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HomeMy WebLinkAboutMiscellaneous - 4 HOLBROOK ROAD 4/30/2018Wv Date... ......................... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ... !a ........................... has permission for gas installation . ....... . ................ in th e building ) Of... ... Lrf IN ................................................................... at .......... o ... 1. ! 7 () 1. "...L ......... ............. . North Andover, Mass. . ..................... Feetph .... Lic. No br- . ......... ....................................................... GASINSPECTOR Check 4t%3x 91-94 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY I North Andover MA DATE 3/24/2014 J PERMIT # ` 1� JOBSITE ADDRESSI 4 Holbrook St OWNER'S NAMEJTL �rvt GOWNER ADDRESS I Same TE ^ -�p FAX TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL ( RESIDENTIALE] PRINT CLEARLY NEW: RENOVATION: Ej REPLACEMENT: ® PLANS SUBMITTED:' YES® NO APPLIANCES I 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 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 -------------- --------- ----------------------------- Replace Gas Meter x and Piginq as Needed 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 ED OTHER TYPE INDEMNITY ® BOND OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ® AGENT 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 bepliance with all Pertinent provis" the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUM BER-GASFITTER NAME Joseph Marino LICENSE # 8736 SIGNATURE MP MGF ® JP[j JGF LPGI ® CORPORATION # 3285C PARIP# LLC # COMPANY NAME: RH White Construction Co ADDRESS 41 Central St CITY I Auburn STATE MA ZIP 01501 TEL 508 832 3295 FAX 508-926 4347 CELL 508-832-4614 EMAIL JMarino@RHWhite.com 1 W z z o H U W a a ot `i a z� z o >u) El � w � ~ w o Wo H a z va U) w W a a ° W d w N a d o Ao PLO a x 9 a a a co LU = W H LL h O z z 0 H U w a z x c� 0 x ui co LUz w <Z () ;3 LL OR ..w O OM o > D. F7. C wLn it < 0 LU• k �) . 'F- LLI <4 ai In' ,H :�luz Qu 04/03/2014 14:04 5088326751 RH WHITE CONSTRUCT PAGE 02/02 DATE (MM/DDIYYYYI -- CERTIFICATE OF LIABILITY INSURANCER... 1 of 1 08/29/2013 THIS CERTIFICATE IS ISSUED ASA MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is on ADDITIONAL INSURED, the policy(ies)must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on th is certificate does notconferrights to the Certificate holder in lieu of such endorsement(s). willia of Masaaclhusette, Inc. C/o 26 ce%ltu y Blvd. P. 0. Box 305191 K&Mhville, TN 37230-5191 R. H. White Construction Company, Inc. 41 Central Street P. 0. Box 257 Auburn, MA 01.901 INSURER(S)AFFORD ING COVERAGE NAIC R INSURERA:The Charter Oak Fire Snaur-09 Company 25615-001 INSURERS:Travalats Property Casualty Company of Am 25674-003 INSURERC:National Union Fire Snsuranca Company of 19445-001 INSURER D;Travelers Indamnity Company 25659-001 %0VYGR6HVCCi ULK11FICATE NUMBER:20267680 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER 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, EXCI,USIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. /NSR TYPE OP INSURANCE DD SUB POLIOY NUMBER POLICY EPP POLICY EXP LIMITS A GENERALLIABILITY VTC2000 977RB948-13 9/1/2013 '9/1/2014 EACPIOCCURRENCE F 2.000.00( IMFRCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR AGGREGATE LIMIT APPLIES PER; 13 1 AUTOMOBILE LIABILITY X ANYAUTO AUTOWNED SCHEAUTOS HMIRED AUTOS X NON -OWNED AUTOS X Co Ded X Coil Ded X 95 0 C UMBRELLA LIAR X OCCUR X BxcEss LIAR I CLAIMS -MADE DED I $ RETENTIONS 10 , 0 0 0 D WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN D ANY PROPRIETOR/PARTNF_RIFXECUTIVE(�,� N(A OPPICER/MEMBEREXCLUDErn +L—" J �MendetoaN In NH) u�t�Kill UNudUNERATIONShelew Evidence of Inaurance 977K955A-13 9/1/2013 19/1/2014 BES766140 9/1/2013 9/1/2014 VTRKUB 8205 185-13 19/3,/2013 9/1/2013 19/1/2014 i7BVTC2K8203A71A-13 9/1/2014 Aural L &ADV INJURY AGGREGATE 2,000,000 BODILY INJURY(Perverson) 1z BODILY INJURY(Peraccldon!) $ E.L. EACH ACCIDENT is 3-000,000 E.L.DISEASE-EAEMPI,OYEE! S 1,000,000 E.L,DISEASE . POLICY LIMIT IS 1,000,000 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES SE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE L:OAA:4197504 Tp7.;1694012 Ce7:t-20287680 ®9988-2010ACORD CORPORATION. All rights ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD Location co No. Date lol,)o Y8 TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ C Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL Building Inspector 12 83 41""" 13:39 25.00 PATD iv. Public Works Location No. t Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ Sewer Connection Fee $ Water Connection Fee $ TOTAL Building Inspector I� r i, 0 PAID 10/20/98 13:39 5. lic Works w Q a z � z G Ri NO � A N"z .. a W _ VI w Z 4) w z s 1 O � G w L -k -K C C uj 30 = J F F 0 n s � Z O u W w M+� '= z J _ LLI W C W w OU u z z i.r C W CJ LLJCM W w cn Ln x Z W r o Z m ui 7, G L� z 0 Z v 1�1 - Q W LU o5 C w z z c w z V} 14 z z _ z C_ .¢i w Z w z 'n F Q ¢ z z O N Z = z z `dz W z z CL C " O o z z z C¢ • Z z¢_ L'1 1' :� :J :J C C C O F c W 4 U W N z c a z z G Ri NO N"z a • a W _ VI w Z r z_ a TOWN OF NORTH ANDOVER AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application MGL c. 142 A requires that the "reconstruction, alteration, renovation, repair, modernization, conversion, improvement, removal, demolition, or construction of an addition to any pre-existing owner occupied building containing at least one but not more than four dwelling units ... or to structures which are adjacent to such residence or building" be done by registered contractors, with certain exception, along with other requirements. Type of Work: v c tz:�`F 11\0<0 1 Est. Address of Work Owner Name: I oJk(:woN Date of Permit Application: ( O I ° O ��J I hereby certify that: Registration is not required for the following reason(s) Work excluded by law Job under $1,000 Building not owner -occupied Owner pulling own permit Other (specify) Notice is hereby given that: cost—o n�II--- - For office Use Only Pemit No. Date OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FIND UNER MGL C. 142A. Signed under penalties of perjury: I hereby apply for a permit as the agent of the owner: Date Contractor Name Registration No. OR: Notwithstanding the above notice, I hereby apply for a permit as the owner of the above property: 16 Dat Owner Name ri W x O a2 u O fA o -a o U x w w w a w w V V w o c4 G u. a� w m cn E cn UJ zCL 5 O F. M P-4 a - J 4 v N LIQ 0 O m O CO L O Z a3 CL O CO) D � O cm Ica p� CD .y O O E ca co ow co O � GD cm CD L M O a a o�aC co O *-� cc CD c Z CD C..± ca O C C CL CO2 ca .. , 0 o c� o ` C N V V �;•nc CL I ea �: Z o E e' m 00'. '� o s' a0a N E5 :gym CM Pi :j c N !O Wm -Cm 3N 4 O =wCm ' c a N IS ..� C o aCJ a mm ��o 2 .- -- . 1► I: C � Q cc c � o CL CD a ca c W O N =... flt � c r mu A c N .E dt C *- m N ca 0 w L3 a ca CD y d CO z =yam CO 5 O F. M P-4 a - J 4 v N LIQ 0 O m O CO L O Z a3 CL O CO) D � O cm Ica p� CD .y O O E ca co ow co O � GD cm CD L M O a a o�aC co O *-� cc CD c Z CD C..± ca O C C CL CO2 ca .. , 0 Date. �V?. //!�/ ........ TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION .............. This certifies that ............... has permission for gas installation i/. lf� e� in the buildings at ... Fee..'-9.� I ,of 7 ............................. ................ f North Andover, Mass. ic. No. 'GAS INSPECT R Check # 2 Ti 31 MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT' TO DO GAS FI TI ING (Type or print) Date NORTH ANDOVER, MASSACHUSETTS Building Locations Permit # 3/ Am $ �l (Print or type Name �i' (- dl, - y &Com-f—d" Address--'?/ PQ-nDN—r S� N. A-4-- F-12. P4. Business uusiness I eleptione Name of Licensed Plumber or Gas Fitter i` -•"TE C—heck o3 Certificate Ins tailing Company rp. (J © Partner. Firm/Co. INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ©/ No❑ If you have checked Les, please indicate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity Bond Owner's Insurance Waiver: I am aware that the.licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owneror Owner's Agent Owner 0 Agent 0 11 -11, w:1A,a1 _ii _ra-' -" __...., .......... ........ ,, ; ,,, 4.1.1 niiui,iiai,uii i uavu buuuuueu dor enterea) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations perf der Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State G /off egjC� 142 of the General Laws. Title City/Town Gas Fitter OVED (OFFICE USE ONLY) I n Journeyman sedPer Or Gas Fitter /J Owner's Name F,i=, ount 2� New ❑ Renovation Replacement E Plans Submitted (Print or type Name �i' (- dl, - y &Com-f—d" Address--'?/ PQ-nDN—r S� N. A-4-- F-12. P4. Business uusiness I eleptione Name of Licensed Plumber or Gas Fitter i` -•"TE C—heck o3 Certificate Ins tailing Company rp. (J © Partner. Firm/Co. INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ©/ No❑ If you have checked Les, please indicate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity Bond Owner's Insurance Waiver: I am aware that the.licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owneror Owner's Agent Owner 0 Agent 0 11 -11, w:1A,a1 _ii _ra-' -" __...., .......... ........ ,, ; ,,, 4.1.1 niiui,iiai,uii i uavu buuuuueu dor enterea) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations perf der Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State G /off egjC� 142 of the General Laws. Title City/Town Gas Fitter OVED (OFFICE USE ONLY) I n Journeyman sedPer Or Gas Fitter /J � W w w a a° x x d a F o x a � w ¢ x w �, a x w ¢ Gv: C7 CS F z d x f2 Q� 9 W O F x w F ¢ z a F, �� W > U p ? o t,r °o F w U .a c W x w o 3 0 a a> o° o SUB-BASEM ENT B A S E M ENT . IST. FLO O R 2ND. FLOOR 3RD. FLOOR 4TH. FLOOR 5TH. FLOOR 6TH. FLOOR 7TH. FLOOR -- - -- - STH. FLOOR (Print or type Name �i' (- dl, - y &Com-f—d" Address--'?/ PQ-nDN—r S� N. A-4-- F-12. P4. Business uusiness I eleptione Name of Licensed Plumber or Gas Fitter i` -•"TE C—heck o3 Certificate Ins tailing Company rp. (J © Partner. Firm/Co. INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ©/ No❑ If you have checked Les, please indicate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity Bond Owner's Insurance Waiver: I am aware that the.licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owneror Owner's Agent Owner 0 Agent 0 11 -11, w:1A,a1 _ii _ra-' -" __...., .......... ........ ,, ; ,,, 4.1.1 niiui,iiai,uii i uavu buuuuueu dor enterea) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations perf der Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State G /off egjC� 142 of the General Laws. Title City/Town Gas Fitter OVED (OFFICE USE ONLY) I n Journeyman sedPer Or Gas Fitter /J zzfi The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, AM 02111 www.mas&gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legubly Name (Business/Organization/Individual): Address: City/State/Zip: Phone #: Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* 2. ❑ 1 am a sole proprietor have hired the sub -contractors listed or partner- on the attached sheet ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] 3. ❑ .I am a homeowner doing all work officers have exercised their right of exemption per MGL myself. [No workers' comp. C. 152, § 1(4), and we have no insurance required_] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 1 L ❑ Plumbing repairs or additions 12.0 Roof repairs 13.❑ Other uu V4L 122C uCr:rlUn rM.-MV snoN^.^..t,^ anew w,,n;ers' comp cation pohc}:nfo.Watron. 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 isproviding workers' compensation insurance information. for my employees. Below is the poliQ7 and job site Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: 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 certify under the pains and penalties of perjury that the information provided above is true and correct Signature: Date.: Phone #:_� Fonly. 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 #: 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 in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint 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 not more 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 notbecause 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, §25CM 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 of this chapter have been presented to the'contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if f necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of ' insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the 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 pert3aitof license is being reaues%d, not the Department of Industrial Accidents. Should you have any questions regardiag the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed 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 that most submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) 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 is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum 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 questions, please do not hesitate to give us a call The Department's address, telephone and fax number. The.Commonwealth cif Massachusetts Depaztment of Industrial Accidents Office of Investigatims 600 Washington Street Boston, IIIA 02111 Tel. # 617-72.7-4900 ext 406 or 1-8 77-MAS.SAFE Revised 5-26-05 Fax # 617-72.7-7749 - www.mass.-govfdia