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HomeMy WebLinkAboutMiscellaneous - 389 MARBLERIDGE ROAD 4/30/2018 (2)Date....................... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that.. ...... .................................. .:! -i has permission for gas installation 6.4, .... A ... c. .6.) ..... ...0 in the buildings of ............. S! r3j , .............................................................................. at ... 3&el ........ . ............. . ............. ; North Andover, Mass. FeelO)T ..... Lic. Nol�17).(,,.a ........ M..' ..................................................... GASINSPECTOR Check #%I 9457 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK F CITY I N. Andover MA DATE 7/31/2014 I PERMIT # JOBSITE ADDRESSI 389 Marble Ridge Rd OWNER'S NAME LE GOWNERADDRESS Same TEFAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL [j RESIDENTIAL❑ PRINT CLEARLY NEW:E] RENOVATION: Ej REPLACEMENT: ® PLANS SUBMITTED: YES[j N0E3 APPLIANCES Z FLOORS, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR E GRILLE INFRARED HEATER LABORATORY COCKS 1-3 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 inq INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES Ej NO I 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 [j 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 willbe in co liance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �n PLUM BER-GASFITTER NAME Jose h Marino LICENSE # 8736 SIG/N/A/TURE MP Q MGF ® JP ❑ JGF L]LPGI L] CORPORATION ❑# 3285C PARTN SHIP®# LLC ❑# COMPANY NAME: RH White Construction Co ADDRESS 141 Central St CITY I Auburn I STATE MA ZIP 01501 L]TEL 508 832 3295 FAX 508-926-4347 CELL 508-832-4614 EMAIL JMarino@RHWhite.com !1► 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 M CA) LU �-- CERTIFICATE 4F LIABILITY INSURANCE page 1 of x 08/29/20 3' T U; 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 BETWEEN THE ISSUING INSURER(S), AUTHORIZED RE=PRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies)murt 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 certitieate does notconierrights to the eertiflcaie holder in lieu of such endorsement(s). willim 09 MRasKchUQ(atte, Inc. c/o 26 contury Blvd. P. 0. Box 305191 Nnlghville, TN 37230-5191 R. H. White Conatructiou Company, Inc. 41 Cant-val Street P. 0. Box 257 Auburn, MA 01501 E-MRIUJ- xlI �� ��'�'��s�c I inir88B-4f7-2378 ADDRI;S,SL cextificat( Willis.c_om INSURER(8 AFFORDINGCOVERAGE NA10Tt INSURERA:The Cha):tGr Oak rizo Inauranpg Company 25615-001 INSURERS:TrKVQ1AXS property Casualty COMPany 01 Am 25674-003 )NSURERC:Nnti0nAl Union Firg Insuranaa Company o£ 7.9445-001 INSURERD-, Travelers Tnd=Ajty CompIny 25658-001 UUVLKAGES CERTIFICATE NUMBER: 20287680 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. [NSR rypEgFIN$URANCE OD' SUe POLICYNUMBER POLICYEFF POLICY EXP LIMITS jl GENFAALLIA9ILITY VTC20C0 977A9948-1319/3./.2023 g/1/?ATG FAr_wnrrriaaen,nc m .. ..,.. 04F,RCIAL GENERAL LIABII.ITY CLAIMS -MADE OCCUR AGGREGATE LIMITAPPLIES PER; S I AUTOMOBILE LIABILITY X ANY AUTO I ALI,OWNED SCHEDULED li AUTO$ AUTOS X HIREDAUTOS X NON -OWNED AUTOS X Co Dad X Coll Ded 0500 C UMBRELLA LIA6 X OCCUR EXCESS LIAR CLAIMS -MADE DED $ RETENTIONS 10,000 D WORKERS COMPENSATION AND EMPLOYERS' LIABILITY D ANY PROPRIETOR(PARTNFRIFXECUTIVEN(A ! OFFICERrMEMSFREXCLUDED? FRI 'MandatogIn NH) Tyyee,dae rihoundnr UEtfl;K11• I ION M ONFRATIONS WOW SO xvidence of =naUtance VTQCAP 977K955A,-7.3 19/1/2013 [9/1/2014 BE87661.40 9/1/2013 19/1/2014 VTRKUB 8205A1g5-13 19/1./207.3 19%1/207,4 VTC2KUB 8203.A71A-13 9/7,/2013 9/1/2014 more epaee MED EXP (Any one arson F 1 000 PERSONAL&ADV INJURY 2 000, 000 GF_NERALAGGREGATE $ 4�g00 000 PRODUCTS-COMPIOPAGG 000,000 OM131�EDSINGI,FLIMIT acs dent 2, 000, 000 BODILY INJURY(Perperson) & BODILY INJURY(Peraccidont) 6 E.L.FACHACCIDENT $ 1,000,000 E.L.DI8EA9E-EAEMPI.OYP.E 5 1,000,000 F.,L-DISEASE- POUC`/LIMIT S 1,000,000 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED APPReBENTATIVE COAI:4297604 7!p1:1694012 Cert:20287680 ©1988-2010ACORD CORPORATION. All ''I CORD 25 (2010!05) The ACORD name and logo are regi sf®red `narks of ACORD T -71J Date. MAY ° ORTH OF NORTH ANDOVER Qy`,NEO- �, R .II P:AS INSTALLATION This certifies that has permission for gas installatiow.{�..1.'j/!r.{ in the buildings of at ....:? ..� .,.'1..., r r :! _tf !r North Andover, Mass. Fee. 0 .`.�... Lic. N.o.A., � ... .......................... GAS INSPECTOR WHITE: Applicant r CANARY: Building Dept. PINK: Treasurer GOLD: File MASSACHUSETTS UNIFORM APPLICAi-ION FOR PERMIT TO DO GASFITTI?4(3 I (Print or Type) ,( NORTH ANDOVER Mass. Date �'-�'f 7- e (Jvi aPermit # kuilding Location YS � �� � o r = Owners Name OW = New '—t Renovation Replacement Plans Submitted. ❑ '� FIXT 1p, c (Print or Type)A-11 Check one: Certificate Installing Company Name4( Corp. Address _ - h Partner. �i�✓dh11'�>�I� W(//� 61�3Z- Firm/Co. Business Telephone: Name of Licensed Plumber or Gas Fitter Insurance Coverage: Indicate the type of i.isurance coverage by checking the appropriate box: _ Liability insurance policy '§4 Other type of indemnity Q Bond J_j Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance coverages. Signature of owner/agent of property Owner U Agent F] I hereby certify that all of the details and infotmition I have tubmitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and InitAllalions performed under Permit itseed fa: this application will be in compliance with aft pertinent provisions of tho Wasachusetts Slate Gas Code and Chaplet 142 of tho Genual Laws. By Title City/Town: APPROVED (OFFICE USE ONLY) XPE LICENSE: Pluiriber Gasfitter Signature of Licensed ---Vaster Plumber or Gas tter 10 Journeyman License IJumber Cn � W N CC r W W 0 cc O U Cj Q r z - l— x to o w~ a z a w d cc W o N o 4 w w O O a O cc Z W F— 4 N O z W d x x a N w o �" w >' 1' W x W O F- to Z a j !- Z 1, W W c d > a f- w a 0 1— cr W X Q W G a .. F' 4 } N td O Z O N X Q iJ > C W, Z r- Q d O O w .. O W 1-- v 0 O a ca V a y a a t✓ o SUR-13St.1T. BASEMENT 1ST FLOOR 2ND FLOOR 31113 FLOOR 4TH FLOOR STH FLOOR 6THFLOOR 7TH FLOOR STH FLOOR (Print or Type)A-11 Check one: Certificate Installing Company Name4( Corp. Address _ - h Partner. �i�✓dh11'�>�I� W(//� 61�3Z- Firm/Co. Business Telephone: Name of Licensed Plumber or Gas Fitter Insurance Coverage: Indicate the type of i.isurance coverage by checking the appropriate box: _ Liability insurance policy '§4 Other type of indemnity Q Bond J_j Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance coverages. Signature of owner/agent of property Owner U Agent F] I hereby certify that all of the details and infotmition I have tubmitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and InitAllalions performed under Permit itseed fa: this application will be in compliance with aft pertinent provisions of tho Wasachusetts Slate Gas Code and Chaplet 142 of tho Genual Laws. By Title City/Town: APPROVED (OFFICE USE ONLY) XPE LICENSE: Pluiriber Gasfitter Signature of Licensed ---Vaster Plumber or Gas tter 10 Journeyman License IJumber