIAL[]
NEW: ® RENOVATION: El REPLACEMENT: Lj
APPLIANCES -1 FLOORS-
BSM
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
FRYOLATOR
(�
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM / SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
f
INSURANCE COVERAGE
PLANS SUBMITTED: YES® N0[j
II�>■tifi�i��®�
have a current liability insurance policy or its sulistanriaI ;h meets the requirements of MGL. Ch. 142 YES ® NO
IF YOU CHECKED YES, PLEASE INDIC, C ING THE APPROPRIATE BOX BELOW
LIABILITY INSR TYPE INDEMNITY [j BOND L]
OWNER'S INSURANCE WAIVER: I an !t
j �Ux., ,the Insurance coverage required by Chapter 142 of the
Massachusetts General Laws, and thi J 1, on waives this requirement.
I SIGNATURE OF OWNE
CHECK ONE ONLY: OWNER ED AGENT Ej
I hereby certify that all of the details and inn ui entered regarding this application are true and accurate to the best of my knowledge
and that all plumbing work and installations , --japed under the permit issued for this applicatqbepliance with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.PLUMBER-GASFITTER NAME Jose h Marino LICENSE# SI ATUREMP MGF JP ❑ JGF ® LPGI ® CORPORATION �# 3285C IP ®#�_� LLC
COMPANY NAME:j RH White Construction Co ADDRESS 141 Central St
CITY I Auburn STATE MA ZIP 01501 ^TEL (508) 832-3295
FAX 508-926-4347 j CELL 508-832-4614 EMAIL JMarino@RHWhite.com
Location-- Qg���
N o.' 17 Date Z11 7
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
Sewer Connection Fee $
Water Connection Fee $
TOTAL $
"i"" 1063623/9714:47
Building Inspector
25.00 PAID
Div. Public Works
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