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Home My WebLink AboutMiscellaneous - 36 EVERGREEN DRIVE 4/30/2018 (2)10119 Date'F/& / S... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that....... Pzx 'a G,! Ca,6 .. has permission to perform ... .. ,!f plumbing in the buildings of , !?-. , . , , . at ..............'V'� ..... . , North An vew, Mass. Lie. No. PLUMBING INSPEC OR Check # 2 7- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK P TYPE,OR PRINT CLEARLY CITY -Vprh1 An J ov er MA DATE 913 PERMIT # M' q JOBSITE ADDRESS OWNER'S NAME r AA OWNERADDRESS 36��ittiP' th TELTO 0X11 FAX OCCUPANCY TYPE COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIALX NEW: ❑ RENOVATION: REPLACEMENT: ❑ PLANS SUBMITTED: YES ❑ N0'K FIXTURES Z FLOOR— BSM 1 2 3 1 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 FOOD DISPOSER FLOOR 1 AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET URINAL , WASHING MACHINE CONNECTION WATER HEATER ALL TYPES 9 WATER PIPING 0 OTHER mi i ` INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YESx NO ❑ IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW 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 , Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ❑ AGENT ❑ SfGNATURE 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 plumbindwork and installations performed under the permit issued for this application will be in m lien wit Pertinent pr 'ion of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME` +e � i �I�GCO � LICENSE # (040,20 SIGNATURE MP W JP ❑ CORPORATION'K# 3193 PARTNERSHIP ❑ # LLC ❑ # COMPANY NAME %-v &J%Qi1 d al'�l��Bi( ADDRESS CITY STATE ZIP TEL '70'1 FAX CELL C"I141' / 370 � EMAIL��e'la �� b • r r� z b n H O z z 0 H t�1 m m cn eA � r- r n � C Zca y m z < O w � -o O cft z � m � 0 H 3 � ❑ y ❑ O ar �z ro H O _ z � V ( �J } •may r^ J 1.j The Commonwealth of Massachusetts L Print Form -' Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 Boston, MA 02114-2017 www. mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): "lf C� x /�� 11� +�� Oi(A�`N(P / tSmyte Address: � % Temly, City/State/Zip: J bv'i' ��- �L Phone #: Are you an employer? Check the appropriate 11.)( I am a employer with 6 box: 4. E]I am a general contractor and I Type of project (required): employees (full and/or part-time).* have hired the sub -contractors 6. ❑ 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 me in any capacity. [No workers' comp. insurance employees and have workers' comp. insurance. # 9. E] Building addition required.] 5. E] We are a corporation and its 10.0 Electrical repairs or additions 3. Fl I am a homeowner doing all work officers have exercised their 11. ❑ 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 13. Other %61 employees. [No workers' comp. insurance required.] til r *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 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: �i 1 i� 1 :�.� it (� itilll j ®1 �R AOL fl Policy # or Self -ins. Lic. #: M 4S " S, 91 �I C V Expiration Date: Job Site Address: R � v"� ��'r1 City/State/Zip: 44dwer ,S, Attach a copy of the workers' compYnsation 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 Phone #: `7 ( IS C R 3�� that the information provided above is true and correct. natP. SR., i3 1. 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 #• i .: SSA o mss' w ( •�: "g' i •ii� ZZ' � �+_ � Y O0* CER7'Ipj�O 0V Lu P�O y.� ■ Ory � co ai m� F 4n e !in w N� Z O 2 N O ;.w Ufa Q�� S: O sU- w a �. o {—, i ® V - ClQ 'o Zcn m w o ua t!1 CD o A r �W , (1), O Q u z c. U, Cinl O WW , m W w aQZ. H. j = M i d Z �T 3 ". 40, U RS Ix rA CDLO m uj1 0cn z •~ EQ �LL�LL' (nw 4?w CLQ LU 'W 2::,- o pyo •,. m \ CCi f.4 Z m @' QQ w c0 w O > Ln o rALr Q N N rl- Q .. OVA W 3 - U) Wp7 N O Z: Zvi W z mWri.'." = a CD 9 JW b Q... W IS .O. _. io w %7:. W NEWEN4 OP ID: JY '4�� l'R CERTIFICATE OF LIABILITY INSURANCE � M3 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(SL 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 endo s PRODUCER Phone: 978 688 8829 Michaud, Rowe And Ruscak Ins. P.O. Box 188 Fax: 978 557 2130 North Andover, MA 01845 Michaud, Rowe & Ruscak pCONTACT PHONE E-MNL ss: S AFFORDING COVERAGE NAIC # INSURER A: Harleysville Worcester Ins Co. 26182 SPP42517H INSURED New England Solar Hot Waterinc Bruce Dike 677 Temple St UIsum B: Travelers Insurance Company INSURER c: Commerce Insurance Company 34754 RMRER D: DuxbuM MA 02332 - INSURER E: INSURER INSURER F : GENT AGGREGATE LIMIT APPLIES PER POLICY F—IJERO- CT LOC UJVEKAGI--S CERTIFICATE N"MRFR• c=ncrnw w""Mmm 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- NLTR TYPE OF INSURANCEVIPM POLICY NUMBER POLICY EFF. POLI p I EXP LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE � OCCUR SPP42517H 09111112 09/11/13 EACH OCCURRENCE S 1,000,00 DAMA TO RENTEO PREMISES aonsrence $ 100,00 MED EXP (Arty one persm) $ 5,00 PERSONAL 8 ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GENT AGGREGATE LIMIT APPLIES PER POLICY F—IJERO- CT LOC PRODUCTS - COWIDP AGG S 2,000,00 $ C AUTOMOBILE LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS1xx X HIRED AUTOS NON-0WNED AUTOS BBCM55 08/21/12 08121/13 COMBINED LIMIT(Emaoci$ 1,000,00 BODILY INJURY (Per person) $ BODILY INJURY (Per accidenQ $ PROPERTY DAMAGE Per�I $ $ A X UMBRELLA LIAB EXCESS UAB X OCCUR CLAIMS -MADE CMB92125K 06114113 06114/14 EACH OCCURRENCE $ 2,000,00 AGGREGATE S 2,000,00 r� X RETENTIONS 0 $ B 111101"MRSCOMPENSATION AND EMPLOYEW LIABILITY ANY PROPRIETORiPARTNERfiDMCUTIVE Y / N OFFICERANEMBER EXCLUDED? ❑ (MandatonlnNHI�TRAVELE If yes, describe under SCRIPIION OF OPERATIONS' N i A O BE ISSUED BY RS WCSTATU OTH T M EL EACH ACCIDENT S E.LDISEASE- EAEMKO $ EL DISEASE -Pourw uw s DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, AddrJanal'Renwks Schedule, N nw a space is requited) NORTH13 Town of North Andover 1600 Osgood Street North Andover, MA 01845 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION HATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORED REPRESENTATIVE W T9SS-2070 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD Rightfa,x N3-2 8/20/2013 10:15:01 AM PAGE 2/002 Fax Server `! CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDIYYYY) KATE 6 ISSUED AS A MATTER OF INFORMATION ONLYAND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND. EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. IS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED ,REPRESENTATIVE OR PRODUCER. AND THE CERTIFICATE HOLDER. IMPORTANT: Ifthe certficate holler Is an ADDITIONAL INSURED, the policy(les) must be endorsed. N SUBROGATION IS WAIVED, subject to he terms and conditions of the policy, certain policies may require and endorsement. Astatement on this certificate does not confer rights to he certificate holder in lieu of such endomemen s . PRODUCER CONTACT NAME: PHONE FAX MICHAUD ROWE AND RUSCAK P O BOX 188 (AIC, No. EPO; (AIC. Wok EdNA� NORTH ANDOVER, MA 01845 ADDRF�S: 29Y5D iNSURER(S7 AFFORDIING COVERAGE NAIL 0 INSURE) INSURER A: TRAVELERS