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HomeMy WebLinkAboutMiscellaneous - 39 PRESCOTT STREET 4/30/2018r Date ..... *4.C5 ............... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION ........................................ rt'ifies that This ce .... ... R.P has permiSsion for gas installatiofiN.Jl .. V . ...... ................... SA . .......................................................................... in the buildings of ......... ........ ....... 15j... ................. I North Andover, Mass. \.'A Feelof) ............ Lic. No. .................................................... GASINSPECTOR Check # "52 098.940 G TYPE OR PRINT CLEARLY APPLIANCES Z BOILER BOOSTER MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK : DATE' . -YU _ _ JOBSITE ADDRESS OWNER'S NAME # {l ¢sNr A . -] OWNER ADDRESS TE FAX OCCUPANCY TYPE COMMERCIAL) EDUCATIONAL RESIDENTIAL NEW:E] RENOVATION: [J FLOORS-+. CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER TEST ` UNIT H' ATER UNVENTED ROOM HEATER WATER HEATER et -en. VKOJC oj k REPLACEMENT: ER - 2 1.3' 1 4 1 5 1 6 INSURANCE COVERAGE PLANS SUBMITTED: YES ❑J NO R- 7 1 8 1 9 1 10 1 11 1 12 1 13 1 14 I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch.142 YES 0<O El I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Eg--' OTHER TYPE INDEMNITY ® BOND F 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 9 AGENT SIGNATURE OF OWNER OR AGENT 1 hereby certify that all of the details and information I have submitted or entered. regarding this application are true d AIPCur e th b t of my knowledge and that all plumbing work and Installations performed under the permit Issued for this application will be in corn li th erti n provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. t PLUMBER-GASFITTER NAME LICENSE# I56w SIGNATURE MP �MGF ®I JP [I JGF © LPGI ® CORPORATION PARTN SHIP ®# COMPANY NAME: eero ADDRESS - CITY �e�-�¢ STATE'/1'I 2 (Z 2- TEL FAX CELL s°� �d6T1gg4�EMAIL fit . ®MMONW <•� ti. PLUM6ER�S�,1 �5F I TTE, S . $ ISSUES T FOL,sLOWI ,,. � :LrItC,E'l,1ESr,ED. qS �1�'ENSE 21 15x64 th1A o23p 1 141x- ^ }t 0/O 1/1.6 2 6 K; a. v,°� >{ 2 _442 COMM.ONWEAdfH. OF'MASS7 CHI SETTS ��� PLUMBERS AIsb G"ASFr1bT,T�C$tS w I SSUES. TH " FOLLOW I N��Cx, L CENSE tn<° RE.G;IsSIA�PLUhIBI` pAV,I Q W GARF4 ELD y � EYENE`Y BRQTr}1=R°5 SERVICE, 2,1 WILLOW f $ROKtbN IM 02301 , 36T `05 —2 Ir 0 FE15MRO.01 SMORAN _........ .... __---_.---CERTIFICATE OF LIABILITY INSURANCE � FDATIYYIY}-- 11130/20301201 b 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(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 Rogers & Gray Insurance Agency, Inc. 434 Rte 134 South Dennis, MA 02660 CONTACT NAME: PHONE PAX AIc Na Exti: Arc No): (87 7) 816-2156 ADDRESS: INSURERS) AFFORDING COVERAGE NAIC 0 02/0112015 INSURER A:Old Republic General Insurance Corp. 24139 EACH OCCURRENCE S 1,000,00 INSURED INSURER B INSURERC: Feeney Brothers Services LLC 103 Clayton St PO BOX 220801 INSURER D • INSURER E: Dorchester, MA 02122 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 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. 1�7R TYPE OF INSURANCE DD S BR POLICY NUMBER MhVDD1YYLICY 1 f n WDD YY LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIAS•MADE a OCCUR � 2CG0750160i 02/0112015 02101/2016 EACH OCCURRENCE S 1,000,00 DAMAGE TO RENTED- PREMISES Ea occurrence $ 300,00 MED EXP (Anyone person) $ 10,00 PERSONAL B.ADVINJURY S 1,000,00 GEN LAGGREGATE LIMIT APPLIES PER: POLICY JEC M LOC OTHER: GENERALAGGREGATE S 2,000,00 PRODUCTS -COHP/OPAGG $ 2,000,00 $ AUTOMOBILE LIABILITY ANY AUTO ALLOVMED SCHEDULED AUTOS AUTOS h" -OWNED HIREDAUTOS AUTOS COMBINED SINGLE LIMIT $ Ea accident BODILY INJURY (Per person) $ BODILY INJURY (Per axidenl) $ PROPERTY DAMAGE Peraotide t $ $ UMBRELLA LIAROCCUR EXCESS UAB CLAIf.IS.hIADE EACH OCCURRENCE $ AGGREGATE $ - DED RETENTION$ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY At7YPROPRIETORIPARTfIERIEXECUTNE YEN2CW07501501 OFFICERR,SEMBEREXGLUDE04 (Mandatory In NH) If yyes, describe under DESCRIPTIONOFOPERATIONSbelaN NIA 02!0112015 02101/2016 X PER O7H- STATUTE ER E.L. EACH ACCIDENT S 1,000,00 E.L.DISEASE -FJAEMPLOYEE $ 1,000,00 E.L. DISEASE -POLICY LIMIT $ 1,000,00 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached If more space Is required) CERTIFICATE HOLDER CANCELLATION ©1988-2014 ACORD CORPORATION. Allrights reserved. ACORD 25 (2014/01) -The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Tow Tow n of North Andover And THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Osgood ACCORDANCE WITH THE POLICY PROVISIONS. North Andover, MA 01845 AUTHORIZED REPRESENTATIVE � ©1988-2014 ACORD CORPORATION. Allrights reserved. ACORD 25 (2014/01) -The ACORD name and logo are registered marks of ACORD r Date..///*r/D647`/`**/*/`* ........ TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ......... ....... C, ........................ has permission to perform ..... co ................................... �> wiring in the building of ........... at ....... 3 .27 ............ ...... n .................. North And' q Fee..c�41'0 ..... Lic. No...NW-3 .............. .. . .... .... ALECTRIC;AL IiN��SP�EMIJIUI ,�heck # 19 7 10477 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordancew ith the provisions of M.G.L. c. 143, § 3L, the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to m. aL c. 166, § 32, an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shall -be limited as to the time of -ongoing construction . a , ctivity, nd may be-deemed-bythe -Inspector-of-W-ires abandoned -and -invalid -if he --- or she has determined tha't the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A pennit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. The Permit Extension Act was created by Lection 173 of Chapter 240 of the Acts of 2010 and extended by Sections.74 and 75 of Chapter 23 8 of the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act firithers Us purpose by establishing an automatic four-year extension to certain permits and licenses conceming the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence' during the qualifying period beginning on August 15, 2008 and extendingthrough August 15, 2012. PermitAD.ate Clo sed: Note: Rea p -ply for new permitIl-" zzu lzv r -,- -- 0 Permit Extension Act — Permit[Date Closed! �Q+� �cc/7�/la�ac�ussef� �eparfaren� o��}ire �seviee� AD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. _ 14 �"� Occupancy and Fee Checked p1xv.1107] (h:ave bhmk) . APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be W%ffned m accordance with the Massaehm is Elecaical cone {moi. 527 CMR 12:00 WLEASE PRIWX BVK OR TYPE ALLDWORMATiOA9 Date: /% ffS/ it City 6r Town of: �� f 1+,�} fidTo the Inspector o, f Tnft-es: By this application the undersigned gives notice of hes or her intention to Location (Street & Number)_5,�0 d'e electrics! work described below. Owner or Teuaat L�G'nL t!f, Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No Purpose of Building F1 (Check Appropriate Boa) Utility Authorization No. Heisting Service Amps 1 Volts Overhead ---- Q Undgrd ❑ No. of Meters New Service -Amps 1 Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: f✓ lRIA,__44T Y G of Recessed Lutuinaires ----- --- -- ^... No. of Qe L-Susp. (Paddle) Fans ., - •uwc tors ar wu"W By tile( r ttrreL o. of Transformers KVA [No. o. of Luminaire Outlets No. of Hot Tubs Generators KVA o. of Luminaires Swimmin Pool `L g a �' ❑ o. o cy d. d. Battery Units No. of Receptacle Outlets o. of On Burners -ALARMS No. a. of on and _ of Zones No. ofSwitches No. of Gas Burners ' No. of Ranges No. of Air Cond. TotaiTom W-Hadn Devices No. of Alerting Devices o. of -Contained De'tectionlAlertln Devices No. of Waste Disposers TOta%S: umbel Pons I KiYr No. of Dishwashers Space/Area Heating KW Municipal ❑ other Connection No. of Dryers Heating Appliances s No.0 No. of Water - Heaters KW No. of o. of ces or Data Whin ivaient Si Ballasts No. of De ices or ivalent No. Hydromassage Bath#abs No. of Motors Total -AP IT ecommunications wiMr. ' No. of Devices or Equivalent OT1lLR: n""Wi allUMUN alaPfali F" j aemrefl {77' QS ..•T'°" `^-` J Me • or J /rPd Estimated Value of Electrical V %L- (When required by �i� po&cy.} Work to Start: Inspections to be requested in accordance with WC Rule 10, and upon completion. INSURANCE COVERALL: 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 Eh BOND ❑ O lUm ❑ (Specify ) I certify, under the pains and penalties ofpedwy, that the mformajon an this enaiicniiml :r true — (o Id FIRM NAME: i Licensee: Orav fTfapplicaH4 enter Address:_ i Boa. AIt. mP e LIC. NO.: LIC. NO.: TeL No.-JIf -m�-62b2 *Per IVLG.I.. c. 147, s. 57-61, security work reD TeL No.: - a is -.� 1_17 - quires apartment of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER.- I am aware that the Licensee does teat have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check onel ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMUIEEE: $ ~ The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Uf www mass:gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): &/%%i �� �Gjo�/G-gL �LXi7 a//. %�i zzc Address: J5 Za ol_l T 3T City/State/Zip: Phone #: Are you an employer? Check the appropriate box: 1.9 I am a employer with _' 4. ❑ I am a general contractor and I employees (full and/or part-time).` have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. j ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. [1 We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. e. 152, § 1(4), and we have no insurance required.] t employees. [No workers' 0 comp, insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.ectrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other '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 box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #: `y 52 O It % Expiration Date: Job Site Address: ! / r�Cy c5 % City/State/Zip:,X%,2�Y �Y 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. 1 do hereby certify under Phone #: ofperjury that the information provided above is true and correct. Date - Official use only. Do not write in this area, to be completed by city or town ofciaL 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 #: