Loading...
HomeMy WebLinkAboutMiscellaneous - 361 MARBLERIDGE ROAD 4/30/2018 (2)IF7- Date . . 3662 .......... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies'that .. ! ....y1wV. -,,,0V,.-41!1. Q1 ................... *hasWn pp � ission to perform 14 ............................ plumbing in the buildings of ................... at. l? 0 Awl? /i I ............ North Andover, Mass. ' Fee. Lic. No. .. .............................. PLUMBING INSPECTOR 04/16/98 11:a 5.00 PAID WHITE: Applicant CANARY: Building Dept. PINK: Treasurer MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO ASF (Print or Type) n � I le— New ❑ Renovation ❑ 19 emit * 6C2� Owner's Nam ,tip /7 Type of Occupanry, 1 -1 ---)CN /1 14 Replacement Plans Submitted: Yes❑ No ❑ Installing Company Name CjAe(Z T :� At -n AIA T Check one: Certificate Address 3 %, ODA C H /h fa rO i- KI . ❑ Corporation lit t= 7 N U E tj ri1 ►a 0 1 ❑ Partnership Business Telephone /o •,1?2 -9 97 f 2--Firm/Co. Name of Licensed Plumber or Gas Fitter -RO O E P. T 8 • 58 M m H i A leo INSURANCE COVERAGE: 1 have a current I' bility insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes No ❑ If you have checked yes, please Indicate the type coverage by checking the appropriate box A liability insurance policy 0""' 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 Q 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 installations performed undeuthe Vn for this application be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 oaws.By T of License:Plumber cen u or Gas fitter Title tter er License Number 913312) O IC NL Journeyman 11111111111111 111111 MEMO IKMIMEMMIXIM Installing Company Name CjAe(Z T :� At -n AIA T Check one: Certificate Address 3 %, ODA C H /h fa rO i- KI . ❑ Corporation lit t= 7 N U E tj ri1 ►a 0 1 ❑ Partnership Business Telephone /o •,1?2 -9 97 f 2--Firm/Co. Name of Licensed Plumber or Gas Fitter -RO O E P. T 8 • 58 M m H i A leo INSURANCE COVERAGE: 1 have a current I' bility insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes No ❑ If you have checked yes, please Indicate the type coverage by checking the appropriate box A liability insurance policy 0""' 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 Q 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 installations performed undeuthe Vn for this application be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 oaws.By T of License:Plumber cen u or Gas fitter Title tter er License Number 913312) O IC NL Journeyman z 0 W CL N Z N N W Q 0 O d. � W S V F- W I Y N I O U W a N Z J Q Z LL W r N � a J D 'Z O O � W O W N ~ O Z F c W GW1 O a m d j O F a m O O ti } J O IL N m < ut W W NI W S V F- W I Y N Z O U W a N Z J Q Z LL Date .. �� .! .... . 3? TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ... . f. }. ...... ...:................... . has permission for gas installation."* .............. in the buildings of ...?�'' �—�''`-`�....................... . atr�� ... ... , North Andover, Mass. Fee. -�. �.. Lic. No.7lcr ./......... . J�GAS INSPEG � � R Check # / �S� El t • MASSACHUSETTS UNIFORM APPUCATON (Type or print) NORTH , D GAS FITTING Building Locations _Z�a mlwhleRf( ,, ! d . Permit # /- /,/ 9 Amount $ Owner's Name /'%Pall � � ` New ❑ Renovation ❑ Replacement ❑ Plans Submitted ❑ Name of Licensed Plumber or Gas Fitter eck one: Certificate Installing Company Corp. ❑ Partner. Firm/Co. INSURANCE COVERAGE Check one: I ha' e a current liability Insurance policy or it's substantial equivalent. Yes 0 No ❑ Ifyou have checked es please indicate the type coverage by checking the