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HomeMy WebLinkAboutMiscellaneous - 45 KEYES WAY 4/30/2018 I�'�5 ITE yES WAY b� 5 a a��3 Date....... ................................... OF OORT/f,h TOWN OF NORTH ANDOVER PERMIT FOR WIRING g8'�CMU9E r This certifies that ............... ..... .. ....... ................................................................ has permission to perform ..��a o�>r�a_ �*,� Sy �� ............................................................... . . wiring in the building of..... ".Is �at ........ ......a...?...:.. ��D. .t°TS....�� a.. .--. rth Andover,.Mas /y ................. Fee... 5 .......Lic.No.Z Jl 3?` .............................. t ELEC MAL INSPECTOR t° Check# 76 11 42U G C voa C.otrrnaoruuBa i o�/1'jasaac cells Official Ilse Only Ilenuit No......11.4 Zp _ epvl&s d 613im Servi'coeTT- Occupancy and Fce Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 leave hlank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MIXT 527 CMit 12.00 (PLEASE PRINT IN INK OR TYPE ALL IM OR AT16NW tc; City oh•7`o1�•It of: r�`{ � 0 rE r"' To the Iiaspecldxl•of N'fires: By this application the-undersigned gives notice of his.or her intention to perform the electrical work described below. Location(Street& Number) . Owner or Tenant (- 'i'clephc►nc No.. $t G`L tS ftp Owner's Address Is Ibis permit in conjunction with a building permit? Yes No ❑ (Cheelt Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / ._ Volts OverheadEl Undgrd Q No.of Meters New Service Amps 1 Volts. Overhead'Q Undgrd 1-1 No.of Meters Number of Feeders and Ampaeity Location and Nature of Proposed Electrical Work: # ' 0U ,o ,'t Com lelimr o the ollowirn /able nrav be ivaired b the firs Ceclor of[fn es. No.of Recessed Luminaires No.of Ceil.-Susp.(Paiddle)Fans o.of lotal Ti ansforniers KVA No.of luminaire Outlets No.of loot Tubs Generators KVA Above n- o.o :mergency Ag r ng No.of Luminaires Swimming Pool rod. grnd. Ilattery Units No.of Receptacle Out.lets No.of Oil Bursters FIRE:ALARMS No.of Zones No.of Switches No.of Gas Burners o.of )election and Initiating Devices No,of Ranges No.of Air Cond. Total Tons No.of Alerting Devices Heat qmp _..um o'* Ions o.o Se ontained No,of Waste Disposers Totals: _ "� """" Detection/Alertin Devices _ _ Municipal No.of Dishwashers Spacc/Area Heating KW Local[�� ❑ Other _ Connection No.of Dryers Heating Appliances RW SecSystems: echo.of Devices 01 No. o.o1' ater KW o.01' o.of Data Wiring: Heaters Si ns Ballasts _. No.of Devices or t bivalent No.Hydromassage BathtubsNo.of Motors Total liI' a ecommunicat ons Wiring: No.of Devices or h uivalent OTHER: G Attach additional detail ljdesir ed.or as reqby lire Inspector of Wires. Estimated Value off Electrical Work: U.la60 (When required by municipal policy.) Work to Statt:_'jq P inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE:COVEIRAGE: 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 iii lirrce,and Inas exhibited proof of same to the permit issuing off-ice. CHECK ONE:: INSURANCE [] imi) L[ OTHER U (Spccilj:) I cer7 y,under lhepains acrd penalties gLpesynt y,that the Inform n oa this application is true and complete. FIRM NArm.': = +— t _ LIC.NO..: �11� Licensee: lir ttlJ Signature _ _- LIC.NO.: A5 , J + (lfapplicable,enter"exempt'int the license arc,11her line) Bus.Tel.No.;_ Address: AJ,.'j tit u d ,tt !", + 1 1 Alt.Tel.No.:— *Per M.G.L.c. 147,s,57-6 1.security work.re wires l)cpartinrni of I'ubl afety"S"License: Lic.No. OWNER'S INSURANCE WAIVE It: 1 am aware that the t•icensee does not have the liability insurance coverage nonnally '1 required by law. lay my signature below,I hereby waive this requirement. I am the(check one [1 owner 0 owner's a cot. OwnerlAgent Signature _—'E'elephoue No. PIsRA?IT I?t L: $ (Z'> 1 < • T {' � ti w � _ � �,� �/ � 5 Q 1NF. 