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Miscellaneous - 371 MARBLERIDGE ROAD 4/30/2018
r, This certifies that ......... has permission to perform -504.41(. .. ................ 7r .. ............................ wiring in the building of ...... 5� -1. ........ ................................................. ...... ....... at ... A . ........ e . .... . No Andover, Ma S. Fee ............ Lic. No �o I ......... �ICALINSPECT .. ... OR Check4 70G 12545 bafe.... ................... TOWN OF NORTH ANDOVER PERMIT FOR WIRING Commonwealth of Massachusetts - - Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS 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 PRINT IN INK OR TYPE ALL INFORMATION) Date: . 7/27/2015 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) 371 Marbleridge Road Owner or Tenant Seth Gagnon Telephone No. 978-657-6505 Owner's Address same Is this permit in conjunction with a building permit? ' Yes No ❑ BLDG PERMIT # Purpose of Building Residence. 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: Installation of a 7.0 kw (28 panels) rooftop solar array COmpletion of the followine table may be waived by the Inspector of 17"ires. No. of Recessed Luminaires No. of Ceil (Paddle) Fans Total TransSusp. Trsformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Above in- Swimming Pool rnd. rnd. ElBatter 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 Detection and No: In nitiatin Devices No. of es Ran Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pum Number Tons �� KW ................... No. of Self -Contained Totals Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal Connection ❑Other No. of Dryers Dr y Heating Appliances KW Security Svstems:* No. of Devices or Equivalent No. of Water KW o. 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: Attach additional detail if desired, or as required by the inspector of fNires. Estimated Value of Electrical Work: $21,789 (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 Z BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRMNAME: The Boston Solar Company LIC. NO.: 12689A Licensee: William T. Foglietta Signature LIC. NO.: (Ifopplicable, enter "exempt" in the license number line.) Bus. Tel. No.: 781-462-8702 Address: 10 Churchill Place, Lynn MA 01902 Alt. Tel. No.: 978-836-6220 *Per M.G.L. c.147, s. 57-61, security work requires Department of Public Safety "S" Licen 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: $ 2S-- Signature Telephone No. Mailing: The Boston Solar Company, 55 Sixth Road, Woburn MA 01801 Attn: permits Email: permits@bostonsolar.us� a CONTROL # iJ 2 8 418 ` Y — IMPORTANT If your license is lost, damaged or destroyed; is inaccurate; or needs to be corrected; visit our web site at mass.gov/dpl for instructions to ensure the proper mailing of your Renewal Application and any other correspondence. This license is subiect to Massachusetts General Laws and regulations. Your license is a privilege, and cannot be lent or assigned to any person or entity under penalty of law. Keep this license on your person or posted as required bylaw and/or regulations. r The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations a 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/Organizationnndividual):. The Boston Solar Company Address: 10 Churchill Place Lynn, MA 01902 Phone #: 617-858-1645 Are you an employer? Check the appropriate box: 1. H I am a employer with 20 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2.0 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.t required.] 5. E]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. 0 Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑■ Othersolar *Any applicant that checks box tl l 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. I am an employer that is providing workers' compensation insurance for my, employees Below is the policy and job site information. Insurance Company Name: HDI -Gerling America Insurance Company Policy # or Self -ins. Lic. #: EWGCC000153815 Expiration Date: 1/14/2016 Job Site Address: 371 Marbleridge Road City/State/Zip: North Andover, MA 01845 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 cep tify under 0"ains and penalties of perjury that the information provided above is true and correct. 7/22/2015 Phone #: 6178581645 Offccial 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 #: Client#• 103109 BOSSO ACORD. CERTIFICATE OF LIABILITY INSURANCE DATE (MWDDIYYYY) 1 1/13/2015 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 pollcy(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 People's United Ins. Agency CT NAME C Peggy J. Merati PHONE.,(AC. EI: 860 524-7624 AIc Na ; 844 702-8075 One Goodwin Square a DRESS: peggy.merati@peopies.com Hartford, CT 06103 860 524-7600 INSURER(S) AFFORDING COVERAGE NAIC 0 INSURER A: HDI -Gerling America Insurance C 41343 INSURED The Boston Solar Company, LLC 55 Sixth Road, Suite 1 Woburn, MA 01801 INSURER B: Merchants Mutual insurance Co 23329 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 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. LTR TYPE OF INSURANCE INSRLSUBR WvD POLICY NUMBER POLICYEFF MMIDD EXP LIMITS A GENERAL LIABILITY EGGCC000153814 0/03/2014 01/01/201 EACH OCCURRENCE $1 1000,000 X COMMERCIAL GENERAL LIABILITY RENTED PREMISES Ea occurrence $100,0()o POEM CLAIMS -MADE FR OCCUR MED EXP (Any one person) $ PERSONAL &ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 PRODUCTS - COMPIOP AGG $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICYFX PROT LOC $ A AUTOMOBILE LIABILITY EAGCC000153814 0/03/2014 01101!201 MCOMBINED n SINGLE LIMIT 1,000,000 _._ A X ANY AUTO EAGCC000153914 0/03/2014 0110112016 BODILY INJURY (Per person) $ ALL OWNED SCHEDULED BODILY INJURY (Per accident) $ AUTOS AUTOS NON -OWNED X X HIRED AUTOS UTOS P.rracddROPE enDAMAGE $ $ B X UMBRELLA LIAR X OCCUR CUP0001367 1010312014 01/01/2016 EACH OCCURRENCE $5,000,000 EXCESS LIAB CLAIMS -MADE AGGREGATE s5,000,000 DED I X RETENTION $10,000 $ A WORKERS COMPENSATION EWGCC000153815 1/14/2015 01/14/2016 X IWT.CRSTATUjYoTH- AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNERIEXECUTIVE Y 1 N E.L. EACH ACCIDENT $1,000,000 OFFICERIMEMBER EXCLUDED? � NIA (Mandatory In NH) E.L. DISEASE- EA EMPLOYEE $1,000,000 Ifyes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is required) RE: Permit Work Certificate Holder is included as Additional Insured per the terms, conditions and exclusions of the referenced general liability and umbrella policies, if required by written contract or agreement. Town of North Andover SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1600 Osgood Street ACCORDANCE WITH THE POLICY PROVISIONS. North Andover, MA 01845 AUTHORIZED REPRESENTATIVE jOQ4,ra I ciitl'�k4l h20c ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD #S5656471M565467 SMGCT LO 00 0 � Q c Q G Z 0) 1 LO O C "O a OO O 2 C 'a w 0).fl C z(9�Q( W (1)� O U (D M Z a N o � z g.