MEMNLTY CO uSURERB: NEW ENGLAND SOLAR HO WATER INC INSURER C: iNSURER D: 677 TEMPLE ST INSURER E: DUXBURY. MA 02332 INSURERF: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: TO THEINSURED N)AMEDABOVEFOR THEPOLICYPERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT. TEM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WINCH THIS CERTIFICATE MAY BE ISSUED OR MAY . PERTAIN. THEIISURANCE AFFORDED BY THEPOLJCWS DESCRIBED HEREIN B SUBJECT TO ALL THE TERNS. EXCLUSIONS AND CONDITIONS OF SUCH POLICE. LRMTS SHOWN MAY HAVE BEEN REDUCED BY PAD CLAMS. NSR ADD SUB POLICY EFF DATE POLICY EXP DATE LTR TYPE OF INSURANCE L R POLICY NUMBER. (MN MWYYY) (NiMM01YYYY) UMTS GENERAL LIABILITY OCCURRENCE S COMMERCIAL GENERAL LIABILITY CLAIMS MADE M OCCUR AEMI E S( a OC=F S EMISES (Ea ocamell=) ED OP (Ary one person) $ & ADV INJURY S L GENAGGREGATE LIMIT APPLIES PER S RDffEMAGGREGATEODUCTS 0 POLICY Q QPROJECT LOC - COMPIOP AGG $ AUTOMOBILEUABIUTY COMBINED SINGLE S ANY AUTO LIMIT (Ea aoddut) BODILY INJURY $ ALL OWNED AUTOS SCHEDULE AUTOS Person) BODILY INJURY $ (Par accident) HIRED AUTOS NON -OWNED AUTOS PROPERTY DAMAGE S (Per acdderd) UMBRELLA UAB OCCUREACH OCCURRENCE $ EXCESS i NAB CLAIMS MADE GATE $ DEDUCTE It� $ $ RETENTION S A WORKHYS COMPENSATION AND ENPLOYEYSLIABILITY YIN UB -56756805-12 12IM=212 121032013 X WC STATUTORY UMRS OTHER ANY PROPERrrCWA ifN6WEJO CUrNE EI OFFICERIMEMBER EXCLWED? L" r MIA E L. EACH ACCIDENT S 500,000 EL DISEASE -EA EMPLOYEE $ 500,000 (IYlade)ory In rep YYes. desarbe under DESCRIPTION OF OPEiMATKM below EL DISEASE - POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATKWSLOcAnot4sivEncLesRMsTmCT=SpjpEMAL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AMcrI O WORKERS COMP COVERAOH_ CERTIFICATE HOLDER CANCELLATION TOWN OF NORTH ANDOVER SHOULD ANY OF Tim ABOVE DESCRIBED POLICIES BE CANCELLED BUILDING DEPARTMENT BEFORE THE I7WiRAT1ON DATE THEREOF. NOTICE WI L BE DELVER D IN ACCORDANCE WITH THE POLICY PROVISIONS. OR H ANDD ST NORTH ANDOVER, MA 01845 AU7HOR¢ED RB'RESETIT -�� rawKv ,a wiwu2J Ane AI.UKu name arta Togo are regismea marcs OF Awku 1!RR-AJ1U AWKL? WKr UKA I IUN. An r(gnts nrserven. r Date .. �........ . TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ... r5.+ .Y. TA `"................. has permission for gas installation ... jl/ ' : .114. C.� ...:...... . in the buildings of ... /I �y :� n ............................ at .... North Andover, Mass. FeeLic. No..' / � ! ... ....yzINSPECTOR Check # 3 �� 6515 hey} f y`� a' V -. k^ i' �x� "-: New:F-1 MASSACHUSETTS UNIFORM APPLICATION: FOR PERMIT TO DO GAS FITTING Replacement 1Y City/Town• �� Date:, Permit# No Qj� Building Locati �v� E : Owners Name: �� , ye zi i . C P ` a: Type of Occupancy: Commentialo, Edik� final Andusfialn- Institutional Residential rTi Xs �f�E`v t. 4. A111", t4 �p � '{ • �, i -. k^ i' �x� "-: New:F-1 ri ,',:�•+ni Replacement 1Y 0 'Plans Submitted Yes No Qj� . �� rTi Xs �f�E`v t. 4. A111", t4 �p � '{ • �, i I 1 it k - + . ,I -. k^ i' �x� "-: 5{ x �� ri ,',:�•+ni 'r* .� -t . �� rTi Xs �f�E`v t. A111", t4 �p � '{ • �, i I 1 k - + . ,I LU CO 4- z ' '• � W � O W. f•ii. IV . O 1� '. yd Sk f Y� }^ �y1yR J:G ,�T ./Yy/ Y/' I.. j j % j � rm 1 O Z z T O LL Z >. N =J `Z Q >W LUV D LL aU' _ > , O ;G7 "W: }Z "Z. IW a .F SUB BSMT.:r- t BASEMENT 1 FLOOR 2 FLOOR k .x 3 FLOOR , 4. FLOOR 6 FLOOR t . i 6 FLOOR � dl }} �` $ # .. Ft p y ,i�3;1 t -�F i6r',�7 ° '� v� t a I, ; s J ' FLOOR *C� . � s•t� OOW7 a ,.;. i Installin C #,r g ompany Name: KL SoN st s,., Check One Only,! * "Certificate ; :. S a. t ,i�� #rig, . , t Address: S. ghdv Cfty,Tovrnl,UIiL.L7b Corporation " Business Tel: _r -2d-,3 Fax•=76, % >. �Firm/Company Name of Licensed Plumber/Gas Fitter. I C • `r „I INSURANCE COVERAGE: I have a current liability Insurance policy or its substantial equivalent wkhich i If you have checked Ys. please indicate the type of coverage by checking thi A liability insurance policy Other type of indemn-71 ity # tdxr ti Ott. OWNER S INSURANCE I am aware that the Ikensee' rt Massachusetts`,General Laws, and that my signature on tbia'jpennit applicatib. �'114w� a�5��}t.tax�A.4, a:�n.t It � I i �+n �yk,;iahJ� �•, � By checking �thls box ;1 hereby certify that all of.the details and IMonnatton:.l h6vesu accurate to the beat of.trn►;Knowledge;and:that ali piumbing:.work ar�d irrstallaflonli perp compliance with'all Pertinent provision of the Massachusetts State PI' Code` Nets the requirements of MGL. Ch.142 Y�10 NQ Npprcpriate box below. I + I Bond 0 Insurance Coverage.requiM by Chapber;142 of the . re awes- `' this rlequirement. t,'Check One,Onty " Owrterr'N" ' sAge`M` {;� �a;a +;� rifted (or entered) !e9aMing_tlils appllcedon pre;ltrue and.i red under the permit issued for this applfcatlon'wgl be 1 Lli'�.r'R''°at^ .. ,,: ; , rz: 4 t4 a t...i , F a "Y .•j By Plumber k k TM °; r 'r , Title �i Gas Fitter Master ig atut'e of Llbensed- , lumber/ Fitter -ity/Towni Journeymen APPROVED OFFICE USE ONL LP Installer LicenseAumber:. O r .f C P ` Date..�d �'.;�•° '.��a TOWN OF NORTH ANDOVER PERMIT FOR PLUM,B'INArG ,SSACNUS� . This certifies that ...! . V !. ...': " .................... . has permission to perform .....- ........... v. :._ ....... plumbing inFtthee buildings of . !. V at .. 7 ... r. .... ............... North Andover, Mass. � Fee � Vv.Lic. No... �d 3 G �. . ......�...... PLUMBING INSPECTOR Check #' ve- i v MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Location ,ate / few.erniitl G v # Amount '7; Lf Type of Occupancy� v -rt Lt - New rl Renovation Replacement ' Plans Submitted Yes No ❑ (Print or type) -7' Check one: Certificate Installing Company Name_ /C I r ��} , ��G f a Corp. Address 6 �J X r— d itJ _ Partner. 15.- _ ❑ usmess elephone p IlFinn/Co. Name of Licensed Plumber: Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity ❑ Bond Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance ignature Owner 0 Agent 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 and in llati s performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massae ett to Plu ng Co and C ter 142 of the General Laws. By: - I � A—� 19 a ure o icense n, Nr City/Town APPROVED (OFFICE USE ONLY Type of Plumbing License Licens7774urnoer MasterIT Journeyman F1 i i1 -.®m...-.--�..--....-.-. MMMMM MM 0 WWM MM MW -�.m-5. - - 0 0:' =®-M------ MM-. M-�� W 1 01:' -5.-M---�--�.� .-- (Print or type) -7' Check one: Certificate Installing Company Name_ /C I r ��} , ��G f a Corp. Address 6 �J X r— d itJ _ Partner. 15.- _ ❑ usmess elephone p IlFinn/Co. Name of Licensed Plumber: Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity ❑ Bond Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance ignature Owner 0 Agent 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 and in llati s performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massae ett to Plu ng Co and C ter 142 of the General Laws. By: - I � A—� 19 a ure o icense n, Nr City/Town APPROVED (OFFICE USE ONLY Type of Plumbing License Licens7774urnoer MasterIT Journeyman F1