appropriate box Liability"insurance policy Lk 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 ❑ ucrcvy c army cnat au of the aetaus ana mrormatnon 1 nave submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachp (5 s State Gas Qode apd Chapter,142-efthe General Laws. VED (OFFICE USE ONLY) ❑Signature df Licensed Plumber Or Gas Fitter Plumber 12466 ❑ Gas Fitter License Number ❑ Master Journeyman Pit 111101 WIN Name of Licensed Plumber or Gas Fitter eck one: Certificate Installing Company Corp. ❑ Partner. Firm/Co. INSURANCE COVERAGE Check one: I ha' e a current liability Insurance policy or it's substantial equivalent. Yes 0 No ❑ Ifyou have checked es please indicate the type coverage by checking the appropriate box Liability"insurance policy Lk 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 ❑ ucrcvy c army cnat au of the aetaus ana mrormatnon 1 nave submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachp (5 s State Gas Qode apd Chapter,142-efthe General Laws. VED (OFFICE USE ONLY) ❑Signature df Licensed Plumber Or Gas Fitter Plumber 12466 ❑ Gas Fitter License Number ❑ Master Journeyman Date..!a.kelm TOWN OF NORTH ANDOVER 11 PERMIT FOR GAS INSTALLATION This. certifies thatIZT6 has penmission for gas nstallation �?.Lz..6)...: I., P in the buildings of ... ... 16 ....... ....................................... ....... North Andover, Mass. Fee.( .... Lic. No .$ ....... ... M. ................................................ GASINSPECTOR Check # 9453.. MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK F'd CITY I N. Andover MA DATEL7/31/2014 �J PERMIT # 6" JOBSITE ADDRESS 361 Marble Ridge Rd OWNER'S NAME GOWNER ADDRESS Same TE FAX TYPE OR OCCUPANCY TYPE COMMERCIAL[] EDUCATIONAL ® RESIDENTIALQ PRINT CLEARLY NEW: ® RENOVATION: REPLACEMENT: ❑ PLANS SUBMITTED: YES[j NDE] APPLIANCES 7 FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 1213 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 / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER Re lace 1 Gas Meters x and Associated Piping INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES Q NO ❑ I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [j 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 El 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 c liance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME I Joseph Marino LICENSE # 8736 SIGNATURE MP Q MGF ® JP ❑ JGF ® LPGI Q CORPORATION Lj# 3285C PARTNERSHIP ®# LLC ®# COMPANY NAM E:j RH White Construction Co ADDRESS 41 Central St CITY I Auburn STATE MA ZIP 01501 �:]TEL 508 832-3295 V 11111 00 FAX 508-926-4347 j CELL 508-832-4614 EMAIL JMarino@RHWhite.com ROUGH GAS INSPECTION NOTES I THIS PAGE FOR INSPECTOR USE ONLY IFINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES M '1'i:f• •its'. '�::•�' .: :%'1 t lo"�"Il :,'..,;��., .I r, ':,' ':.; I..:e:;f :':,: 'i•�ll'iJ.rr'.�� !: I•• tI' Ilfn, .:1 :i ,`;ifi ( y-'�.!. �..., ':.1':f jA.+:'• rA'�74?„�,, ej' � ._d{t,.'. • 'iiii t•.'fi y p� i�J�-'.�: t'. `•y`�;rl•'�':7i'.� ,.. �Iyp*�1?FcJ�� G`�'J J�i`yQ::; .. LL> - Z Cow W '. rl LL • -. �y MV) `a; il3• `I: w iGaJ:ijr.: la lii:; .I�r.11 h:F .3�J^� ( t-%LLFY �:�'fi �f: f�•••. •x'31': '•jai'; !��t�:i•' v Wj Ev f': ''fJ vl:�: idPba�� i �:,;,{. i„J'rl ' nt;,' :,,• 1,: �i!�3it, ?i a.. t. 1=%i'�t":: t .: ';!F i•.,7 �:r J �Ii' .. •' •.;1iii '.:.:1:'F,,it,'; �'!:':5.'af,J'il,7f: r,%'r•�i, � IJ -.t;-"'., ... r.�i�..�.. ... �C �® DATE (MMIDONMI r CERTIFICATE OF LIABILITY INSURANCE page 1 of 3. 08/29/2013 THIS CERTIFICATE IS ISSUED ASA 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 RETYVEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the 130HOY(i6s)muct be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain Polioies may require an endorsement. A statement on this certifleate does not conferrig hts to the certificate holder in Ileu of such endorsement(s), willia of MaeasChusette, Ins. c/o 26 co ttury Blvd. P. 0. Box 305191 Naghville, TN 37230-5191 R. H. White Construction Company, Inc. 41 Cmntral Street P. Q. Box 257 Auburn, MA 01501 •+.«nlv nrrviauirvu4VYCKAGC NAICtt INSURERA!The Charter Oak Fixe IneuranC9 Company 25615-001 INSURERS. Trava7,grei property Casualty COX�I?any oP Am 25674-003 INSURERC:Nati4>aa1 Union Piro Ineuranco Company o£ 7.9445-001 INSURERD:Travelers, Inda=jty Company 25658-DOl VV1{.RnV Ct7 LtK I 11-IGATr- NUM13ER:20267680. 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 ITP POLICYEFF POLICYEXP LIMITS A 9/1./2013 '9/1/,2014 EACH OCCURRENCE a a -nnn _ nnr C IEs TYPEQF►N$URANCE 00 SUB POLICY NUMBER GENERAL VTCaOCD 977R9948-13 X CQMMP,RCIALGENERAL LIABILITY CLAIMS -MADE OCCUR GEN'LAGGREGATE LIMITAPPLIES PER; POLICY PRO- 511,!"LOC AUTOMOBILE LIABILITY VT.TCAP 977R955A-13 X ANYAUTO AUTOS NED AUT08ULED X HIREDAUTOS X NON OWNED AUTOS X COM Ded X Co 11 Deg UMBRELLALIAB OCCUR 13S6766140 EXCESS LIAR CLAIMS -MADE DED 17 IRETENTIONS j0, 000 WORKERS COMPENSATION �tFti7Fj g205A185-13 9 AND EMPLOYERS' LIABILITY ANY PROPRIETORIPARTNERIFXECUTIVE NIA VTC2KUB 8203.A71A-13 9 OFFICERVEMSEREXCLUDED? 0ytridetor�r I" NH) IIJE�I Kll+ I IUN OF OPERATIONS heloW tvidence 01' Inmurance 1/1/2013 9/1/2014 BODILY INJURY(Perperson) IS BODILY INJURY(Peraccident) 3 /1/2013 9/1/2014 /1/2013 19/1/2014 g /1./2013 9/1/2014 E.L. E rmore epeeo 2,000,000 1,000,000 1,000,000 1,000,000 SHOULD ANY OF TWE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZEDREPRE8ENTATNE Col1:4197604 `1'p1:1694012 Ce7;t::20287680 ©1988-2010ACORDCORPORATION. All rights reserved. CORD 25 (2010105) The ACORD name and logo are registered marks of ACORD Date ....?..,3 A...... 11344 plumbing in the Zbus of .. ........... at .. Fee .,S 4T?.. Lic. No. .�/ ,1.. ... ....... Check # ANDOVER .UMBING NortA Andover, Mass. U NG INSPE TOR Date ....... �1.....3�.��................... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that-yt �',.........w "J/G ....... has permission for gas installation .......!�a inthe buildin sof....:...:..::..........:............./.......:........,......................,........,..................:..... .� �...,...... �., No Andover, Mass. ,C.�a. Lic. No.......... A INSPECTOR Check # . 3v4a 10149 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY NORTH_ ANDOVER.- MA DATEL. PERMIT# JOBSITE ADDRESS 1361 MARBLERIDGE RD OWNER'S NAMEDUFFY P OWNER ADDRESS -__ _----- -- _ __--- -- 'TEL[____. _ _ _ ._ FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL Q RESIDENTIAL E] PRINT CLEARLY NEW: E3 RENOVATION: REPLACEMENT:E] PLANS SUBMITTED: YES EJ NOM, FIXTURES'l 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/OIUSAND SYSTEM -- - - -- -- DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR / AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK LAVATORY j — - ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET - -- --- —_ --- -. - - URINAL 0 WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER BACKFLOW FOR BOILER 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 0 OTHER TYPE OF INDEMNITYE] 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 0 AGENT 0 SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information 1 have submitted or entered regarding this