'iH OF �. t: ' �i ; � 5SUE5 TNI OLLOIJI NG fE AS < LV sof 1) I�RSTIECTR I C FAf�} ti RCITY COR ION 24 S%1 N i % g UNIT 11 � e { OROU H . A x1752-30� l 13i'j / 1897 k. CUMMQNWEALTtt ur IWASSACHUSETTS MEM :• •:. AS A ELECTRICIANS��������IJ�tY4���:��cralrrr�►�I;: IAN G NADWORNV 120 BLOOD RD ` n TOWNSEND MA 0I474-11152 ALLk The Conmionwealth of Massachusetts Print Form Department of Industrial Accidents i Office of Investigations 1 Congress Street,Suite 100 Boston, AIA 02114:2017 _ www mass goildia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Nul11C(Business/Organizatiot►/tndividual): SolarCity Corporation Address:3055 Clearview Way City/State/Zi :San Mateo,CA 94402 Phone#:650 963-5100 Are you an employer?Check the appropriate box: Type of project(required): .n i am a employer with 1500 4. ❑ 1 am a general contractor and 1 6. ❑ New construction employees(full and/or part-time).* have hired the sub-contractors 2.[] I am a sole proprietor or partner- listed on the attached sheet. 7. [❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working :for me in any capacity. employees and have workers' q ❑Building addition [No workers'comp.insurance comp.insurance required.] 5• ❑ Weare a corporation and its I0.❑Electrical repairs or additions 3:0 !-am a Homeowner doing all work officers have exercised their I l.❑Plumbing repairs or additions myself.[No workers'comp. right of exemption per MGL 12❑hoof repairs insurance required.[t c. 152,§1(4),and,.-6,e have no employees.[No workers' 13.❑OtherSolar PV comp:►nsuranec required.) `Any applicant that checks box#I must also till out the section below shoring their%vorkerti compensation policy inronnation. t I lomeowners who subunit this affidavit indicating they arc doing all%vork and then hire outside contractors must submit a neer affidavit indicating such: $Contractors that check this bor:roust attached an additional shod shoving the name of the sub-contractors and state wlictfter or not thea-c entities have employees. If the sub-contractors have employees.they must provide their corkers'cramp.Imlicy number. lam an empioter that is providing workers'compensallon Insurance for my employees Beloit,is the policy and job site information. Insurance Company Name:Zurich American Insurance Company Policy,#or Self-ins.l.ic.#:WC96734670 _W Expiration Date©9/01/13 Job Site Address: { & City/State/Gip: Qj!d-45- 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 tine up to$1.500.00 and/or one-year imprisonment,as well as civil penalties in the tbrm 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 he forwarded to the Oil ice of Investigations of the DIA fur insurance coverage verification. I do herebl,cer ' +updar the . n /ties gteeL'ure t/crit the information provided above is true and correct. S&gllurc: _ _ Date Phone 978-215-2358 Ojfcial use r n(y. Do not►atrite in this area,to be completed hl'cin•or lawn rffrc al. City or Town: Permit/License# Issuing Authority(circle one): ' 1. Board of Health 2.Building Department 3.City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector 6.Other Contact Person: Phone M s A,CORdBATE LksM+DOJYYYrI CERTIFICATE OF LIABILITY INSURANCE 00/16/2012 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE ODES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT 13ET11V'EEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.- IMPORTANT: If the Corttfleato holder Is an ADDITIONAL INSURED,the pollcAles)must be endorsed, IT OU13ROGATION IS WAIVED,subject to Me terms and conditions of the policy.certain policies may require all endorsement. A statement on this Certificate does not corMrx rights to the Certifleate holder in ifsu of such gndoroom a ►Ratan 0726291 1-415-546-9100; CONTACT Arthur d. Callagist 6 Co. reHANE Bndan Quinlan Insurance Brokers of Cal.ifornlit, lnc... License 00726293 /(A�A�/C�. tok. 413-536 -4020 ���aor One Market Plata, Spear Tower E• 2 brenQaa suits 200 Zooms: Qvinlaa0aig.com San Prancisco, CA 94165 INSURER(s)AFFORMOCOVERAGE NNCa INSURERA.ZURICH AMER IMS CO 16535 "SUREO Solarcity Corporstion IwSUllER8:LIBERTY INS CORP 42404 INauRERc UNDYRMUTBBB AT LLOYDS 132721 )DSS Clearviw Hay elbURtRD. son Nate* . CA 94402 tnuRNta: - - -_:._ - - .---.�•. URE - _ COVERAGES CERTIFICATE NUMBER:.26723200 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 IN AFFORDED BY THF POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCI US[ON5 AND CONDITIONS OF SUCH POLICIES-l UdITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. 1YSR TYPE OFUISURANCE ADDUSVBR� _ '". POLICYEFf-. .KY POLICY BER touts A X NERAILMaiCtiY "OL0967364404 09/01/1' 09/01/13 EACH OCCURRENCE S1,000.000 COLIMERCIA&GENERAL UABRItY - DAMAGE 10"tED 1..000.000 REM($ESLEa0mwm,cel ! ,CUtbleP r •2 ;OCCUR. MrorrvfA . -vr 10,000 PWwn) ! X Deductibles 1;25,000 E !.. - PERSONA!aAnVFNJMV 1,000,000,f '�. CEWERAL AGGNEGAtF 52.000.000 GFMrt AGGREGATE.LOOT AoPLIESVFR PHOOUCtS•COMIPIOPAGG S1,000.000 Art Il1G .. A AUrONO EWp41'tY SAY9e2931702I C.OMOINEO SINUL USpt .. F (E�Aoaoe.&ty $1.000,000 x a ANY A01 O ° ; BOOR Y FNJURY(PW PWGW l f t - �fA'wioswLD i s�at�Iru l I N0�10WkYD MOILYINJURYIPs'ewAarl s X 4II1Rr:I AUf05 x AUTOS I ' PROPERTY DAMAGE t I �3 B X UMBRELLA LOAD It OCCUxt ( TH7662066265022 f 09/01/1 09/01/13 EACIOCcumRcNCr £r.CEES Ie&e =10,000,000 Cl Ant$-MADE + AGGREGAIL i DEO 'X IENLON 10,000 x ` 't 10.000,000 s A ANDEVRSCON► UASILIt .NIA KC967146704 '- 0 V7C 'alto. ANYEwLOETOMPA94INEY YJN 04/01/1 09/01/13 X:TORYLMOTS. .ER 0FYPROPRIETQR:PXQUDF/EIII:CF111VC 'j LL EACH ACCIDENT 1!2.000.000. (u ffwa"is"NJ ErGLtld[O'+ N J IItMOahHNl l -HEWOF OPE .I - - FDSEASE•EVAOYF LC1ITf'{ 1,000,000 PION RAIIONStdmy E:L.gSLASL•f`OL&CY 1.111 $2.000.600 C trrora and Onisaiana 80146LDUSA1204$24 09/01/1 09/03/13 Limit of Llity 5.000,000 q Aggregate 5,000.000 i IDeductlble 100.000 OESCRWTION OF OPERATIONS I LOCATIONS I VEHICLES IAdeth ACORO t01 Amilwast RF MWks aehe".O RWO Mptte h requked� Certificate issued as proof of coverage. CERTIFICATE HOLDFR CANCELLATION SHOULD ANY OF 1HL ABOVL DESCRIBED POLICIES BE CANGE.LLED BEFORE evidence of insurance Only THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUtHORILEO RCPRESEN1AtlVL ��� i7 1908.2010 ACORD CORPORATION. All right:roservod. ACORD 25(2010105) The ACORD name and logo ase registered marks of ACORO goksan IB723200 • deems, Maura From: Christine Larson [clarson@solarcity.com] Sent: Wednesday, April 1-0, 2013 8:17 AM To: Deems, Maura Subject: RE: Permit modification/Master License Hi Maura, The electrician is an employee of Solarcity and the master electrician Matt Markham is our master electrician. Thank you, Christine Larson I Marlborough I SolarCity I T: 774-258-8180 F:508-460-0318 clarson solarcity.com www.solarcity.com From: Deems, Maura [mailto:mdeemsCabtownofnorthandover.com] Sent: Wednesday, April 10, 2013 8:13 AM To: Christine Larson Subject: RE: Permit modification/Master License Christine, Is the new electrician for the job at 45 Keyes Way an employee of yours or is he a subcontractor? Maura From: Christine Larson [mailto:clarson(absolarcity.com] Sent: Tuesday, April 09, 2013 12:55 PM To: Deems, Maura Subject: RE: Permit modification/Master License Hi Maura, Solarcity has pulled the permit for the solar panel installation and we have modified the permit due to the change on our Master Electrician License. Let us know when to send a that letter in stating the change in master electrician. Thank you, Christine Larson I Marlborough I SolarCity I T: 774-258-8180 F:508-460-0318 clarsonasolarcity.com www.solarcity.com From: Deems, Maura [mai