= Q o�� 000 O � N � F tON� L U w�. W nUW ,Og m < C) 0 °i 0 0 00 z w c O E x o N m ' .n . U) N O � - _ ao �. $ � p O J Z r c !11 m 0 uo�lo OOO LO 00 0 � Q c Q G Z 0) 1 LO O C "O a OO O 2 C 'a w 0).fl C z(9�Q( W (1)� O U (D M Z o � 000 O � N � F tON� L U W nUW m < E °i 0 0 00 z w c O E x o n n ' .n . U) N O � - � p O J N c m 0 LL c d d 41 N A EU) U) LO 00 0 � Q c Q G Z 0) 1 LO O C "O a OO O 2 C 'a w 0).fl C z(9�Q( W (1)� O U (D M Z � � N A Z - � Vi N Q a Q O K - d °a If c w N � C C i 7 a m F j W = Q W �0 o W # u cli � m Z c m d U m a Z - � Q d U� N ° Z a d m � r W O 1010 - LO H 00 LL N d .. -Dr J�f/J J N d (O aONNJ J - - ., NO 1.1_ �QC a�D N V' °gyp fD n - - Z �� LO l`r' M VV'N 0. 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YO 1W- Z W ��� Z m�� Z ��� Q (7 LLI Z U O V z� p Q WZo �y WW�- Q �o o= Q O pp z Q W Q. w o�� pY 2 p ZCl) , ¢ i- _ LU o � Q- a O O O LO d Cl) o N O o0 W o; oW O ci I, ¢zW 0) LO 'v ZOW v0� N OLu W z U ~2ti Z U tiWpQ O UI_ C��� �Zo i� W o co 9 Lo LU E3 U = J�.O �L = app @Q Q Q U Ocn Q U 2�� Q J Q w � V J W zC) 0>� V U i)Mz O U o�w U �-_Aon w � i- W � > W � (uj X O O z O CO W Cil aQ. 7 � 1� fn N oyc�xti d0 Z ¢ O W 7v7_ Y ��wo� J F- C Z OUOW 2 z p;>a� Z W' W Z W cc 2 Z W o J W 0 O J LU mo w Z � Z Z � W Lu i =_ W W � o �_ �z CC >2z g w O W ¢ CO C) 03 W� N N Z r, ¢ �J ui m W %' � o)r w C/) CJ 0 ca J Q —j -i J J Z O J V W¢ 2 O IW— 2 � co Z) c� co O O Wp 2zW Co Co (no Coa U _ � V� qQWz= qWZ CC)qW O Q o~W OS� WtWi� (1 O Lu CL ¢� ¢ W 0 300 Date . A ! �........... �' TOWN OF NORTH ANDOVER VLI PERMIT FOR MECHANICAL INSTALLATION OA' This certifies that . U0 O : ... 710 . �:-��- ... . has permission for mechanical installation ...-A. 1 Z - ............ in the buildings of .. ` .e4!':..661 )IJ01 at... (.. 11,rNorth Andover, Mass. Fee.�Lic. No.... A. ... r.............. GAS INSPECCTOTO R WHITE: Applicant CANARY: Building Dept. PINK: Treasurer Date Commonwealth of Massachusetts Sheet Metal Permit Estimated Job Cost: Plans Submitted: YES NO Business License # / � Permit # �o 0 Permit Fee: $ (� Plans Reviewed: YES NO Applicant License # M Business Information: Property Owner / Job Location Information: Xto Name: .Seen Street:��'L:�4 sr--�'--�` Street: City/Town:,,,n// i�►'�y'"l�/ � City/Town - r1�J �dv�r Telephone: 31, Telephone: Photo I.D. required / Copy of Photo I.D. attached: YES NO Building Type: Residential: 1-2 family A� Multi -family Condo / Townhouses Commercial: Office Retail Industrial Educational Institutional Building Cubic Footage: under 35,000 cu. ft. over 35,000 cu. ft. Sheet metal work to be completed: New Work: Renovation: HVAC >!"" Metal Roofmg Kitchen -Exhaust System Chimney / Vents Provide brief description of work to be done: 01 �- r r r INSURANCE COVERAGE: I have a current liability insurance policy or its equivalent which meets the requirements of M.G.L. Ch. 112 Yes ❑ No ❑ If you have checked Yes, indicate the type of coverage by checking the appropriate box below: A 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 112 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 Owner's Agent By checking this bozo, 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 sheet metal work and installations performed under the permit issued for this application will be in compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws. Date Prog=ress Inspections Comments Final Inspection Date Comments Type of License: By ❑ Master Title ❑ Master -Restricted City/Town ❑Journeyperson Signature of Licensee Permit # ❑Journeyperson-Restricted License Number: Fee $ Check at www.mass.gov/dpi Inspector Signature of Permit Approval Sheet Metal Commercial Guidelines / Life Safety / Critical Systems Inspection Checklist Yes No N/A., Set of stamped engineering documents and detailed description of mechanical system to be installed has been provided All workers performing sheet metal work onsite has valid Massachusetts sheet metal license All sheet metal work being performed with proper journeyperson-to-apprentice ratios Fire dampers with access door properly installed and checked for operation Smoke and combination fire / smoke dampers with access doors properly installed - actuator checked for proper operation (May also be verified by fire department during fire alarm testing) Duct smoke detectors with access doors properly located (May also be verified by fire department during fire.alarm testing) Smoke / atrium exhaust systems installed and operation verified (May also be verified by fire department during fire alarm testing) Stair pressurization systems installed (where required) and operation verified (May also be verified by fire department during fire alarm testing) Grease / kitchen hood exhaust system installed with all seams and connections welded airtight with properly located cleanouts. Proper cleai`ances, fire rated enclosures and pressure testing required: Soi' .caint3 InstalleC �Xf3i0d required 'on. egtiipment and d�=.. tV. J, Duct penetrations in fir'e'rate, crab:: and floors sealed Metal roofing systems installed watertight using proper materials and fasteners Flexible duct runs installed 6'-0" maximum length Ductwork installed using proper hanger spacing, hanger stock, threaded rod and angle iron Ductwork / plenum connections sealed substantially airtight Ductwork insulated by means of external covering or internal lining Volume dampers installed for each supply air branch duct New/clean - properly sized filters installed (final inspection) Testing and Balancing report complete (final sign -ofd t Sheet Metal Residential Guidelines / Inspection Checklist Yes No N/A Detailed description and sketch of sheet metal system to be installed has been provided All workers performing sheet metal work onsite has valid Massachusetts sheet metal license All sheet metal work being performed with proper joumeyperson-to- apprentice ratios Equipment sized per heating / cooling load calculations Duct work sized per manual "D" calculations Bath / shower rooms contain mechanical exhaust fan vented outdoors Electric dryer exhaust properly installed maximum total run 35'-0", maximum flexible run 8'-0" Flexible duct runs installed 14-'-0" maximum length Volume dampers installed for each supply air bra duct 3 Ductwork installed using proper gauges and hangers Ductwork / plenum connections sealed substantially airtight Ductwork insulated by means of external covering or internal lining New/clean - properly sized filter installed (final inspection) Testing and Balancing report complete (final sign-ofo CERTIFICATE OF LIABILITY INSURANCEDATE(MMIDD/YYYY) 12/3/2014 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 terns 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 endnreamanhfel PRODUCER NAME. Sandi Munroe M P ROBERTS INS AGCY INC PHONE F,,,.(978)683-8073 FAX (978) 683-3147 1060 Osgood Street EMAIL _San i titpro ertsinsurance.com North Andover, MA 01845 _ INSURED NORTHEAST HEATING & COOLING, INC. INsuRER 6: 90 HALE STREET N HAVERHILL, MA 01830 COVERAGES CERTIFICATE NUMBER TWIG M REVISION NUMBER Tn �c�— r, T ..... .-..-_ __ tittN TO THE NAMED BOVE FOR THE INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITIONVOF ANYICONTRACT OR OT EREDOCUMENT WITH RESPECT TTOICWHICHIOD 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. 'NbK LTR TYPE OF INSURANCE ISS COMMERCIAL GENERAL LIABILITY 1 O I POLICY EFF POL CY EXP LIMITS CLAIMS MADE X OCCUR EACH OCCURRENCE S 1,000,000 -PREMISES o• rn _ $ 500,000 MED EXP (Anyone erson S 15 000 Pl BOP9093769 04/26/1404/26/1 5 GEN'L AGGREGATE LIMITAPPLIES PER: POLICY ECT Ej LOC OTHER- PERSONAL& ADV INJURY $ 1 000 000 GENERAL AGGREGATE s 2,000,000 PRODUCTS-COMP/OPAGG $ 2 OOO OOO COMBINED SINGLE L IT a e $ , 71Mr AUTOMOBILE LIABILITY -B AUTOS00 X SCHEDULED AUTOS X HIRED AUTOS �{ NON -OWNED AUTOS BA -5E459740 04/26/1404/26/1 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) S PROPERTY DAM E Pe accid n $ $ a UMBRELLA LIAB EXCESS LIA6 OCCUR CLAIMS EACH OCCURRENCE S -MADE AGGREGATE $ X ST T OTH A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNERIEXECUTIVE OFFIER CERIMEMBER EXCLUDED? N (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS belo%v NIA WCA9094494 04/26/1404/26/1 5 E -L EACH ACCIDENT $ 11000,000 EL DISEASE - EA EMPLOYEE $ 1,000,000 E.LDISEASE- POLICY LIMIT S 1,0001600 DESCRIPTION OF OPERATIONS /LOCATIONS /VEHICLES(ACORD 101, Additional Remarks Schedule,may beattached'd more space is required) W MCKAY CONSTRUCTION LLC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 18 ACADEMY AVENUE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN HAVERHILL MA 01835 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED RE ATIVE ,, ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD Nm -t C `�� Heating & Cooling 90 Hale Street Haverhill, MA 01830 800-691-0122 Seth Gagnon 371 Marbleridge Road North Andover, MA 01845 September 18, 2014 We are pleased to quote you a price of $9,601.00 for the following, Equipment: 1. One Trane XL m/n-TAM7A0B30H21 air handler 2. One Trane XR16 m/n- 4TTR6030BI 16seer AHRI#5865398 a/c only condenser for 2nd floor 3. All needed duct work and fittings for a complete install ($4,886.00) 4. All needed copper lines and fittings to connect evaporator coil to condenser 5. One condenser pad 6. One new thermostat Services: 1. Install air handler in attic with safety drain pan 2. Set and mount condenser on pad at ground level 3. Install all new ductwork and fittings for new system 4. Install A/C lines from condenser to coil and cover with Slim Duct 5. Start and test operation of cooling system 6. Install condensate drain line to outside 7. Electrical by Northeast Customer obligation: 1. Any code updating outside our scope of work will be an extra charge 2. System qualifies for a Cool Smart rebate of 650.00 Extras: 1. One Aprilaire 1000 series air filter (promotion) --------------------- N/C Warranty: One-year parts and labor by Northeast Heating & Cooling, INC. All warranty work will be done during normal business hours Manufactures warranty there after ten years parts on the air handler and ten years on parts for condenser if registered. Payment as follows, 1/3 as a deposit, 1/3 upon arrival of stock and equipment, final payment due upon start up of system. Owner Quote valid for 30 days Northeast Heating and Cooling S .+Wrightsoft- Right J® Mobile Report oa 11125l2014 Entire House By: Northeast Heating & Cooling, INC. 90 Hale Street, Haverhill, MA 01830 Phone: 978-691-56822 Fax: 978-374-9500 Email: Office@northeasthc.com Web: www.northeasthc.com License: 13 Flbied Information For: Seth Gagnon 371 Marbleridge Road, North Andover, MA 01845 Phone: 860-460-5458 Component .'Desighl• • • % of load Walls Location: 6325 Indoor: Heating Cooling Lawrence Muni, MA, US 14.5 Indoor temperature (°F) 70 70 Elevation: 151 ft Ceilings Design TD (°F) 61 18 Latitude: 43°N 0 Relative humidity (%) 30 50 Outdoor: Heating Cooling Moisture difference (gr/Ib) 25.7 41.5 Dry bulb (°F) 9 88 Infiltration: 0 Dailyrange (TF) - 18 (M ) Method Simplified 0 Wetbulb (°F) - 73 Construction quality Average Adjustments Wind speed (mph) 15.0 7.5 Fireplaces 1 (Average) 1 Component Btuh/ft? Btuh % of load Walls 5.5 6325 20.3 Glazing 34.6 4498 14.5 Doors 23.7 497 1.6 Ceilings 3.0 3664 11.8 Floors 0 0 0 Infiltration 6.5 8446 27.1 Ducts 7686 24.7 Piping 0 0 Humidification 0 0 Ventilation 0 0 Adjustments 0 Total 1 1 31116 100.0 Component Btuh/ftz Btuh % of load Walls 2.3 2621 12.2 Glazing 49.8 6470 30.2 Doors 11.8 247 1.2 Ceilings 2.6 3239 15.1 Floors 0 0 0 Infiltration 0.8 1080 5.0 Ducts 6097 28.5 Ventilation 0 0 Internal gains 1660 7.8 Blower 0 0 Adjustments 0 Total 1 1 214131 100.0 Latent Cooling Load = 3062 Btuh Overall U -value = 0.066 Btuh/ft2--'F Data entries checked. V\HI Dils Gad -- -- OhEr Irfiltrm Celirgs `""� CeilinT. 'Y ri -hftu ofr 2014 -Nov -25 05:35:08 Right -Suite® Universal 2015 15.0.04 Right J® Mobile Page 1 \wstmp\Ob091809-2589-4438-bb66-ae02clde11b4.rup Calc = MJ8 Front Door faces: E Project Summary wr ghtsoft Date: 11/25/2014 Entire House By: Northeast Heating & Cooling, INC. 90 Hale Street, Haverhill, MA 01830 Phone: 978-691-56822 Fax: 978-374-9500 Email: Office@northeasthc.com Web: www.northeasthc.com License: 13 Project Information For: Seth Gagnon 371 Marbleridge Road, North Andover, MA 01845 Phone: 860-460-5458 Notes: D- •n� Information Weather: Lawrence Muni, MA, US Winter Design Conditions Summer Design Conditions Outside db 9 °F Outside db 88 °F Inside db 70 °F Inside db 70 °F Design TD 61 °F Design TD 18 °F Daily range M Relative humidity 50 % Moisture difference 41 gr/Ib Heating Summary Sensible Cooling Equipment Load Sizing Structure 23430 Btuh Structure 15316 Btuh Ducts 7686 Btuh Ducts 6097 Btuh Central vent (0 cfm) 0 Btuh Central vent (0 cfm) 0 Btuh Humidification 0 Btuh Blower 0 Btuh Piping 0 Btuh Equipment load 31116 Btuh Use manufacturer's data y Rate/swing multiplier 1.00 Infiltration Equipment sensible load 21413 Btuh Method Simplified Latent Cooling Equipment Load Sizing Construction quality Average Fireplaces 1 (Average) Structure 1954 Btuh Ducts 1107 Btuh Heating Cooling Central vent (0 cfm) 0 Btuh Area (ft') 1232 1232 Equipment latent load 3062 Btuh Volume (ft) 11088 11088 Air changes/hour 0.69 0.30 Equipment total load 24474 Btuh Equiv. AVF (cfm) 127 55 Req. total capacity at 0.70 SHR 2.5 ton Heating Equipment Summary Cooling Equipment Summary Make Make Trane Trade Trade XR16 Model Cond 4TTR6030131 AHRI ref Coil TAM7AOB3OH21 AHRI ref 5865398 Efficiency 0 AFUE Efficiency 16 SEER Heating input 0 Btuh Sensible cooling 0 Btuh Heating output 0 Btuh Latent cooling 0 Btuh Temperature rise 0 °F Total cooling 0 Btuh Actual air flow 1177 cfm Actual air flow 1177 cfm Air flow factor 0.038 cfm/Btuh Air flow factor 0.055 cfm/Btuh Static pressure 0 in H2O Static pressure 0 in H2O Space thermostat Load sensible heat ratio 0.87 Calculations approved by ACCA to meet all requirements of Manual J 8th Ed. `+�/rightsOft' Right -Suite® Universal 2015 15.0.04 Right J® Mobile 2014 -Nov -25 05:35:08 Page 1 /itA A \wstmp\ObOg1809-2589.4438-bb66-aeO2cl dell b4.rup Calc=MJ8 FrontDoorfaces: E AL wrightsoft* Right -M Worksheet Job: Entire House Date: 11/25/2014 Northeast Heating & Cooling, INC. By. 90 Hale Street, Haverhill, MA 01830 Phone: 978-691-56822 Fax: 978-374-9500 Email: Office@northeasthc.com Web: www.northeasthc.com License: 13 1 Room name Entire House Second Floor 2 Exposed wall 144.0 ft 144.0 ft 3 Room height 9.0 It 9.0 It heattcool 4 Room dimensions 44.0 x 28.0 ft 5 Room area 1232.0 ft' 1232.0 ft' Ty Construction U -value Or I HTM I Area (ftp) I Load I Area (ft') Load number (Btuh/f t2- F) (Btuh/ft') or perimeter (ft) (Btuh) or perimeter (ft) I (Btuh) Heat Cool Gross N/P/S Heat Cool Gross N/P/S Heat Cool 6 12C-Osw 0.091 ne 5.5 2 2.29 396 _335 1850 767 396 335 1850 767 1 D-c2ov 0.570 ne 34.60 44.32 40 0 1384 1773 40 0 1384 1773 11DON „_xe_• w F 0.390 -n,e ,- -23.67_ 11.76 , .._---- 21 -.._. .21 497 f1254 247 21 21- 497 247 Vy 12C-Osw 0.091 se 5.52 2.29 252 227 _._ 520 _ _ 252 _ . _ 227 _ 1254 ..-,_ 520 11 �. G 1 Dc2ov, 0.570 _ _ se 34.60 ...,, m - 55.22- - 25 1381 25 0 865 1381 12C Osw ry 0.091 , sw 5:52' 2:29 396 T y e _- -0--_- 356 .865 . 1966 • . _., . . 815 396 _ - . 356' _ 19fi6' . - 815 1 D c2ov . 0.570 - sw 34-80 40 - -. _ ._ ::, 0 .-'_13M 2209 - 40 0 1384_ 2209 VN 12C-Osw 0.091 nw, 5.52 2.29 252 227 1254 520 252 227 _ 1254 .. - 520 _1 Dc2ov _.. _ _,...,._0.570 „nw. ,.._. °34.60.. _ ...44; 32. _. - —. .-_ 0 1108 25 865 1108 C 166-19ad. _ 6.049 2.97 2.63 .... _ ._25. r _. 1232 _ 1232 .... ,. _865. _ _-3664.,. _ 3239 1232 . _.. e.. .0 1232 . , _.. 3664 3239 F _ FOO— _ 0.000 -_ 0.00, , 0.00- . _- y_ 1232 , 1232 — 0 _ 0 .._ _1232 .. 1232 0 0 --- . . { e 61 c) AED excursion 0 0 Envelope loss/gain 14984 12576 14984 12576 12 a) Infiltration 8446 1080 8446 1080 b) Room ventilation 0 0 0 0 13 Internal gains: Occupants @ 230 2 460 2 460 Appliances/other 1200 1200 Subtotal (lines 6 to 13) 23430 15316 23430 15316 Less external load 0 0 0 0 Less transfer 0 0 0 0 Redistribution 0 0 0 0 14 Subtotal 23430 15316 23430 15316 15 Duct loads 33% 40% 7686 6097 33% 40% 7686 6097 al 1 311771 211771 31177 14131 21177 Air required I I I I I 1 Calculations approved by ACCA to meet all requirements of Manual J 8th Ed. {riJF:R,gIli�sit 2014 -Nov -25 05:35:08 Right -Suite® Universal 2015 15.0.04 Right JO MobileAM ...\wstmp\ObO91809-2589-4436-bb66-aeO2cl dell b4.rup Calc = MJ8 Front Door faces: E Page 1 Component Constructions Job: W rl�igi"ltsoft* Date: 11/25/2014 Entire House By: Northeast Heating 8r. Cooling, INC. 90 Hale Street, Haverhill, MA 01830 Phone: 978-691-56822 Fax: 978-374-9500 Email: Office@northeasthc.com Web: www.northeasthc.com License: 13 For: Seth Gagnon 371 Marbleridge Road, North Andover, MA 01845 Phone: 860-460-5458 Location: Lawrence Muni, MA, US Elevation: 151 ft Latitude: 43'N Outdoor: Heating Dry bulb (°F) 9 Dailyrange (°F) - Wet bulb (°F) - Wind speed (mph) 15.0 Indoor: Construction descriptions Walls 12C-Osw: Frm wall, vnl ext, r-13 cav ins, 1/2" gypsum board int fnsh, 2"x4" wood frm, 16" o.c. stud Partitions (none) Windows 1 D-c2ov: 2 glazing, clr outr, air gas, vnl frm mat, clr innr, 1/4" gap, 1/8" thk; 6.67 ft head ht Doors 11 DO: Door, wd sc type Ceilings 1613-19ad: Attic ceiling, asphalt shingles roof mat, r-19 ceil ins, 1/2" gypsum board int fish Floors Flor1: Flor1 Heating Cooling 70 70 61 18 30 50 25.7 41.5 Simplified Average 1 (Average) Or Indoor temperature (°F) U -value Design TD (°F) Htg HTM Relative humidity (%) Cooling Moisture difference (gr/Ib) 88 Infiltration: 18 ( M) Method 73 Construction quality 7.5 Fireplaces Construction descriptions Walls 12C-Osw: Frm wall, vnl ext, r-13 cav ins, 1/2" gypsum board int fnsh, 2"x4" wood frm, 16" o.c. stud Partitions (none) Windows 1 D-c2ov: 2 glazing, clr outr, air gas, vnl frm mat, clr innr, 1/4" gap, 1/8" thk; 6.67 ft head ht Doors 11 DO: Door, wd sc type Ceilings 1613-19ad: Attic ceiling, asphalt shingles roof mat, r-19 ceil ins, 1/2" gypsum board int fish Floors Flor1: Flor1 Heating Cooling 70 70 61 18 30 50 25.7 41.5 Simplified Average 1 (Average) Or Area U -value Insul R Htg HTM Loss Clg HTM Gain sw ft' Btuh/ft'--°F ft-°F/Btuh Btuhff Btuh Btuh/ft' Btuh ne 335 0.091 13.0 5.52 1850 2.29 767 se 227 0.091 13.0 5.52 1254 2.29 520 sw 356 0.091 13.0 5.52 1966 2.29 815 nw 227 0.091 13.0 5.52 1254 2.29 520 all 1145 0.091 13.0 5.52 6325 2.29 2621 ne 40 0.570 0 se 25 0.570 0 sw 40 0.570 0 nw 25 0.570 0 all 130 0.570 0 ne 21 0.390 0 2.97 1232 0.049 19.0 0 1232 0 0 34.6 1384 44.3 1773 34.6 865 55.2 1381 34.6 1384 55.2 2209 34.6 865 44.3 1108 34.6 4498 49.8 6470 23.7 497 11.8 247 2.97 3664 2.63 3239 0 0 0 0 2014 -Nov -25 05:35:08 righo'W Right-Suite®Universal 2015 15.0.04 Right J® Mobile Page 1 / ...\wstmp\ObO918O9-2589-4438-bb66-aeO2cldell b4.rup Calc=MJ8 FrontDoorfaces: E - - wrightsoft" AED Assessment Jo „nsiso,a Entire House By: Northeast Heating & Cooling, INC. 90 Hale Street, Haverhill, MA 01830 Phone: 978-691-56822 Fax: 978-374-9500 Email: Office@northeasthc.com Web: www.northeasthc.com License: 13 • • MIMI• For: Seth Gagnon 371 Marbleridge Road, North Andover, MA 01845 Phone: 860-460-5458 VII®- • • • • Location: Indoor: Heating Cooling Lawrence Muni, MA, US Indoor temperature (°F) 70 70 Elevation: 151 ft Design TD (°F) 61 18 Latitude: 43'N Relative humidity (%) 30 50 Outdoor: Heating Cooling Moisture difference (gr/Ib) 25.7 41.5 Dry bulb (°F) 9 88 Infiltration: Dailyrange (°F) - 18 (M ) Wet bu lb (° F) - 73 Wind speed (mph) 15.0 7.5 8, 7, 6, 5, 4, 3, 2, 1, Hourly Glazing Load Hour of Day / Orly / Average / ADIin it Maximum hourly glazing load exceeds average by 24.9%. House has adequate exposure diversity (AED), based on AED limit of 30%. AED excursion: 0 Btuh wrl ht"ft'2014-Nov-25 05:35:08 Right-Suite®Universal 2015 15.0.04 Right J® Mobile lwstmp\Ob091809-2589-4438-bb66-ae02c1de11b4.rup Calc = MJ8 Front Door faces: E Page 1 10943 . This certifies that .... has permission to Date 1A3o 1 ......... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING �:...�... . ...� � �� . :Y7..:.1. . n?.5�?....0 6 r NSP C plumbing in the buildings of .......:4.�^!................................... :................. at ...... ................. North Andover, Mass. Fee.. �Q.""-... Lic. No.... �c� �' ...... .............................................................. L� PLUMBING INSPECTOR Check # ' . MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY MA DATE [ PERMIT# 1 JOBSITE ADDRESS _1�'l�l`��� /��/, II OWNER'S NAME P OWNER ADDRESS _ TEL_— —FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL tt PRINT CLEARLY NEW: RENOVATION: ® REPLACEMENT:' PLANS SUBMITTED: YES ® N0 FIXTURES I FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB - 4 —1 CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM _.._.__( _____j j ^__( j____.._. f [ DEDICATED GRAY WATER SYSTEM I ^[ _.[ ___.. DEDICATED WATER RECYCLE SYSTEM (( .._._...._I ( � ..___._( I __._► ____-_ ___I .-....___I DISHWASHER �! ._.__( ._.._ .____v _� _._____( ._____! . __..__1 __.._._� _._..1 _.__....._ ._..___i _l ._._.__.d DRINKING FOUNTAIN FOOD DISPOSER FLOOR / AREA DRAIN INTERCEPTOR (INTERIOR) s� _._i ____.__I _.__._ KITCHEN SINK I L-_._J �� LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK 1 .__._ I __._.-__[ TOILET (__._-_.._f _ _._ URINAL .__.___ � __ _._._( ____� __.__1 ._.____�-__...._J===== WASHING MACHINE CONNECTION _ _ t WATER HEATER ALL TYPES WATER PIPING i .___ i t _.._._. __!' 0TIkER _J INSURANCE COVERAGE: 1 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 LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY i 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 10 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 com ' nc with all Pertingnt pro ' on of the )Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME ILICENSE # SIGNATURE c MPO JP 0 CORPORATION PARTNERSHIP # ; LLC Q#€ COMPANY NAMEG i� i ADDRESS CITY _ - _f STATE 1 ZIP ��, �c� TEL j FAX CELL EMAIL -r W H O U a w � oo z !❑ O w Fil Ci - LU Z a p a a co LLI w w co a p z W F= a � J CL a Q cn w Tj w F- LL H 0 H U a CIOz0 a a p O 4' .The Commonwealth of .iV1assachusetts Department of Indifstrigl Accidats Office of Investigations 600 Washington,S'tteet Boston, MA 02-111 www.massgov/ciia Workers' Compensation Yntsurance Affidavit: Builders/Contract A lieant information Name (Business/Organization&dividual): Address:4rT� , City/State/Zip: �„ �Phone #: Are ou an employer? Check the appropriate box: Type of project (required): /,-� � I am a employer / 4. El am a general contractor and I 6. New construction EJwith _1. employees (fall and/or pax tune) 2. ❑ Z am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. t ` . ❑Remodeling ship and`have no employees These sub -contractors have 8. ❑ Demolition working forme in any capacity. workers' comp. insurance. 5. ❑ We are a corporation and its g. F] wilding addition [No workors' comp. insurance required.] officers have exercised.theix 10.❑ Electrical repairs or additions 3. ElI am a homeowner doing all work right of exemption per MGL 11. [] Plumbing repairs or additions myself. [No workers' comp. insurancere ed. ] c.152, §1(4), and we have no employees. [No workers' 12.❑ Roofrepairs 13.� Other comp. insurance required.] 'Any applicautthat checks box#1 must also fill outthe section bel6w showingtheir workers' compensation policy information. t'Homeowners who submit this affidavit indicatingthey are doing all work and then hire outside contractors must submit anew affidavit indicating such. 1'Contractors that checkthis box must attached an additional sheet showing the name ofthe sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance formy employees Below is the policy and joh site information. Insurance Company Policy # ox Sol£ i mLic. M Expiration Date: lob Site Address: City%StatelZip: Attach a copy o#the workers' compensation -policy declaration page (showing the policy number and expiration date). Failure to secure ooverage as requiredunder Section 25A ofMGL o. 152 can lead to the imposition of criminal penalties of a tine 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 tine of up to $250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of investigations of the DIA for insurance coverage verification. Ido Hereby certgy uric tie pains and pena�ies o0erjury that the ire, formation provided abovejs true and correct. Phone #: Official use ortly. Do not write in this area, to be completed by city or town official. City or Town: Permit0cense # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. CH34T. own 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 iii the service of another under any contract ofhire,- express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or anytwo oxmore of the Foregoing engaged in a j oint 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 notmore 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 ofthis chapter have beenpresented ta the contracting authority." Applicants Please fiff 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 certificates) 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, a policy is required. Be advised ihatthisaffidavit maybe, submitted tothe 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 oxif you are required to obtain a workers' 4 compensation policy, please call the Department at the number listed below. Self-insured compantes should enter Their t,.5 sed -insurance, license number on the appropriate line. City or Town Officials Please be sure thatthe affidavit is complete andprinted 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 thatmust submitmultiple permit/license applications in any given year, need only submit one affidavit indicating current Policy information (ifnecessary) 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 -ii on file for future permits or licenses. Anew affidavit must be filled out each year. Where a home 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 cluestions, please do not hesitate to give us a call. The Department's address, telephone and fax number: Tho Commonwalth ofwfusachuseits Depar(ment offhdustrial A,ccidanta Office of fAvestigAtIon 690 Washiagtm ftteot 13oslou, M. 02111. TO, # 617-72-7-4900 ext 406 ox 1;-877�MASS.F`,E Revised 5-26-05 Fax # 617-727-7749 WWW.Ma5,%goV1dia ................. Date .... ) .................. TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ... .... ............. . ....................................... R ........ has permission for gas installation ... I. Q ...... .... in the buildings of ........ !;..� ........... b ........................................................................................ at ... North Andover, Mass. Fee.?�t ........... Lic. No. ..... ....... Che . ck # 1017V5, A INSPECTOR J MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY MA DATE "Y PERMIT # l lT j JOBSITE ADDRESS l� _ d �/ OWNER'SNAMEr�h_y/ GOWNER ADDRESS _ TEL FAX TYPE TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL (I EDUCATIONAL [3 RESIDENTIALg CLEARLY NEW: [l RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES 0 NO APPLIANCES Z FLOORS- BSM 1 2 3 4 5 8 9 10 11 12 13 14 BOILER -- 1......_. I ! E W67 BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER I�) ._._ _ .... _._ _.. _ - _.. _-... DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR � I GRILLE_J INFRARED HEATER - LABORATORY COCKS MAKEUP AIR UNIT OVEN- ._ _ I_ POOL HEATER _ ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER �� _ INSURANCE COVERAGE havta current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch.142 YES *O [�! 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. CHECK ONE ONLY: OWNER F --Q AGENT SIGNATURE OF OWNER OR AGENT 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 provis. of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUM BER-GASFITTER NAME LICENSE # S GNATURE MP,4 MGF EI JP ® JGF LPGI ©j CORPORATION P#�J i PARTNERSHIP ©#= LLC ®!#= COMPANY NAME: ADDRESS S CITY _� STATE ZIPi(TEL — FAX CELL _ EMAIL U O z� H a z El O NEl O � � � H °z o W w qt ~ Q N W a W W co o c a U J ILQ � = f- 111 W LL O Z O H H U W C7 O a • Date.... ...................... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION ........... This certifies that ..................`".V.....................:. ................................................ has permission for gas installation in the buildings of ...... ................................ at.. ....... ........... ....... Andover, Mass. Fee ........Lic. No. —' .... ,) ............................... 1 .................. GAS INSPECTOR Check #q 611, L5 6455 9 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING' WORK c.• CITY N. Andover MA DATE 7/31/2014 PERMIT # I "� 'r --"A — JOBSITE ADDRESS 371 Marble Ride Rd OWNER'S NAME OWNER ADDRESS I Same I TE FAXI�� TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ® RESIDENTIAL PRINT CLEARLY NEW:❑ RENOVATION: Q REPLACEMENT: ❑ PLANS SUBMITTED: YES® NOQ APPLIANCES -1 FLOORS, BSM 1 .2 3 4 5 6 7 8 9 10 1 11 12 13 14 BOILER I 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 Pi in 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 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 Q 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 inco fiance with all Pertinent provision orf the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. t PLUMBER-GASFITTER NAME I Joseph Marino LICENSE # 8736 SIGNATURE MP Q MGF ® JP [j JGF ® LPGI ® CORPORATION Lj# 3285C PARTNERSHIP❑# LLC ®# COMPANY NAME: RH White Construction Co ADDRESS 141 Central St CITY I Auburn STATE MA ZIP 01501 TEL 508 832-329 1508-926-4347 1 C � FAX CELL 508-832-4614 EMAIL JMarino@RHWhite.com ROUGH GAS INSPECTION NOTES I THIS PAGE FOR INSPECTOR USE ONLY I FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT # PLAN REVIEW NOTES 'I m AC ® DATE (MMlDDryYYYI CERTIFICATE OF LIABILITY INSURANCE P .g. 1 of 1 08/29/2013 THIS CERTIFICATE IS ISSUED ASA MATTER OF INFORMATION ONLYAND 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 SETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the Certificate holder is an ADDITIONAL INSURED, the polioy(ios)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 notconferrights to the certificate holder in lieu of such endorsement(s). willia 09 Masae:ehusetts, Inc. C/O 26 CQntvey Blvd. P. 0. Box 305191 X110hville, TN 37230-5191 R. 73• White COnst:raction Company, Inc. 41 Central Street P. 0. Box 257 Auburn, MA 01501 INSURERA! The Chartar Oak Tiro Insuranpq INSURE_RS:TrdvolMrS Property Casualty Co INSURER C. NatiOnAl Union Pirg Insurance INSURER D;Tra4e1er8 Indamnity Company INSURER F; My 25615-001 or Am 25674-001 y of 194457001 25658-DO1 I:UVt;KAGEU CERTIFICATE NUMBER: 20207680 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 INDICA7ED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER OOCUMENT 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. INSRrypEOpIN$URANCE DD' SUB POLICYEFF POLICYE(P POLIGY NUMB@R LIMITS A GENERALLIA6ILITY VTC2000 977x9949-13 9/1/2013 '9/1/2014 EACHOCOURRENCE E_ 2,000,000 X COMMERCIAL GENERAL LIABILITYDa TO RENTED I PR��I�s�S(EeOcwroncrf � 30tl _pOO CLAIMS -MADE OCCUR MEDEXP(AnyoneAnon ,S 10.000 OF ;hKTIFIGATE Evidonce of Inoutance more ep see SHOULD ANY OF THE ABOVE DESCRIBED POLICIES 8E CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, AUTHORIZEDREPREaeNTATNE Co,l1:4197604 TPI:1694012 Ce7:t:20287680 ©1988®2010ACORDCORPORATION. Allrightsreserved. CARD 25 (2010/05) The ACORD n2me and logo are registered marks of ACORD PERSONAL&ADV INJURY S 2 ODO, 000 GENERAL AGGREGATE $ 4� 000, 000 GEN'LAGGREGATFLIMITAPPLIESPER; PR4 PRODUCTS-COMPIOPAGG L-24.1-0 00, 000 POLICYfil LOG $ SINGLE LIMIT AUTOMOBILELIA6ILITY VT7CAP 977R955A-13 /pMBINED 9/1 2013 9/1/2014 C ANY AUTO accident g 2, 000, 000 BODILY INJURY(Perpera0rq 8 BODILY INJURY(Pera0cid0n!) ;5 AUTO$ NED AUTOS X HIREDAUTOS X NON -OWNED AUTOS X Co Deo gCQz1 Deg ereccldent S EACHOCCURRENCF $ q-1100,000 C UMBRELLALIAO, OCCUR BE8766140 /1/2013 9/]./2014 EXCE58 LIAR CLAIMS -MADE XbdAGGREGATE $ Sr 000,000 DED $ RETENTIONS ],0,000 D WORKER$CO RVLI ATION ANDEMPLOYEO LIABILITY LIT VTRKUB 8205A185-13 9/1/207.3 9/l 2014 / $ p FH x TAI�YL) D Yvv��INNt� ANYPROPRIE7oRrPARTNFRIFXECUTIVEfX OFFICERVEMSEREXCLUDED? I `u" 1 N/A VTC2KU8 9203A71A-13 9/3,/2013 9/1/$014 E.L. EACH ACCIDENT 1,000,000 (MendatoNrylnNN) IT ee, dqq bo under u�cstttll+IwNUIUI't:RATION30el0w E.L.DIBEASE-EAEMPI,pyF.E S 1,000,000 I I FELL, DISEASE. POLICYLIMIT S 1,000,000 OF ;hKTIFIGATE Evidonce of Inoutance more ep see SHOULD ANY OF THE ABOVE DESCRIBED POLICIES 8E CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS, AUTHORIZEDREPREaeNTATNE Co,l1:4197604 TPI:1694012 Ce7:t:20287680 ©1988®2010ACORDCORPORATION. Allrightsreserved. CARD 25 (2010/05) The ACORD n2me and logo are registered marks of ACORD 09839 Date TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that g�V--, . � has permission to perform . . --�. V� ............................... plumbing in the buildings of�\'e at ........ , North Andover, Mass. Fee:?--'5,'.�O. Lic. No.11.;Y.K. . . Mbr .................. ... PLUMBING INSPECTOR Check #°I C) ab 3 o -� 2,:s-0/ �' = 4 3-� (a'l V V MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK _- CITY - . __ _ MA DATE ����� PERMIT # JOBSITE ADDRESS JMCtj C OWNER'S NAMErhiwa o e P OWNER ADDRESS --- — - _ . _ -_.r� TELL': AX� s TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL 0 RESIDENTIAL PRINT� CLEARLY ' . NEW:E1 RENOVATION: [ REPLACEMENT, -1 PLANS SUBMITTED: YDS Q N00 FIXTURES 7 FLOOR— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 1 14 BATHTUB {. CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM _ i a I I DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM _ j — DEDICATED WATER RECYCLE SYSTEM DISHWASHER __. 1 _ _ _ _' _ _ _ _ _ _ DRINKING FOUNTAIN FOOD DISPOSER FLOOR I AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK LAVATORY_ __J . _.._....9 _ _ _ -' _ _ _-.- __ _ J ___ _..-._-..... _ ' ___.-- - ._._-' • _- - .. _..__ . _ . __ ____.: - _ _-. ROOF DRAIN . -__.J SHOWER STALL __I SERVICE / MOP SINK TOILET i URINAL WASHING MACHINE CONNECTION 4 WATER HEATER ALL TYPES WATER PIPING OTHERL_-_..__-. _.._. _- . _. _.._- - ._._ _ _✓v d __ _ __J _ ; __-__ ' _� -_ ... . J w._ __. ___ v INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the. requirements of MGL Ch. 142. YES E] NO Q IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW s LIABILITY INSURANCE POLICY .�_E OTHER TYPE OF INDEMNITY ©—i BOND Q 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 F-1 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 tru and accurato the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will bei comp nc with a1 Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. — PLUMBER'S NAME Stephen Ritchie _ _ LICENSE # 10355 SIGRATURE MP 0; JPQ CORPORATION# 2551 ___• ',PARTNERSHIP#[::=LLCE]#r^ COMPANY NAME I Worcester Gold Corp ADDRESS 1134 Gold St. CITY Worcester � ;STATE;STATEF MA I ZIP 101608 TEL 1 508-4004007 FAX 508-713-9556 CELL 508-400-4007 EMAIL dispatch@mrplmb.com Z V V Deems, Maura ZZ. From: Deems, Maura C". Z5i Sent: Tuesday, January 22, 2013 3:15 PM To: 'dispatch@mrplmb.com' Subject: Plumbing Permit for 371 Marbleridge Road, ticA- Maureen,I I spoke Stephen Ritchie and he asked me to refer the following issues t i We received the application in the mail and in order for us to process, 1) A copy of the plumber's license Z 2) Copy of the current insurance binder 3) Check was in the amount of $35.50, itshouldbe $37.50, $30.0 fixtures. You n fax or email (number and email below) the license and insuranc Thank Maura Deems Building Department Assistant Town of North Andover 1600 Osgood Street Bldg. 20 Suite 2035 North Andover, MA 01845 Phone 978.688.9545 Fax 978.688.9542 Email mdeems@townofnorthandover.com Web www.TownofNorthAndover.com ►�(� e4 '4 ifVYICL'�"� 4 C' v'r p�" t, c ZZ� SQ Au -6 27A -vv, 1� c� e e" V-4 �J �� r YAA �. U I �7 Deems, Maura From: Deems, Maura Sent: Tuesday, January 22, 2013 3:15 PM To: 'dispatch@mrplmb.com' Subject: Plumbing Permit for 371 Marbleridge Road, North Andover MA Maureen, I spoke Stephen Ritchie and he asked me to refer the following issues to you regarding the above permit application. We received the application in the mail and in order for us to process we need the following: 1) A copy of the plumber's license 2) Copy of the current insurance binder 3) Check was in the amount of $35.50, it should be $37.50, $30.00 fee + $2.50/fixture and there were three fixtures. You can fax or email (number