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HomeMy WebLinkAboutMiscellaneous - 45 FOREST STREET 4/30/2018 (2) 45 FUKt51 b I Ktt I 210/106.A-0071-0000.0 6/20/2016 v � Date: June 20, 2016 20616 This is an e-permit.To learn more,scan this barcode or visit northandoverma.viewpointcloud.com/#/records/20616 TOWN OF NORTH ANDOVER 0" 1 '0 PERMIT FOR WIRING M 0� This certifies that Earl G Morrill has permission to perform Generator 18KW 10 Circuit Transfer Station wiring in the buildings of GOC. KIMBERLY A. at 45 FOREST STREET , North Andover, Mass. Lic. No. 17389 1/1 6/14/2016 E Date:June 14,2016 20562 This is an e-permit.To learn more,scan this barcode or visit north a ndoverma.viewpointcloud.com/#/records/20562 � SbS(tE'It� • �.� •� TOWN OF NORTH ANDOVER ' PERMIT FOR GAS INSTALLATION • r This certifies that Benedict J Breituna has permission for gas installation CONNECT A GENERATOR in the buildings of GOC.KIMBERLY A. at 45 FOREST STREET,North Andover, Mass. Lic. No.30283 1l1 C '�Y.as Fermi 12aY,2-VeeF % F C L`h`.4)s,/,bwharidoverma.vlewpolntcixd.wm/K,Temrd•„2O552/41O?3 .. y ei Aria a»nwarK Town of North Andover,MA 4 search... - 20562 •>,,,., P -Gas Permit:-Renwation/Alteration(Addidon(Commercial or Residential NOT In conjunction with a Building PermIQ TIMELINE 0 Submission rec6ved lun 9,2016 at 3:16pm Permit Fee Gas Permit R6New Processing will proceed upon payment. 0 Completeajun 10,2016 e;719a1 O B Credit Card ®Cash/Check Permit Fee Due Now OPermit 1,suante T Price for LP.Gas Installation $35.00 1 Price tar a Test $30.00 Price for generator Install $36.00 + +n,do[Fee... Total Fee Amount: $66.00 Processing Fee $2.99 Total Due: $68.99 � 1} ww I TJ VJ 1'V 61'1J 6 Monday,Jun 13,2016 01:58 PM The Commonwealth of Massachusettsru (� Department of IndustrialAccidents > 1 Congress Street,Suite 100 rr 0 51 G Boston,MA 02114:2017 ' www mass gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Leeiblv Name(Business/Organization/Iudividu4: C�S�Pyr,� y(k,, �g�� am C . Address: 13 t U,q S . City/State/Zip: '-n ve J a. O 15 a 3 Phone#: Ci_)T' -75 c = 6--o Sc, o re you an employer?Check the appropriate box: Type of project(required): Li - A.�I am a employer with 1-5 employees(full and/or part-time).' 7. [:]New construction ` 2.0 1 am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 3. I am a homeowner doing all work myself 9. ❑Demolition ❑ g y [No workers'comp.insurance required.]t 4. I am a homeowner and will be hiring contractors to conduct all work on m property. 10❑Building addition ❑ g Y P party. I will ensure that all contractors either have workers'compensation insurance or are sole I L❑Electrical repairs or additions proprietors with no employees. S.Q I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 12.E]Plumbing repairs or additions These sub-contractors have employees and have workers',comp.insurance.t 13.❑Roof repairs 6.❑We area corporation and its officers have exercised their right of exemption per MGL c. 14.dOther G o S i= 152,§1(4),and we have no employees.[No workers'comp.insurance required.] 'JV%S'1 c l t0 i ", a•.�l -tv ,t S�, Q► 'Arty 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 fob site information. Insurance Company Name: Hal - G e,,l:n 5 A r,,-y-;C ci .1 v%S u a a,n C a Policy#or Self-ins.Lic.#: C W G C 6 00 o o 160(o I( Expiration Date: 31 t 51 17 Job Site Address:-`�`� !—�J e5 City/State/Zip:0 t71-4, CA t" 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 and airs and penalties of a 'ury that the information provided above is true and cokrect Signature: Date: Pho 1 S' 'SU 0 Official use only. Do not write in this area,to be completed by city or town o ficiaL 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#• ���® DATE(MMIDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 3/14/2016 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 CONTACT ma aI1Il Plass NAME: G & A INSURANCE, INCPHONE (603)742-2644 FAX No;(603)742-2406 Ext), C34 Dover Point Road E-MAIL ADDRESS: INSURERS AFFORDING COVERAGE NAIC# Dover NH 03820 INSURERA:HDI—GERLING AMERICA INS INSURED INSURER B Eastern Propane Gas Inc. INSURER C: P.O. BOX 1800 INSURER D: 28 Industrial Way INSURER E: Rochefter NH 03866-1800 INSURER F: COVERAGES CERTIFICATE NUMBER:CL1631402210 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. INSR I TYPE OF INSURANCE ADDL SUER POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER MMIDD/YYYY MMIDDIYYW X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 ADA MAGERENTED 250,000 PREMI ESS(E. occurrence) $ X EGGCD000080616 3/15/2016 3/15/2017 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X PRO ❑ JECTPRO- LOC PRODUCTS-COMP/OPAGG $ 2,000,000 POLICY 1:1 OTHER: $ AUTOMOBILE LIABILITY COEa accMBINEDidentSINGLE LIMIT $ 2,000,000 A X ANY AUTO BODILY INJURY(Per person) $ ALL OSCHEDULED AUUTOSS AUTOS X EAGCDOOOOS1616 3/15/2016 3/15/2017 BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident UMBRELLA LIAB Ld OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ S WORKERS COMPENSATIONPER OTH- AND EMPLOYERS'LIABILITY Y/N X STATUTE ER ANY OFFICERIMEMBER EXCLUDED PROPRIETORIPARTNERIEXECUTIVE a NIA E.L.EACH ACCIDENT $ 1,000,000 A (Mandatory in NH) EWGCD000080616 3/15/2016 3/15/2017 E.L.DISEASE-EA EMPLOYE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Includes additional insured status when required by written contract. CERTIFICATE HOLDER CANCELLATION cs@eastern.com, SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Any City/Town in Massachusetts THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN MA ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Maryann Plass/MP ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD INS025(201401) Fold,Then Detach Along All Perforations a� :COMMONWEALTH OF MASSACHUSETTS e a o w ® BOARD OF PLUMBERB AND GASFITTERS E ISSUES THE FOLLOWINGLICENSE LICENSED AS A JOURNEYMEN PLUMBER BENEDICT J BREITUNG ' 1� ii9UTLER ST: W SALEM VH03079-3924 Iz iU ".,. 1'J 30283 05/0112018 .: 45588 7 y Q d -)—Q , " V No Date......ell-............................ TOWN OF NORTH ANDOVER PERMIT FOR WIRING 7SgAcm This certifies that ................................ ...................................... has permission to perform .................................... .................... - 4" - '"- ,I � -I wiring in the building of t�...............................................!................................... at...... . ;—'... .:f'.`... ......... .......................... .North Andover,Mass. V Fet—.��.........-..I ..... Lic. ............................................................... ELECTRICAL INSPECTOR 06/23/98 09.58 35-00 PAID WHITE: Applicant CANARY: Building Dept. PINK:Treasurer J ±\ /eUnly f title (r1atI11I10I1WeaJt11 IItc�55c�rllu�ett i Persil No. __ ✓ 90-0 lr OrparfairIII of 1-Jublic �afrtg Occupancy E Fee Checke&z- a, BOARD OF FIRE PREVENTION REGULATIONS 527 Chill 12:00 3190 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance aith the Massachusetts Electrical Code. 527 CMIR 12:00 (PLEASE PRINT IN INK OR TYP ALL I�1FOtF'iMATION) Da;e City or Town of r ''.�t?�Jf-.,k_ To the Inspector of Wires: The udersigned applies for a permit to perform the eLizlectrical Work described below. Location (Street & Number) 3a1. �7d Sentry Vendor Code Owner or Tenant _ Circuit Owner's Address Location Phon #- q 7113 3 - M R Is this permit in conjunction with at building permit: Yes ❑ No El (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps _J VJits r--; Overhead tui, Uncgrnc L— ::o. of lAeters New Service Amps _/ Volts Overhead LJ Undgrnd El No. of Meters Number of Feeders and An1pdCity Location and Nature of Proposed Electrical Work LOW VOLTAGE ALARM SYSTEM No. of Lighting OutletsNo. of Hol Tubs i No. of Trans:or,ers Total K♦rA No. of Lighting Fixtures Swimming Pool Above In I grnd. ❑ grnd. ❑ I Generators KVA No. of Emergency Lighting No. of Receptacle Outlets No. of Oil burners 1 Ballory Units No. of Switch outlets No. of Gas Burners FIFE ALARMS No. of Zenos No. of Ranges No. of Air Cond. Total No. of Defection and tons Inrliatirg Devices No.of Disposals No of Heat Total Total Pumps Tons KW No. of Sounding Devices Nc. of Sell Contained No. of Dishwashers Space/Area Heating KW Detection/Sounding Devices No. of Dryers I Heating Devices KW Lccal Municipal ❑Othe: Connec:io I I No. of No, of N Volt Burg Fire No. of Water Heaters KW Signs Ballasts v.,ring Card Acess 1 CCTV No. Hrd:o faassaca TutsNe. of Mot^rs Total HP ho. of Devices OTHER: INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts general Laws I have a current Liability Insurance Policy including Comploted Operations.Coverage or its substantial equivalent. YES — NO G I have submitted valid proof of same to the Office. YES 0 NO 0 It you have checked YES.please indicate the type of coverage by checking the appropriate box. INSURANCE lit BOND G OTHER = (Please Specify) _ Frontier Insurance Company 10/8/98 Estimated Value of Electrical (Expiration Date)cal Work S Work to Start Inspection Date Requested: Rough Fina( Signed under the Penalties of perjury: FIRM NAME Security Systems Inc. d/b/a Sentry Protective Systems 1109 C Licensee James W. Lees , UC. No. signature �- a _IC. No 0( SO�Yu—blic Sus. Tel. No. (781) 388-9700 Safety) Address 110 Florence St. P.O. Box 250 Malden MA. 02148 At,.Tel. No. S 65-45 5 OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its substantia( equivalent as re- quired by Massachusetts General Laws. and that my signature en this permit application waives ;his requirement. Owner Agent (Please check one) - v _Telephone No. _ PER,:IT FEE S (Signature of Owner or Agenq