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HomeMy WebLinkAboutMiscellaneous - 41 VILLAGE GREEN DRIVE 4/30/20181 1 � Q �EiJ Date ,D1.1. j.a..5.......... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that �--e o ^''r j UA -,0 ........................ ......................................... '............. has permission to perform .. �-�(..'" ... `..:.. S P ,s,� .................... � plumbing in the buildings of... at....................1.(............................................................, North Andover, Mass. PLUMBING INSPECTOR Check # &4 LM PO P TYPE OR PRINT CLEARLY MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY MA DATE I - / PERMIT# 1103 JOBSITE ADDRESS OWNER'S NAME OWNER ADDRESS -e l _ -c TEL 7&?jJ/jFAX OCCUPANCY TYPE COMMERCIAL [I EDUCATIONAL NEW: 0 RENOVATION: 2r REPLACEMENT: Q RESIDENTIAL UA --- PLANS PLANS SUBMITTED: YES ® N0a FIXTURES -1 FLOOR- �F�-1�I11�—f�l�i�--i�lF�—F�-11 l --F r�liF�—lli�— CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/ AREA DRAIN INTERCEPTOR (INTERIO KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATLR PIPING 67- H RER f—� INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES Q NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 2' OTHER TYPE OF INDEMNITY 0 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 El AGENT IF -1 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 compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME L. LaR cy9' ,r %�-C/ j LICENSE # v SIGN E MP Ell JPff CORPORATION # PARTNERSHIPD#LLC EI COMPANY NAME ��,� r f. �, ,� ADDRESS CITY�7' y�N--cin _IISTATE N% ZIP TEL FAX I CELL I EMAIL O F1 Z N ❑ a w CL w LU The Commonwealth of Massachusetts Department of IndustrialAceldents I Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE MILED WITH THE PERMITTING AUTHORITY. Mplicant Information Please Print Legibly Name (Business/Organization/Individual): Le G/ Address: e £"� City/State/Zip: Phone Y S"/9 /oGf `3 Are you an employer? Check tiie appropriate box: Type of project (required): 1. ❑ I am.a employer with employees (full and/or part-time).* 7. ❑ New construction 2.[T am a sole proprietor or partnership and have no employees working for me in $. Wemodelirig any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 9. ❑ Demolition 4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition ensure that all contractors either have workers' compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. 13. E] Roof repairs These sub -contractors have employees and have workers' comp. insurance. 6. Q We are a corporation.and office nd its ocers have exercised their right of exemption per MGL c. 14.F1 Other 152, § 1(4), and we have no. 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 box mustattached 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. Iain an employer that is pi'ovid6ig workers' compensation insurance for my employees.' Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. Expiration Date: Job Site Address: 1z ",114 C. ,e e re el- 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 MGL c. 152, §25A is a criminal violation punishable by 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. 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. Phone #: % O /® �z 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 Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: J 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 tofhire, 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 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 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 necessary, supply sub-contractor(s) 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 foi• 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 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 must 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 burn leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia Date............................ TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that .... P.^..!..........✓�� . ! e .............................................................................. has permission for gas i stallation .......J........—............................................. in the buildi %f .��T"` .............7......................................................... at .............. V././!............ ........................ North Andover, Mass. /19,574 Fee....................... Lic. No................................................................................................ j GASINSPECTOR Check # 161 eZ, 'I U622 ,�,� � � � - j c5- /�.. 312.4 I IS �I✓� '•` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY MA DATE // `/5 PERMIT# I'62ZG' JOBSITE ADDRESS �1 _ %/� y r� p�OWNER'S NAME �. OWNER ADDRESS TEas'�g1�FAX� TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL E]J EDUCATIONAL ® RESIDENTIAL CLEARLY NEW: 11 1 RENOVATION: 2 REPLACEMENT: El PLANS SUBMITTED: YES D NO APPLIANCES 7 FLOORS- BSM 1 2 3 4 5 6 7 1 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 INSURANCE COVERAGE 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES I[] NO El IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY RR"' OTHER TYPE INDEMNITY 0 BOND 01 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 Di AGENT 0 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 provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME mr. I -.C/ �c„-�',��- LICENSE # 9 So v SIGNATURE MP 0 MGF 0 JP [ff JGF Q LPGI 0 CORPORATION 0# = PARTNERSHIP ®#= LLC ®# COMPANY NAME: �,�,, jti ADDRESS CITY STATE ZIP ]TEL FAX CELLi EMAIL 0 z H U W V o o Z O N El W } � ~ W OE a Z LU W 00 CO) w O LU � a �+ w C0 a g a a v J a � Q iii x w F- LL H O z 0 H U W P-1 c�7 �p 6 Date ...... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies thatonrlj-i' ..................................................................... has permission to perform ..... Y- .............................................................. ...... .. ..... ......... wiring in the building of .... H -C .(I. T . .............................................................. atL.....w ................................... �.".korth Andover, Mass. .............. M ..... JA ��F 07) ......... J, Tee. .................. Lic. No. ............ ELECTRIC 7)9;A - L INSPECTOI� "" Check #1 - —C7 %) & 4 ,� 7 ,r �' �� . � �' ��' �- W t t 3 (.ornmotuveat�h o�ccl�a�eacheese� JJeParimerxi o�_tire Jervice� BOARD OF FIRE PREVENTION REGULATIONS Permit No. I " Occupancy and Fee Checked lev. 1/071 (IeNve hlank) 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: 2/19/2015 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) 44 VILLAGE GREEN DRIVE Owner or Tenant SHANNON MCCARTHY Telephone No. 978-918-4607 Owner's Address SAME Is this permit in conjunction with a building permit? Yes 0 No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters_II fv. New Service Amps ! Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: REWIRING OF ELECTRICAL DUE TO WATER DAMAGE (`n—lotinn nftho Allnu,hea tnhlo mnv ho iunived by the Insnector of Wires. Altacn aaartionat aetau y aesirea, or as regiarea ay me rnspec,ur uj rr r, ea. Estimated Value of Electrical Work: $13 , 975.00 (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 ❑x BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRMNAME: Crowe & Sons Electrical Coxpn LIC. NO.: 17 16 8A Licensee: James B. Crowe Signatur LIC. NO.: 17168A (ff applicable, enter "exempt " in the license number line.) Bus. Tel. No.: � 9 7 8) 453 - 6696 Address 590 Middlesex Street, Lowe 1, MA 01851 Alt.Tel.No.: (978)453-6696 *Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. SS CO 001051 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 a ent. Owner/Agent PERMIT FEE: $55.00 am !l Telephone No. EE: No. of Total No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires SwimmingPool Above ❑ In- El rnd. rnd. o. o Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Detection and No. of Switches No. of Gas Burners Initiating Devices No. of Ranges Tot No. of Air Cond. Tons No. of Alerting Devices Heat Pump Number Tons KW No. of Self Contained No. of Waste Dis osers p Totals: T Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW S p g Local ❑ Municipal El Other Connection No. of Dryers Heating Appliances KW SecNo. rity Devices or Equivalent No. of Water Kit No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications firing: No. of Devices or Equivalent OTHER: Altacn aaartionat aetau y aesirea, or as regiarea ay me rnspec,ur uj rr r, ea. Estimated Value of Electrical Work: $13 , 975.00 (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 ❑x BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRMNAME: Crowe & Sons Electrical Coxpn LIC. NO.: 17 16 8A Licensee: James B. Crowe Signatur LIC. NO.: 17168A (ff applicable, enter "exempt " in the license number line.) Bus. Tel. No.: � 9 7 8) 453 - 6696 Address 590 Middlesex Street, Lowe 1, MA 01851 Alt.Tel.No.: (978)453-6696 *Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. SS CO 001051 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 a ent. Owner/Agent PERMIT FEE: $55.00 am !l Telephone No. EE: The Commonwealth of Massachusetts t Department of Industrial Accidents , Office of Investigations 4 _ 600 Washington Street + J Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): CROWE & SONS ELECTRICAL CORP. Address: 590 MIDDLESEX STREET itv/State/Zia: LOWELL , MA 01851 Phone #: (978)453-6696 Are you an employer? Check the appropriate box: 1.11 1 am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. employees and have workers' [No workers' comp. insurance required.] comp, insurance.$ 5. [] 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 3. ❑ Demolition �. ❑ Building addition 1051 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.0 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 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: Utica Policy # or Self -ins. Lic. #: 4755523 Expiration Date: 5/24/15 Job Site Address: 44 VILLAGE GREEN DRIVE City/State/Zip: N. 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby qkV under the pain and1renalties ff perjury that the information provided above is true and correct. FEBRUARY 25, 2015 (J78)453-6696 Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Pl,.ease visit our web site at http://www.mass.gov/dpI/boards/EL r ' CROWE & SONS ELECTRICAL CORP JAMES B CROWE (EL) 590 MIDDLESEX STREET LOWELL MA 01851-1428 Fold, Then Detach Along All Perforations * :::COMMONWEALTH OF MASSACHUSETTS X01 :�:t°1 � �•���{.°] ► ►_� q [�l a ► F•`iol :� .�.�+/�'��01► ::::B0 RD OF' E€LE'CTRICIANSz'>"<> i SSUESTH.E:;; FOLLOWI NG` L1 CENSE AS;; <::R ;:;:I : :;» >:>:< REGISTERED MA:STE.R.,ELECTRICIAN a . CROW'E & SONS ELECTRICAL CORP,<' JAMES B;CROW'E 590 MIDDLESEX STREET `,\\ / IW x-LOWELL...`A 018 1-1428 x::'::::+:55: i:: ;:.: :... I07 t?$>>Q>'" `' ` 7 0 1; `L:61<''> 7/3./. `%>' 57 010 ACOO CERTIFICATE OF LIABILITY INSURANCE DATE/YYYY) 10/30/22014014 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 Insurance Marketing Agencies, Inc. CONT CT Trac NAMEAMECampbell : PHONE508-753-7233 FAx 508-754-0487 306 MAIN STREET Worcester MA 01608 E-MAIL •tic@imaagency.com IKISURER(SI AFFORDING COVERAGE NAIC # INSURER A: Utica Mutual Insurance Company 25976 INSURED CROWE Crowe & Sons Electrical Corporation INSURERB:Acadia Insurance Company 11295 INSURER C:Republic Franklin Ins. Co. INSURER D: 590 Middlesex St Lowell MA 01851 INSURER E INSURER F: GUVtKACitb %,_RIIro j6%i PIunnoCrt. —v -----. --•–•------ THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR I LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MM/DD/YYYY LIMITS C X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE ❑X OCCUR 4745767 /22/2014 3/22/2015 EACH OCCURRENCE $1,000,000 DAMAGE TO RENTED PREMISES Ea occurrence $50,000 MED EXP (Any one person) $5,000 PERSONAL &ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000 PRODUCTS - COMP/OP AGG $2,000,000 POLICY 1 PRO LOC JECT ❑ OTHER: B AUTOMOBILE LIABILITY MAA5144759 /22/2014 3/22/2015 Ea accident $1,000,000 BODILY INJURY (Per person) $ ANY AUTO BODILY INJURY (Per accident) $ SCHEDULED ALL OWNED IX NON -OWNED AUTOS X HIREDAUTOS AUTOS PROPERTY DAMAGE $ Per accident A X UMBRELLA LIAB 4745768 /22/2014 3/22/2015 EACH OCCURRENCE $1,000,000 AGGREGATE $1,000,000 EXCESS LIAB HOCCUR CLAIMS -MADE DED X I RETENTION$0 WRKERSCOMPENSATION� ff AND EMPLOYERS'-LIABILIYIN ANY PROPRIETOR/PARTNER/EXECUTIVE � OFFICER/MEMBER EXCLUDED? (Mandatory In NH) $ PER �RH A N / A 4755523 /24/2014 5/24/2015X E.L. EACH ACCIDENT $500,000 E.L. DISEASE - EA EMPLOYE $500,000 E.L. DISEASE - POLICY LIMIT $500,000 If yes, describe under DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) CERTIFICATE HOLDER CANCELLATION ©1988-2014 ACORD CORPORATION. All rights 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 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN TOWN OF NORTH ANDOVER ACCORDANCE WITH THE POLICY PROVISIONS. ELECTRICAL INSPECTOR'S OFFICE 1600 OSGOOD ST BLDG 20 #2-36 AUTHORIZED REPRESENTATIVE N. ANDOVER MA 01845 ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD Date ��4� Town of North Andover Your permit has been sent back to you for the following reasons: 1) Check amount incorrect 2) No copy of current license 3) Insurance Binder not on file or expired 4) No Workers' Compensation Insurance Affadavit Form Please call with any questions 978-688-9545. Fax 978-688-9542 Workers' Compensation Form and Schedule of Fees can be found on the Town of North Andover Website under Building Department. Mailing Address: 1600 Osgood Street, Building 20, Suite 2035, North Andover, MA 01845 -tA ee 2 � bt) o\,� be- ,� Date ...... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies tha(' has permission to perform r.4.) ....... ......................................... wiring in the building of..... �A. ...... . .. th:l .. . ....................................................... at ..... North Andover, Mass. .. ............ ..... ...... Fee.95 . . ........... Li'c. No. ........,..... tLECTRiCAL INSPECTOR Check # bk-. Commonwealth of Massachusetts Official Use Only Permit No. 174 0 1 Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [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: AUGUST 6, 2014 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) 44 VILLAGE GREEN DRIVE Owner or Tenant SHANNON MCCARTHY Telephone No. 978 - 918 -4607 V' N 1� Owner's Address SAME Is this permit in conjunction with a building permit? Yes ❑ No © (Check Appropriate Box) Purpose of Building RESIDENTIAL 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: TEMP POWER DUE TO WATER DAMAGE Completion of the following table mav be waived bv the In ector o Wires. No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑In- Elo. o mergency Lighting rnd. rnd. Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. TotalTons No. of Alerting Devices No. of Waste Disposers Heat Pump Number Tons KW ...................... No. of Self -Contained Totals: Detection/Alertin Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KW No. 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 Wires. Estimated Value of Electrical Work: $ 5 5 0 . 0 0 (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 ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: CROWE & SONS ELECTRICAL CORP,, n 4 LIC. NO.: 17168A CJ 3 Licensee: JAMES B. CROWE Signature [ "- LIC. NO.: 1716 8A (If applicable, enter "exempt" in the license number line) Bus. Tel. No. -978 -453 -6696 Address: 590 MIDDLESEX STREET, LOWELL, MA 01851 Alt. Tel. No.: 978 -453 -6696 *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: 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 a ent. Owner/Agent PERMIT FEE: $ 5 5. Signature Telephone No. 0 0 4eA--,�k� 119 J r C P1„ea%p visit 'our web site at http://www. mass.gov/dpI/boards/EL i1,, , CROWE & SONS ELECTRICAL CORP JAMES B CROWE (EL) 590 MIDDLESEX STREET LOWELL MA 01851-1428 Fold, Then Detach Along All Perforations � .;COMMONWEALTH OF MASSACHUSETTS o® CERTIFICATE OF LIABILITY INSURANCE F -DATE 8/66/201/201 M/DD/YYYY) 4 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 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 Insurance Marketing Agencies, Inc. 306 MAIN STREET Worcester MA 01608 CT NAD'V Tracy Campbell P"°NE 508-753-7233 Fax 508-754-0487 E-MAIL .tic@imaagency.com INSURERS AFFORDING COVERAGE NAIC # /22/2014 INSURERA:Utica Mutual Insurance Company 25976 EACH OCCURRENCE $1,000,000 INSURED CROWE INSURERB:Acadia Insurance Company 11295 INSURER C:Re ublic Franklin Ins. Co. Crowe & Sons Electrical Corporation INSURER D 590 Middlesex St Lowell MA 01851 PRODUCTS - COMP/OP AGG $2,000,000 $ INSURER E: INSURER F: C(1VGRAr94z CFRTIFICATF NIIMRFR- 1149713279 REVISION NLIMRER' THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDLSUBR INSD WVD POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MMIDDIYYYY LIMITS C X COMMERCIAL GENERAL LIABILITY X CLAIMS -MADE OCCUR 4745767 /22/2014 3/22/2015 EACH OCCURRENCE $1,000,000 DAMAGE TO RENTED PREMISES Ea occurrence $50,000 MED EXP (Any one person) $5,000 PERSONAL &ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO LOC JECT OTHER: GENERAL AGGREGATE $2,000,000 PRODUCTS - COMP/OP AGG $2,000,000 $ B AUTOMOBILE LIABILITY ANY AUTO AUTOS JED X AUTOSULED X HIRED AUTOS X NON -OWNED AUTOS MAA5144759 /22/2014 3/22/2015 COMBINED Eaaccident I L LI I $1,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ Per accident $ A X UMBRELLA LIAB EXCESS LIAB HOCCUR CLAIMS -MADE 4745768 /22/2014 3/22/2015 EACH OCCURRENCE $1,000,000 AGGREGATE $1,000,000 DED X RETENTION$0 $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A 4755523 /24/2014 5/24/2015 X PER OTH- STATUTE ER E.L. EACH ACCIDENT $500,000 E.L. DISEASE - EA EMPLOYE $500,000 E.L. DISEASE - POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) CERTIFICATE HOLDER CANCtLLA I IUN TOWN OF NORTH ANDOVER ELECTRICAL INSPECTOR'S OFFICE 1600 OSGOOD STREET BLDG 20 #2-36 N. ANDOVER MA 01845 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 REPRESENTATIVE U 1988-2014 ACORD CURPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD MM, Date., ...... Ili ........... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that, ...... �'c.� has permission to perform\\v 'J . .......................................................................................................... wiring in the UA'.� 'g of....., ..�I „G~ .. Alk ......................... . N Andover, Mass. at ...... ......................`.V l �j Fee,.: .......... Lic. No. I...I.� Ob m� G, ......... ....... .... ...... ..... 'ELECTRICAL Check # t �; Commonwealth of Massachusetts o ftblP) use my RMEWI�Permit No. Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (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: DECEMBER 22, 2 014 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) 44 VILLAGE GREEN DRIVE Owner or Tenant Owner's Address SHANNON MCCARTHY SAME Is this permit in conjunction with a building permit? Yes LJ Purpose of Building RESIDENTIAL Existing Service Amps / Volts New Service Amps / Volts Telephone No. 978-918-4607 No ❑ (Check Appropriate Box) Utility Authorization No. Overhead ❑ Undgrd ❑ Overhead ❑ Undgrd ❑ No. of Meters No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: INSTALLATION OF (5) 110V SMOKE DETECTORS Com letion of the followingtable ma be waived b the Ins ector o Wires. Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: 5740.00 (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 ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: CROWE & SONS ELECTRICAL CORP. 11 P LIC. NO.:17168A Licensee: JAMES B. CROWE Signature LIC. NO.:17168A (If applicable, enter "exempt" in the license number line.) Bus. Tel. No.; 978_ 453_ 6696 Address: 590 MIDDLESEX STREET, LOWELL, MA 01851 Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. SSCO- 001051 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 a ent. Owner/Agent PERMIT FEE: $ 55.00 Signature Telephone No. No. of Total No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Above In- Swimming Pool rnd. ❑ rnd. ❑ o. o Emergency ig mg Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Detection andInitiating No. of Switches No. of Gas Burners Devices No. of Ranges No. of Air Cond. Tons Tota No. of Alerting Devices Heat Pump Number Tons KW No. of Self -Contained No. of Waste Disposers P Totals: ... ... .............. Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Connection El Dryers No. of D ry Heating Appliances KW Security Systems: No. of Devices or Equivalent No. of WaterKW No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent Telecommunications Wiring: No. Hydromassage Bathtubs No. of Motors Total HP No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: 5740.00 (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 ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: CROWE & SONS ELECTRICAL CORP. 11 P LIC. NO.:17168A Licensee: JAMES B. CROWE Signature LIC. NO.:17168A (If applicable, enter "exempt" in the license number line.) Bus. Tel. No.; 978_ 453_ 6696 Address: 590 MIDDLESEX STREET, LOWELL, MA 01851 Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. SSCO- 001051 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 a ent. Owner/Agent PERMIT FEE: $ 55.00 Signature Telephone No. The Commonwealth of Massachusetts Department of Industrial Accidents �t lrt Office of Investigations 600 Washington Street t� Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information _ _ Please Print Legibly Name (Business/Organization/Individual): CROWE & SONS ELECTRICAL CORP. Address: 590 MIDDLESEX STREET /State/Zip: LOWELL , MA 01851 Phone#: (978)453-6696 Are you an employer? Check the appropriate box: Q 1 am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors ?. ❑ 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' rNo workers' come. insurance comp. insurance.$ required,] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' coma. insurance reauired.l Type of project (required): 6. ❑ New construction 7. ❑ Remodeling S. ❑ Demolition 9. ❑ Building addition 10.91 Electrical 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 subcontractors 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 rued job site information. Insurance Company Name: Utica Policy # or Self -ins. Lic. #: 4755523 Expiration Date: 5/ 2 4/ 15 Job Site Address: 44 VILLAGE GREEN DRIVE City/State/Zip: N. 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 certify under the pains and penalties of perjury that the information provided above is true and correct DECEMBER 22, 2014 (978)453-6696 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 Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: P1„ease visit our web site at http://www.mass.gov/dpI/boards/EL CROWE & SONS ELECTRICAL CORP JAMES B CROWE (E L) 590 MIDDLESEX STREET LOWELL MA 01851-1428 Fold, Then Detach Along All Perforations