and email below) the license and insurance and send in the balance due for the fee. Thank you, Maura Deems Building Department Assistant Town of North Andover 1600 Osgood Street Bldg. 20 Suite 2035 North Andover, MA 01845 Phone 978.688.9545 Fax 978.688.9542 Email mdeems@townofnorthandover.com Web www.TownofNorthAndover.com 1 e Deems, Maura To: dispatch@mrplmb.com Subject: Insurance Binder Dear Mr. Ritchie, A plumbing permit was received by mail on 1/22/2013.for 371 Marbleridge Road in North Andover, MA to install 3 toilets. called on 1/22/2013 to request plumber's license and insurance. Dick Doherty our plumbing inspector spoke with Mr. Ritchie on 1/23/13 who said he would send in the license and insurance information. On 1/28/2013 1 emailed again to request information and Maureen said she would send the information along. On 2/5/2013 1 spoke with Mr..Ritchie that we still had not received the information, on 2/13/13 1 emailed another request to dispatch@mrplmb.com for same information and lastly on 2/27/13 1 spoke with Mr. Ritchie again regarding the need for the license and insurance. We have yet to receive the requested information and we cannot move forward with the permit process until we receivethat information. The information can be faxed or emailed to us, the faxinumber and: email are listed below. Maura Deems Building Department Assistant Town of North Andover 1600 Osgood Street Bldg. 20 Suite 2035 i North Andover, MA 01845 Phone 978.688.9545 Fax 978.688.9542 Email mdeems@townofnorthandover.com Web www.TownofNorthAndover.com +r ,3 1 i 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:STEPHEN G. RITCHIE WORCESTER, MA ""This Licensee -has additional Licenses, stick here to view them."' Licensing Board: PLUMBERS is GASFITTERS License Type: MASTER PLUMBER License Number: 10355 Status: CURRENT Expiration Date: 5/1/2014 Issue Date: 11/18/1986 Exam Date: School: This website 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 Thursday, March 07, 2013 at 9:10:29 AM. 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 Enforcement Process Glossary Glossary of License Status Codes More... © 2007-2011 Commonwealth of Massachusetts Site Policies Contact Us http://license.reg. state.ma.us/pubLic/pubLicenseQ.asp?board_code=PL&type_Class=_M&li... 3/7/2013 09870 Date .�.1.��.7I.... . TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ......... V'... ..... � 1; .............. ep has permission to perform .. . -e plumb* in h buil s of. ... 17 ..................... at ......... .... ....... . , North Andover, Mass. 3 � Fee......... Lic. No.�..... ... ........................ ... PLUMBING INSPECTOR Check # , 23 1 0 MASSACHUSETTS UNIFORM APPLICATION: FORIA>PERMIT'TO PERFORM PLUMBING WORK a F) PERMIT # CITY MA DATE 01%1O JOBSITE ADDRESS 1 ( ; OWNER'S NAME P _-. . OWNER ADDRESS I1�1 - _ TEl (4,. FAX L Vi TYPE OR OCCUPANCY TYPE COMMERCIAL E EDUCATIONAL 0 RESIDENTIAL E] PRINT CLEARLY NEW: E1 RENOVATION:.Ej REPLACEMENT: Q PLANSSUBMITTED: YES° N00 FIXTURES Z FLOOR— BSM 1 2 3 4 5 6 7 8 1 9 10 11 12 1 13 14 BATHTUB CROSS CONNECTION DEVICE _ ! _..,.. __... _ _.._._ 1 i DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY:WATER SYSTEM— DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN ! _.__ . l _.. ' _ _ W i _ - . _ _ I i .__ __...._ — FOOD DISPOSER FLOOR I AREA DRAIN INTERCEPTOR(INTERIOR)__._.._: _- _ _ ; __._...1 I ... __ E + 1 KITCHEN SINK ` x LAVATORY ROOF DRAIN i SHOWER STALLIT- SERVICE IMOP SINK TOILET URINAL 77 I WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER I l INSURANCE I have a current liabilit insurance policy or its substantial equiva entwh whichmeetshe requirements of MGL Ch. 142. YES _� t NO 0 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER TYPE OF INDEMNITY [ BOND El 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 E] AGENT' 0 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 ina provision of the and that all plumbing work and installations performed under the permit issued for this application will be in complianc�W allXc��'�_ Massachusetts State Plumbing Code and Chapter 142 of the General Laws. f'y�,�-.moo -• - PLUMBER'S NAME Michael Porter _- _ _- ______ .. LICENSE # 13671 SIGNATURE MP JPF] CORPORATION ]# 3516 PARTNERSHIP[D#[:�LLC 01# t COMPANY NAME 24 HRS INC ;.ADDRESS 1134 Gold St i CITY Worcester I STATE MA ZIP 01608 TEL 1,598 798-9955 FAX 508713 9556 ,.CELL .413-668-6544 ' EMAIL dispatch@ bb.com �4 0 i z O ~ LU W F O w U "" W (s, O x n. s U) aa : F- W w x � � 7 3 cn -� O w Z o I -- a CL a v� T w = w I-- LL - t� 4�Irli'CONaWEgLTH,tOF MASSACHUSE s ISSl�1ESATHE gB.OUE UGENSE TO: M�I G HIA ESLVx RL,tf"} a ,5 45 f 12 I ASR DjW I C K IM R, _ fl i The Commonwealth of Massachusetts Print Form _ Department of Industrial Accidents Office of Investigations ' I Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurai►ce Affidavit: Builders/Contractors/Electricians/Plumbers .Applicant Information Please -Print Legibly Name (Business/Organization/Individual); 24 HRS INC Address:134;Gold St City/State/,Zip--Worcester. MA 01;608.:,; . Phone#:508-798-9955 I am an employer. that is providing�workers'-coirnpensation insurance for my employees Below is the policy and job site information. Insurance. Company Name: Liberty Mutual Insurance Company Policy # or Self -ins. tic. #: WC531 S387893012 Expiration Date: 10/12/2013 Job Site Address: ALL JOBS City/State/Zip: ALL 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 Jmpri sonment,-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 certify under thins andpenalties ofperjury that the information provided above is true and correct. 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�D.epartment :3. City/Town Clerk 4; Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Are you an. empIoyerftfiecle, the appropriate box: Type of project (required): 1. ❑✓ I. am a employer with 50 4. ❑ I am.a general contractor and I 6. New construction employees (full an, part-time).* 2. ❑ 1. am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. 7..❑ Remodeling ship. and have. no employees These sub -contractors' have g, :❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance required:] i comp. insurance.t 5. oration and its � We are a corporation 10.❑ Electrical repairs or additions 1E]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 13.0 Other I employees: [No workers' comp. insurance required.] *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'boz 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'-coirnpensation insurance for my employees Below is the policy and job site information. Insurance. Company Name: Liberty Mutual Insurance Company Policy # or Self -ins. tic. #: WC531 S387893012 Expiration Date: 10/12/2013 Job Site Address: ALL JOBS City/State/Zip: ALL 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 Jmpri sonment,-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 certify under thins andpenalties ofperjury that the information provided above is true and correct. 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�D.epartment :3. City/Town Clerk 4; Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: TOWN OF-N,OR-1 BUDDING DEQ I ANDOWR CRTlO�IEN'I' DNL_OR 1'WO FAMfi,Y,DWELLIN(_ -� `` b ^ 4m, SECTION 4 - WORKERS COMPENSATION (NL:L.C, R53 �25c Workers Compensation Insurance affidavit must tie completed', dw:submitted wrth this application Failure to provide flus afftdavit will result , in the denial of the."issuatice of tht§uillLinj perm1t, Signed affidavit Attached Yes .....'. SE`CTTON.5 Desch tion:ot Pro `sed`Work checkalta licalrle = . -. ¢ Ne v Construction ❑ Existing itilding 7 pi . ❑R eaos(�Addttton Accessory Bldg, ❑ Demolition 0 Other ❑. Specify Brief Description of Proposed Work: 4 .SECTION 6 ESTIMATED CONSTRUCTION COSTS ." Item Estimated Cost (Dollar) to be Completed by permit applicant. 1. 'Building (a) Building:Permit ding -Permit -Fee Mu1. . • i�i�U� M1 Ul ;)ter 2 Electrical ;. (b) = B§hrna ,Total Cost..of . Constraehon 3 Plumtiin r _� Building Pernut fee (a) x (b) . 4 Mechanical AC Proterion ` ;.5 .Fire - 6 Total ...1+2+3{4+5 v , 06 Lj Check Number . ; t77 SEMON la OWNER AUMOMIZATION TO BE Ci3W&LET'E)(SWEN: OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, as Owner/Authorized Agent of subject property H e y thorrze .._ .. to act on f ip all matt lativ o work authoViW by this/building permit application of Owner Date s SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief y P # N attire o er/A entl Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TII 4BERS x tD isT 2 No 3 RD SPAN t -t DIMEN�SION$.,OF• SILLS DIMENSIONS. OF POSTS lop DRAENSIONS OF GIRDERS HEIGHT OF FOUNDATION — THICKNESS SIZE OF FOOTING t" X Z r MATERIAL OF CHIMNEY y IS BUILDING ON SOLID OR FILLED LAND y tct IS BUILDING CONNECTED TO NATURAL GAS LINE FORM U - LOT RELEASE FORM INSTRUCTIONS: This formis tried to verify that all necessary approvals/pe Boards and Departments having jurisdiction have been obtained This does not its fron r the applicant and/or landowner from compliance with any applicable or requiremeatsts. -�j-�--APPLICANT FILLS OUT THIS SECTION** APPLICANT PHONE 3r LOCATION: Assessor's Map Number -- 3-8 PARCEL—(2-7 0 P5 SUBDIVISION LOT (S) STREET .ho -L. -L ST. NU /' . OFFICIAL USE ONLY******** * CONSERVATf ADMINIST i4TQ AGENTS: DATE APPROVED' DATE REJECTED 71 WN PLAN R DATE APPROVED DATE REJECTED' , COMMENTS_��;�p�� FOOD INSPECTOR -HEALTH SEPTIC INSPECTOR -HEALTH COMMENTS DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTO Revised 9197 jm DATE -- The Commonwealth of Massachusetts �- k" v Print am a homeowner performing all work myself. 01 am a sole proprietor and have no one working in any capacity I am an employer providing workers' compensation for my employees working on this job. ianv nnmta � � �..0 ro„�,a l - Q . . Address 601, v„Q CoaMMf name: Address City: Phone # 61 Failure to secure coverage as requlred under Section 25A or MGL 1.52 can lead to the imposition of c irkr ink penaflies • of a fine up to $1,5W.00 andtor one years' imprisonment as well as cavil penalties in the form of a STOP WORK ORM and afire of ($100.00) a day against me. i understand that a Copan 0` til ement may be forwarded to the Mice of Investigations of the DLA for coverage vefflcad n. I do herby ce ltyyhder the f s' Print provided above is true and correct Official use only do not write in this area to be completed by city or town official' ©Check if immediate response is required Building Dept Contact person: Phone #. RM WORKMAN'S COMPENSATION. 1- , • Building Dept ' p Licensing Board p Selectman's office 0 Health Department 0 4fher T AL 4- C/) m m C/) 0 m ) y CD 'v C d � O a z CA CC) O 'vim C tw � c C. = y aCO -0 C) � o v c� a� o c� �dCD CD o CD C CD y CL v y O CO C F cn cn n O I. C EM - O °' _ O -.yOQ H So � Oy 01 m CD Hma� 3 �o Z ?'p V1 -4 0 to m 0 T mO m y O y ^O' mCD o a 3 0 mOr. p O O 0082 V " O =y� C 06 0 0 ti :JCJ Co CD =- a cr CD cn ?' � H A_ � �'') O (' CT. p�y l o� coco N a. 3 :4 N co 0 'mcnom m y 'R 0 -� -• sCD? d d o ca C O oma. �. m w JO r v cn cn : o o rte'' :vo `n (� o o to b M+ CA x �J 0 0 11% ws 1 # Location `� k(%el) No. Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee TOTAL Check # 9),OD , X60,09 0f�3����� 15487 H Building Inspector 3 16 Date.. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ...... ................................................ has permission to perform ... ..... .......... wiringin the building of ......................c)...................... ................................... , rth And M at .......... 32.1 .. ....... NO ;;a�,overs. Fee....... Lic. No. ...... ........ ELECTRICAL 4�;�a R Check # 161 � Official Use Only r Permit No. a eqt 4 ;VuA�- Sammy Occupancy & Fee Checked BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code 527 CMR 12:00 (Please Print in ink or type all information) Date To the Inspecto of Wes: Town of North Andover The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number I Cy-)Oiv�3 ( t \—Z C)S, R D— Z) Owner or Tenant C? 1 U C` iCk- VO t y Owner's Address Is this permit in conjunction with a building permit Yes No ❑ (Check Appropriate Box) Purpose of Building ---a\ `� C �i V`^ t i �/ Utility Authorization No. Existing Service Amps Voits Overhead .❑ Undgmd ❑ No. of Meters New Service Amps Voits Overhead ❑ Undgmd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical P17 No. of Lighting Outlets ` No. of Hot fuse Total No. of Transformers KVA Above ❑ In ❑ No. of Lighting Fixtures Swimming Pool grnd ❑ grnd ❑ Generators KVA No. of Emergency Lighting No. of Receptacles Outlets No. of Oil Burners Battery Units No. of Switch Outlets No of Gas Burners FIRE ALARMS No. of Zone No. of Detection and Total No. of Ranges No of Air Cond Tons Initiating Devices — Heat Total Total No. of Di sal No. Pumps Tons KW No. of Sounding Devices No./ of Self Contained No.01 Dishwashers Space/Area Heating KW Detection/SoundingDevices ❑ Municipal ❑ Other No. of Dryers Heating Devices No. of No. of KW Local Connection Low Voltage No. of Water Heaters KW Signs Bailases Wiring No. Hvdro Massage Tuds No. of Motors Total HP INSURANCE COVERAGE. Pursuant to the requiremen6ts of Massachusetts General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent YES = NO = have submitted valid proof of same to the Office YES = NO = If you have checked YES please indicate the type of coverage by checking the appropriate box INSURANCE = BOND = OTHER = .(Please Specify) ,� — en (Expiration Date) Estimated Value of Electrical Work$_ Work to Start Signed under the Penalties of perjury: FIRM NAMI= Inspection Date LIC. NO. LIC. NO.3Ci0Zq -c), c C Bus. Tel N `S Address l Sc, t J t m C` I� t a 7 t Tel. No L OWNER'S INSURANCE WAIVF-R: I am aware that the Licenses does not have the insurance coverage or its substantial equivalent as required by Massachusetts General Laws. And that my signature on this permit application waives this requirement Owner Agent (Please Check one) t Telephone No. PERMITVEE $ (Signature of Owner or Agent) REGISTRY USE ONLY i TAX MAP J7D / L 0T 24 564,472 S.F. 12.96 Ac. i OL PjjA OLD L OT LINES (FOLLOW , STONE WALL) PARCEL "B" ti PARCEL "A " NEW LOT LINES pct, D. H. (F) + �► iPs h N ! ©Q. 1 ` ji9�S�Op E l� 11�yFS AQY RIDGEWOOD CEMETERY ASSOCIA 77ON ry• .� 0h a f� TAX MAP 38 / LOT 58 26,4 75 S. F. 0.61 Ac.`s p�nN h `STQ,Qy. U.POLE ' .359 \ D. H. (F) �� 2 �-- ____ U. 1` 12¢) I ,�,{ 2360 S O \ I a 1, r S 292677" W 1. Jo, _ U. POLE 2361 LOT ARE PAR A PA PA LOT MURPHY S. &