application are trues n a urate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in comp" n th a, rovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME JEFF HUTNICK LICENSE # 15212 ' SIGNATURE MP Q JPQ CORPORATIONQ# 3532 _ PARTNERSHIPS# LLCQ# COMPANY NAME I CALLAHAN AC AND HTG ADDRESS 191 BELMONT ST CITY FNORTH ANDOVER STATE MA ZIP 101845 TEL978-689-9233 FAX— CELL 97823-6305 EMAIL PLUMBING@CALLAHANAC.COM IV I 4 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK - - CITY I NORTH ANDOVER - MA DATE PERMIT # JOBSITE ADDRESSI 361 MERBLERIDGE RD OWNER'S NAME I DUFFY GOWNER ADDRESS - - - - -- TE FAX TYPE OR PRINT OCCUPANCY TYPE COMMERCIALE] EDUCATIONAL Q RESIDENTIALQ CLEARLY NEW: M- RENOVATION: F-1 REPLACEMENT: El PLANS SUBMITTED: YES NO[E] APPLIANCES 1 FLOORS BSM. 1 2 3 4 5 1 6 7 8 9 10 11 12 13 14 BOILER- BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER— _- - DRYER FIREPLACE- FRYOLATOR- FURNACE GENERATOR 0 GRILLE INFRARED HEATER LABORATORY COCKS _ .: ' - _ ___-- _ .! . _ _' _ MAKEUP AIR UNIT OVEN -- - ! - POOL HEATER- ROOM / SPACE HEATER - -_. -- _-_- : - - - ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER - -- --- I � INSURANCE COVERAGE I have a current liabili insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES Q NOE] I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY - OTHER TYPE INDEMNITY 0 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: OWNERE] AGENT Q 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 accprate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in complia all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASATTER NAME I JEFF HUTNICK LICENSE # 15212 SIGPOME MP Q MGF Q JP Q JGF 0 LPGI ❑ CORPORATION M# 3532 PARTNERSHIP #�� LLCE]# COMPANY NAME: CALLAHAN AC AND HTG ADDRESS 91 BELMONT ST CITY NORTH ANDOVER STATE MA ZIP 01845 TEL 978-689-9233 FAX CELL 978-423-6305 EMAIL PLUMBING@CALLAHANAC.COM State of New HaMDsnire MECHANICAL IDENTIFICATION NAME: JEFFREY HUTNICK . LICENSE/REGISTRATION _ SERVICE GFE0801283 n A - <: STATE OF NEW HAMPSHIRE BUREAU OF BUILDING SAFETY & CONSTRUCTION PLUMBING SAFETY SECTION i NAM;--: JEFFREY P HUTNI_CK LIC #:4519 M F� M gt ;A--' EXPIRES: 12/31/2015 .'_ OP ID: PS CERTIFICATE OF LIABILITY INSURANCE F DATE11101/20111201133 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(Sh 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 endomemen s . PRODUCER Phone: 978-686.2266 M.J. North Andover Insurance SeriAgency Fax: 978-686-6410 163 Main St. North Andover, MA 01845 Stephen Sullivan H°aMNTTE CT PHONE FAX NO EE4M ss: PRODUCER CALLA -1 fNSUR S AFFORDING COVERAGE NAIC 0 CBP4016154 INSURED Callahan A C and Heating INSURER A: PEERLESS INSURANCE COMPANY Services, Inc. Callahan Air Conditioning and Heating, Inc. INSURER e: GUARD INSURANCE COMPANY INSURERC: PERSONAL a ADV INJURY $ 11000,00 91 Belmont Street INSURER 0: INSURER E: North Andover, MA 01845 INSURER F: A UUVF-RA13ES CERTIFICATE NIIMRER- RPVISSInti Nl IMGCo. 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. tNSR LTR TYPE OF INSURANCEADDL POLICY NUMBER POLICY EFF MM PO CY EXP Mk1/DD LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMSaHADE OCCUR CONTRACTUAL LIAB CBP4016154 09/2512013 - 09/25/2014 EACHOCCURRENCE I S 11000,00 DAMAGE MIS ao red S 100,00 MED EXP (Any era parson) $ 5,00 PERSONAL a ADV INJURY $ 11000,00 GENERAL AGGREGATE $ 2,000,00 GEN L AGGREGATE LIMB APPLIES PER: POLICYFX PRO- LOC PRODUCTS - COMP/OP AGG S 2,000,00 S A AUTOMOBILE X X X LIABILITY ANY AUTO . ALL OWNED AUTOS SCHEDULED AUTOS MIRED AUTOS NON -OWNED AUTOS BA4644035 0912512013 09/25/2014 COMBINED SINGLE LIMIT S 1,000,00 (Ea accident) BODILY INJURY (Per pmon) S BODILY INJURY (Per aeciaeM) S PROPERTY DAMAGE (Pet acadent) S Is is A I X UMBRELLALIAB EXCESS LIAB X OCCUR CLAIMS --MADE CU8809334 .0912512013 0912512014 EACH OCCURRENCE S $1000,00 AGGREGATE S 5,000,00 Is DEDUCTIBLE RETENTION S 1 S B WORKERS COMPENSATION AND EMPLOYERS' LIABILITYER ANFICEOOPRIET RPARTNEEC�� Ya IMandaloryInNH) U s, douRIPTIOo OF O DESCRIPTION OF OPERATIONS below NIA I CAWC471731 09/25/2013 0912512014 I WC STATU- X 0TH- E.L.EACH ACCIDENT $ 500100 E.L. DISEASE - EA EMPLOYEE S 500,00 E.l- DISEASE - POLICY LIME I S 500100 I !1 1 DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHICLES (Attath ACORD 101, AddlUonat RamaAs Sehodulo, If MGM $Paco Is requlmd) 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. fax # 978 688.9542 BLDG. INSPECTOR AUTHORIZED REPRESENTATIVE 1600 OSGOOD STREET NORTH ANDOVER MA 01845 ©1988.2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009109) The ACORD name and logo are registered marks of ACORD. Are you an employer? Checli the appropriate box: 1. *1 I an, a employer v6 ti 25 4. 17 1 ami a general contractor and i einployees (frill and/or part-tiine).* ha';e-hired the sub -cont: -actors 2. M I ani a sole proprietor or paifii?er- listed oil; the attached sheet. ship and hai.e no employees These sub -contractors have world -n— for ine ii? ani. capacit:-. employees and have iAorners- tiomi . insurance.-, FIN -10 ti3'orl:Lrs Coinp. insurance p required.) 3. 1 ani a homeovaier doing all work myself. [_No workers- comp. insurance required.] Y F-1_? We, are a corporation and Its officers have exercised their iEht of exeinptiop_ per NlCjL C.102, 41(-,), and ;.°e have. no e rpioj'e $. [N -o ,vork'-r,>' coirip. insurance reouired.1 Type of project (required): Coiisiiucfion 7. C Remodeling 3. Dennolitior 9. [ aBuilding addiction ME] Electrical repaiTs or addidons I1.E Plunibin,�g repairs or additions 12-n Roof repairs 1=., � Other "y!n= applicant that cl!ecl:s bo- I must also fill outtite section below shop Lag their -workers- compensation poi Ft :" til%rltiatto!t. Homeowners vdio submit this ar1lidaiit indicating diel` are doing at vvorti 2nd then hire ott!side contractors inns- SIN nit a nu -n, a tfidavit indicating` such -- =Contractors that elieck this bos must attached aii additional sheet showing then anie of the sub -contractors and stata -,fiether or not those entities iia v e. employees. If the sub -contractors have emplovees. they mustprot-ide their r=arl;ars comp- porter number. I am all ei91p1OI'el. that is providing workers' CO3ripensa ion insurance dor ntv emplovea. Belo ' is the -pofig— tI11Cr;.JO�1 Site iit f 03'matioil. Insurance Comlpaw Name: ward Insurance PolicF, or Self -ills. Lic. -: C4f IC386931 Job Site Address: Expiration Date: 0a/25/201.5 Cita-/State/?i1): ttacli a colt of tide workers' compensation policy declaration page (shoi'�'ing the policy number and edpiratioi� date' Failure to secure coverage as required under Section 25A of ±vlCrl., C- 152 can lead to the imposition. of criminal anal penaluies- of a fine tip to $1_300.00 and/or one -tear hripriso! a ent. as vveh as cii-il penalties in Che foal, of a STOP 1TV'ORK ORED R and a fine of up to $250.00 a dais against lie i rotator. Be advised that a copy of this statement may be forwarded to the Office of Ilivestigatlons of the DIA for lusuraince coi-erage verification - Trio herehl, ce" tO 1111der the paills C1fl!113enalfies Of _pe Dili yZh,tii tlsE Zii jOiiillf210ii provideti above..s '??L' [I?7Q Z07? FCi QJjki(i/ use pall'. Do not write hi this area, to be completed �v Cid? Ot' towwl.Oj�iCia City, of Town: issuing Mthor it (circle one): L Board of Health 2. Building Depa_ tm.ent 6. Other Contact Person: Permit/ icense 3. Cath'/3{i3'F? Lleili -f. !fetaical inspector 5-ilunibin',-__ Inspector .. Phone: lie CCi%?ZY1?onwe,alih of "I' Llssachusei is Department of Indust a Accide is r I Conte 'ess Sheer. Suite 1 00 �Y- Bostoiz, Al-Ld. 02114•-2 0-7 t Workers' Compensation Insurance -Aliftiaavit: Build ers/Contracl oi•s/Elecir cians/Plu.mbers _applicant Information Please Print Ee2i%ly Name. Callahan A/C and Heating Services, Inc ,BLsinesc-erf,:aniZati6&ffidi..idij;: Address: 9't Belmont Street CiiyiSte,e/Zip: North Andover MA 01845 I Phone F: 978-689-9233 Are you an employer? Checli the appropriate box: 1. *1 I an, a employer v6 ti 25 4. 17 1 ami a general contractor and i einployees (frill and/or part-tiine).* ha';e-hired the sub -cont: -actors 2. M I ani a sole proprietor or paifii?er- listed oil; the attached sheet. ship and hai.e no employees These sub -contractors have world -n— for ine ii? ani. capacit:-. employees and have iAorners- tiomi . insurance.-, FIN -10 ti3'orl:Lrs Coinp. insurance p required.) 3. 1 ani a homeovaier doing all work myself. [_No workers- comp. insurance required.] Y F-1_? We, are a corporation and Its officers have exercised their iEht of exeinptiop_ per NlCjL C.102, 41(-,), and ;.°e have. no e rpioj'e $. [N -o ,vork'-r,>' coirip. insurance reouired.1 Type of project (required): Coiisiiucfion 7. C Remodeling 3. Dennolitior 9. [ aBuilding addiction ME] Electrical repaiTs or addidons I1.E Plunibin,�g repairs or additions 12-n Roof repairs 1=., � Other "y!n= applicant that cl!ecl:s bo- I must also fill outtite section below shop Lag their -workers- compensation poi Ft :" til%rltiatto!t. Homeowners vdio submit this ar1lidaiit indicating diel` are doing at vvorti 2nd then hire ott!side contractors inns- SIN nit a nu -n, a tfidavit indicating` such -- =Contractors that elieck this bos must attached aii additional sheet showing then anie of the sub -contractors and stata -,fiether or not those entities iia v e. employees. If the sub -contractors have emplovees. they mustprot-ide their r=arl;ars comp- porter number. I am all ei91p1OI'el. that is providing workers' CO3ripensa ion insurance dor ntv emplovea. Belo ' is the -pofig— tI11Cr;.JO�1 Site iit f 03'matioil. Insurance Comlpaw Name: ward Insurance PolicF, or Self -ills. Lic. -: C4f IC386931 Job Site Address: Expiration Date: 0a/25/201.5 Cita-/State/?i1): ttacli a colt of tide workers' compensation policy declaration page (shoi'�'ing the policy number and edpiratioi� date' Failure to secure coverage as required under Section 25A of ±vlCrl., C- 152 can lead to the imposition. of criminal anal penaluies- of a fine tip to $1_300.00 and/or one -tear hripriso! a ent. as vveh as cii-il penalties in Che foal, of a STOP 1TV'ORK ORED R and a fine of up to $250.00 a dais against lie i rotator. Be advised that a copy of this statement may be forwarded to the Office of Ilivestigatlons of the DIA for lusuraince coi-erage verification - Trio herehl, ce" tO 1111der the paills C1fl!113enalfies Of _pe Dili yZh,tii tlsE Zii jOiiillf210ii provideti above..s '??L' [I?7Q Z07? FCi QJjki(i/ use pall'. Do not write hi this area, to be completed �v Cid? Ot' towwl.Oj�iCia City, of Town: issuing Mthor it (circle one): L Board of Health 2. Building Depa_ tm.ent 6. Other Contact Person: Permit/ icense 3. Cath'/3{i3'F? Lleili -f. !fetaical inspector 5-ilunibin',-__ Inspector .. Phone: