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HomeMy WebLinkAboutMiscellaneous - 36 BREWSTER STREET 4/30/2018Date. .7 I TOWN OF NORTH ANDOVER 0 PERMIT FOR PLUMBING This certifies that has permission to perform .......... Plumbing in the buildings of.................... at �.6 ... North Andover, Mass. F e e—AR. L i c. No.. .... ....... INSPECTOR Check # 77'13 3Z• A MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Date Building Location (e WS �Y' .t'� Owners Name At d- 615 �N r4Cny Permit # Type of Occupancy Amount New �' Renovation Replacement ' E Plans Submitted Yes❑ No UTYTT 112 Fc (Print or type) Check one: Certificate Installing Company Name_ —XTVAJ �� Goji • 6, „L �C , P -Corp. 17 Partner. 0 Firm/Co. Name of Licensed Plumber.V L beNe Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity ❑ Bond M Insurance Waiver: L the undersigned, have been made aware that the licensee of this application does not have any one of the above ty three insurance Signature IOwner ❑ Agent F I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work ffldiqstallations Derformtd under Permit Issued for this application will be in compliance with all pertinent provisions of the Mas aehu efts to m g Code and Chapter 142 of the General Laws. By:Signature oT LicenseclrJumDal Type of Plumbing License Title Q*5q 3 City/Town 1ce/nse um er Master a Journeyman ❑ APPROVED (OFFICE USE ONLY VDate....`. .` ..... . . CF NORTH F� 2 °A TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION ` SACMUSEt This certifies that ...... ........... ................ ....... has permission for gas installation . in the buildings of .... .......... . at`�� ....................... North Andover, Mass. Fee...... Lic. No....???.... ..... �i .......... GAS INS_P,�CT�OR Check # A 25. MASSACHUSETTS UNIFORM APPUCATON FOR PERNUT TO DO GAS FrITING (Type or print) Date NORTH ANDOVER, MASSACHUSETTS Building Locations 3 �o rc r-vS �c✓' '� �- Permit # �•S� `(�� Amount $ Owner's Name Q�\ t 1 Q, 1 w New ❑ Renovation ❑ Replacement Plans Submitted 0 (Print or type) tt Check one: Certificate Installing Company Name NN1t•Cv G.A. Cd. .1. -NG, - ©Corp. Address 10 u e L -C>r LJti� r'' Partner. UJ ► � M ► �..ra� , Al t1 . O I $g7 ,,�� Business Telephone— ,It 3 3 —)2- ❑ Firm/Co. Name of Licensed Plumber•or Gas Fitter INSURANCE COVERAGE Check one: I have a current liability Insurance, policy or it's substantial equivalent. Yes ❑ No❑ If you have checked Yes, please indicate 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 13 Agent I herehv ePrtifv that an �f H,o ..e ;I ..,-a I L ---- _ - -- - - - - - �•• • ••�-� ,��••••«� kUl VIRUMul In aoove appucanon 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 Mass cus State C)as4�ode and Chapter 142 of the General Laws. By: Title City/Town, PPRQVED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter ❑ Plumber �39 ❑ Gas Fitter (cense Number 01,1laster ❑ Joumeyman v� C Z v; O w W C a Z F GG7 CA O vO a O O w F z F Q x W w "' w W I•• z w > a F > CA m z oz a z o m 3 0 a U z> a F o SUB-BASEM ENT c BASEM ENT 1ST. FLOOR lEfE 2ND. FLOOR 3RD. FLOOR 4TH. FLOOR 5TH. FLOOR 6TH. FLOOR 7TH. FLOOR 8TH. FLOOR (Print or type) tt Check one: Certificate Installing Company Name NN1t•Cv G.A. Cd. .1. -NG, - ©Corp. Address 10 u e L -C>r LJti� r'' Partner. UJ ► � M ► �..ra� , Al t1 . O I $g7 ,,�� Business Telephone— ,It 3 3 —)2- ❑ Firm/Co. Name of Licensed Plumber•or Gas Fitter INSURANCE COVERAGE Check one: I have a current liability Insurance, policy or it's substantial equivalent. Yes ❑ No❑ If you have checked Yes, please indicate 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 13 Agent I herehv ePrtifv that an �f H,o ..e ;I ..,-a I L ---- _ - -- - - - - - �•• • ••�-� ,��••••«� kUl VIRUMul In aoove appucanon 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 Mass cus State C)as4�ode and Chapter 142 of the General Laws. By: Title City/Town, PPRQVED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter ❑ Plumber �39 ❑ Gas Fitter (cense Number 01,1laster ❑ Joumeyman r IF ' Date ... - 6— ..................... NonrH TOWN OF NORTH ANDOVER 0 0 PERMIT FOR WIRING ............ SSA CINU 9 This certifies that ........... -4..... 5. V(.0 K:i7l. c k. ...................... ........ has permission to perform ... / ........... ............................................. wiring in the building of....... (L.... at ..... -?.� ........ o Andover, Mass. N� .............. . a� Fee.:9? ........... Lic. No .................. ...... ............................................ ql?-? :9c ELECTRICAL INSPECTOR Check # 12 77 47,1- Official Use only Commonwealth of Massachusetts Department of Fire Services Permit No. 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: 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\\�p /3 %��(.0 S ZZ--A-,S71 Owner or Tenant f # I i- U ATJ Telephone No. Owner's Address 3 (o Lo ,S'r Is this permit in conjunction with a building permit? Yes ❑ No 0-'- (Check Appropriate Box) Purpose of Building CS f D 05&) 7 kff— 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: W tdZ f AJ 6 /Z— HTE-) T Comnletion ofthP fnllowino tnhle mnv he wnivad by the Incnartor of 6Vi— No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans TransTotal Trsformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- E] rnd. rud. No. o mergency ig ing 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 Initiatine Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting 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 Systems:* 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 TelecommunicationsWiring: No. of Devices or E uivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electric 1 Work: t © 0 (When required by municipal policy.) !O� is Work to Start: rS' 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 ❑(Sped :) I certify, under the. pains and penalties of perjury, that the informati n on thia icati is true and complete. FIRM NAME: D. A • �o is LIC. NO.: 3 i 6 " fii %2 Licensee: bmj Bwsyzi IZT— Signatur LIC. NO.: (Ifopplicable, enter "exempt" in the h nse number line.) Bus. Tel. No.• Address: 1 % L (G�CUL 7; A4 ceff-s �f Q -3I Alt. Tel. No.: Co a —acs,"? *Per M.G.L C. 147, . 57-61, security work requires Department of Public Safety "S" License: Lie. No. OWNER'S INSU N WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally. required by la y my s'gnature below, I hereby waive this requirement. I am the (check one)❑owner ❑ owner's agent. OwnerlAge t PERMIT FEE. $ Signature Telephone No. 0 r The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 42111 wWw, mass.gov/dia Workers' Compellsation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/organizationllndiv idual): Qom, Address: j If 1 ML 11) .-5,4, -# In L.L City/State/Zip:v b f .}!'hone „ 4: Are yyu an employer? Check the appropriate box: 1. yI am a employer with 4. F ] I am a general contractor and I J l�, oma-,, Type of project (required): employees (full and/or part-time).* 2. ❑ I am a sole have hired the sub -contractors listed b ❑ New construction proprietor or partner- on the attached sheet, 7. E] Remodeling ship and have no employees These sub -contractors have g, (-1 Demolition working for me in any capacity, employees and have workers' [No workers' comp. insurance comp, insurance." g• ❑ Building addition required.] 3. ❑ I am a homeowner doing We are a corporation and its officers have 10.52"Electrical repairs or additions all work myself. [No workers' comp. exercised their right of exemption per MGL 1 l .R Plumbing repairs or additions insurance required.] I c. 152, § 1(4), and we have no 12.❑ Roof repairs employees. [No workers' 13.❑ Other_ comp. insurance required.] 'Any applicant that checks box 11 mul also fill out the 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 attached an additional sheet showing the name of the sub -contactors 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: Policy # or Self -ins. Lic. #: Expiration Dater � p 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 ivIGL 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 fide 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 Sinature: Phone 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): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: COR � CERTIFICATE OF LIABILITY INSURANCE DATE(MIN THIS CERT€F€CATE !S ISSUED AS A MATTER OF INFORMATIdN ONLY AND CONFERS 3/4/201 CERTIFICATE DOES NOT AFFIRMATIVELY OR N;GATIVELY AMEND, EXTEND R ALTER THE COVERAGE AFFORDED 8Y THETIFICATE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURERW, AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER OGATION IS WAIVED, IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the po€€cy(€esj must be endorsed, If SUBRSubject to the terms and eondrtioo Of the Policy, certain policies may requite an e certificate FiOidar in lieuuof such 9Rdofsemgt3t(8). ndorsement A statsms nt on this Certificate doss not confsr rights to the PRODUCER FIAT/Cross insurance7STA, Karen Shaughnessy PHONE .(603)669-3218 ° PAX 1100 Elm Street: E MAkL N ; (603) 645-4331 kahaughnesaycroasagency.com Manchester NE 03101 INSURMl Arp INSURED INSURER A MG Ina Co LSA INC INSURER 8: DBA BOISVERT ZLECTRIC INSURER c ; 175 LINCOLN ST M;IT 104 ;NS MANCHE STERI uRER E N>:i 03103-5079 --- vcs[ttrs>r/ittrlilNlt3ER14-15 All lines REVIS€ONNt3lsitBER: C HAT —T�itVG IREQUIREMENT, OiWITHSTRNDER*nFY INDICATED. BELOW THE INSURED ANY I �I OROCONDsTiON 0'r ANY CONTRACVESEEN T OR OTHER CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED E;JT yViTy RESPECT TO WHICH THIS BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO EXCLUSIONS AND CONDITIONS IONS OF SUCH POLICIES. LIMITS SHOV'1N MAY H AAE BEEN REDUCED BY PAZ CLAIMS. ILT'R ALL THE TERMS, TYPE OF INSURANCE } U + POLICY NUMBER -� GENERALLiAaiLIT1 ( LtCY Ell I POUCY EXP - f X f cOnsn Ca! cev RA !�EI!r-Y # ( AI i CLA?US4,l X j CCCUR i I U." S< H OCCURRENCE I s � �.Mao �i Is 1,000,00 2550, 00 [ u 6Ci0988202 !30/2014 9/30/2015 MED FXP(Any omool ni is 10,00 [ s t ( Pooh . Av l�(,R� 1, 000,00 I Gni'! AGGRO A ! AA T i=?L1c5 ?ER. 1 "'� I I PRO- ' t GENERAL AGGRaGAT. s PRODUCTS `s 2, 000, 00+ acucY -OWPIOPAGG 2,0)0,001 iLAUTOMOBILE UASILiTY I $ A tANYAU7O1 "�2�5�I 1000 00( { I A! ! DV�NED —' ECYEDU!^.D j t_I At:T05 � AUiOS CA1C988202 t X } NON-C'An;E. j 1 SOOI�Y �iJURY (PerPa se t; + $ 13C/2414 19/30/2015 7 SODI_, GWURY(Pera r!,c Av OS I i j 1 ; i --t AL -70S to ?rOPEiT asuA - ; X (UMBRELLA LTCB i ' t � OCCUR I � 1 Miff ere-,elS i A s i EXCEs$ ung i—? _ Ali 4 ��M4�RDEs 3 ' EACH OCCURREitiCE S 1, 000, OOt jX' DEC,D'e0 Rrnn„pN$ 3o,0Cq i 0988202 WORKERSl* I ' i AGC-REGAT'e /30/2414 ;9/30/2015 ( $ 1,000,00C AND PMPLOYEw UABIUT'Y I 1 A.4?' PnCaRi- 0.RFAR'4E,g2 ' .%.: tsTY Y—iN: ; N ! A i ; STA: i , . i 1 : 1 .. il4andatory in NM) 1 1 ; cL EAC'; ACCICE,FT Is . hyes, dell (alder I DESCR FTICN OF GERAT70N3 I j { I EL DISE4£_ - £A EtSPLCYE $ ( s 3 i _._ 1 E.L DisilllSF. P[;,• .rV t ua:+ e DE8CFdPTi0N OF OPERATION$ I LOCATIONS t VEHICLES {Attach ACORD 405, Addltjol EI Re, y ` ' i Refer to policy for exClusionary eadorae tl and �C k, pravisiovi ffe is Mquil l aas. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Al REPRESEHTATlYE :Sark ferdinando/ENS la,< �a^✓'� '-'� r ACEJRD 25 (20101O5j 0988-2010 ACO#2D CORPORATION. A!€ rights reser tNSD25.n+rrn;n: Tke Att'll nansn znri Inenn zro �enic4eene{ made of Al:tlRl-f - gr�t Ft« CERTIFICATE OF � LIABILITY SU N�� DATE(MMj0D/YYh'7•) THIS CERTIFICATE lS =LIED ASA MATTER OF INF(SRMATrrtu AM v -- 03/05'2015 .. t,nw{ s c LJties NUT AFFIRMATIVELY OR NEGATIVELY' AiYMEND, EKTEND OR ALTER TIME COVERAGE AFFORDED BY THE POLICIES BELOW. THEA CERTIFICATE OF INSURANCE DOES NO IMPORTANT: If the certificate holder Is an T CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER AND THE CERTIFICATE HOLDER. >!ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certaln policies may require an endorsement, A rsestatement on this certificate does not cosier riohts to tfw Certificate holder in lieu of such Endoment(s;, PRODUCER PAYCHEX INSURANCE AGENCY, INC. Ro ES ESR, NYDRIVE LSA_ 1NC 175 LINCOLt'N STREET REET UNIT 104 MANCHESTER, NH 03103 Insurance Agency ;rr, E-lsiAli. Cerfs�a 9QOBEss• �,Daycnex.cOm INSURER(S) AFFORDING COVERAGE INSURERA: ArrGUARD lnsiralce Corpany INSURER B: INSURER C: INSURER D: INSURER E: 14-qURER F NAIC 42390 COVERAGES CERTIFICATE NUMBER: THIS IS TO CERTIFY T -HAT THE POLICIES OF INSUr�ANCE US S:D SELOW NIAVE SEEN IS RED NAMED ABOVE FOR T INDICATED. NOTWITHSTANDING ANY REQUIRVAENT, T Etvl OR CONDI i MON OF ANY CON -RACE OR OTHER DOCLLME -, WITH RESPECT POLICY TO WHICH TSS'. i�S CEFMFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSUFtQNCE AFFORDED BY 1-1,;E,POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL ; NE TERMS, EXCLUSIONS AND CONDiTiONS OF SUCH POLICIES. LIMITS SHOWN h,`:AY HAVE EEC -t: prr � .men my —_, ---i TYPE OF INSURANCE C0-V,SRC!AL CIE -NERAL LIAaLr.Y =C_ 1!S-V'A0S i&CCUR A,i,REGATEc LIMIT APPLIES PER: A.r: A"Tc ALL CW,k•i_.^ Au-.cs EXCESS+der. ! �vv.5,vs�E WCfi7Q$ CCUPEMSAMN AhO - V&PLOYERS LY ZILITY AnyPz.GR?FuiT•rtx t O tCER4f.E#3ER ExCLGCFG? Y/N cryhw) l Y ? 1 NLA DESCRIPTION OF OPERATONS! LOCATIONS 1 POLICY NUMBER L SWC541923 (Atta:h ACOP.D 101. Additior;8I Remeft POLICY EFF i POLICY EXP 0$/30;2014 j 0&.'30/2015 K Imre space IS required LIMITS EAC -!OCCURRENCE `5 D.AMAGe TC �irTeD �-iuc c • �.. 15 .M.EJEXI(Any '.,"4E,^,etSn� IE ?ERSONAL dADVINJURY i5 GENERAL AC -GREG , E i PRG'D `CTS - COUPJOP AGG S:G-lfiED SINGLE L IMT --- l (Ea x:,�aertt S $OO;LY INJURY {P�pefsOs;) 'i 3 $cOiLY :4.SUR . PROPERTY DAMAGE I'� a0.ide�11 s Is EACH OCCURRENCE I AG^vREGk;= [5 XI WCS 7L, EL, EACP; ACCOEly , S 5C0.00O.ub E.L. DEreE,cE - EA E5k_0?'EE IS wo.000.0G EL. DISEASE - POUC'Y i ilSr ? S son- X0.01" SHOULD ANY OF THE ABOVE DESCRieED POLICIES BE CANCELLED SEFORE THE EXPIRAT..oN DATE THEREOF, NOTICE WILL BE DE NERED iN ACCORDANCE LEITH THE POLICY PROVISIONS, ELT FAILLIRc to MAIL SUCH NOTICE SHALL IMPOSE NO OBLGA-$*N OR LiA -ILITY OF ANY KIND UPON THE COMPANY, rrs AGENTS OR REPRESENTATIVES ,UT14ORI2E0 REPRESENTATIVE ACORD 2S (2010105) The ACORD name and i (MOSS -2010 ACORD CORPORATION. All rights reserved. ego are registered marks of ACORD - COMMONWEALTH OF MAW&AGHUSETT a a ' a a BLtAitD'0F ELECTRICIANS . ISSUES THE FOLLOWING LICENSEAS.`� .REGISTERED MASTER ELECTRIC i DANIEL A BDiSVERT . 175 LINCOLN ST SUITE 104 MANCHESTER NH 03103-5079 16m. o / ali6:.: 100 0- 4• M i' 4 J' iif yC4`Jn J