Ito:mdeems@townofnorthandove[.com] Sent: Tuesday, April 09, 2013 11:52 AM To: Christine Larson Subject: RE: Permit modification/Master License Christine, I will need to run this change by our electrical inspector.As a rule when a change is made and it looks as though a new electrician is on the job, a letter has to be sent from the homeowner stating that the electrician has changed. Also, as a rule a new permit must be issued because of the change of responsibility. I will get back to you tomorrow morning with what needs to be done. Thank you, Maura Deems Building Department Assistant 1 From:•Christine Larson [mailto:clarson(-Osolarcity.com] 'Sent: Tuesday, April 09, 2013 11:25 AM To: Deems, Maura Subject: FW: Permit modification/Master License Hello, Attached is the permit modification for 45 Keyes Way.The electrician and the master electrician licenses are both attached with the documents. Please let me know if anything else is needed. Thank you, Christine Larson I Marlborough I SolarCity I T: 774-258-8180 F:508-460-0318 I clarson solarcity.com www.solarcity.com From: CLARSONCa SOLARCITY.COM [mailto:CLarson(a solarcity.coml Sent: Tuesday, April 09, 2013 10:55 AM To: Christine Larson Subject: Please note the Massachusetts Secretary of State's office has determined that most emails to and from municipal offices and officials are public records.For more information please refer to:ham://www.sec.state.ma.us/pre/preidx.htm. Please consider the environment before printing this email. 2 r� r r Canrmonweald o/Mamackovffe Official Use Only .U•patm.nt o��ity Jitwk•e Permit No.,i 1�' BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked 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: City or Town of: �,QrA� n�Vcr - 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) 4-N,- K;1-14E5 W��1 Ownerer Tenant L Q4-c, i `i rit 5 Telephone No.?F{1 ti3Q$ Q Owner's Address 1� Is this permit in conjunction with s building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building ns� __(')) &-e4i S Utility Authorization No. Existing Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters New Service Amps ____L_Volts Overhead❑ Undgrd❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: t_.. �► (� VJ� C� /y r t Se�Stch1 T Completion o the ollowln table m he waived b the Inspector o Wires. No.of Recessed Luminaires No.of Cell.-Susp.(Paddle)Fans No.o Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No,of Luminaires SwimmingPool ove n- o.o Tergency g ng rnd. rnd. Batter Units No.of Receptacle Outlets No,of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.or Detection an INtiatlnTotal Devices No.of Ranges No.of Air Cond. Tons No.of Alerting Devices No.of Waste Disposers cat Pump um cr ons_ No.of Self-Conta ne Totals: • • DetectionlAlertin Devices No.of Dishwashers Space/Area Heating KW Local un c pa Connection E] Other No.of Dryers Heating Appliances Kit Security ty, ystems: No.of Devices or E uivalent No.o eaters KW ter o.Signs Baof llasts Data Wiring: No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total IIP a ecommun cat ons r ng: OTHER: No.of Devices or Equivalent f Attach additional detail if dr sired,or as required by the Inspector of Wires Estimated Value of Electrical Work: LSD l,¢b U (When required by municipal policy.) Work to Start: A 'S.A .P, inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for(lie 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 UNI:: INSURANCE J@ BOND ] (1TIIIiR ❑ (Specify:) I cerlify,tinder the paints and penalties o f perjury,that the information on this application is true and complete. FIRM NAME: 'el { c� --- LIC.NO.. Licensee: AiGa t 1-,c„� Signature 6 c — LI—, tC.NO. �j jll'applicob%,cuter"exempt”in the license number lire.) �e-1- Address: SE Bus.Tel.No.• 7 19S n -u M A 0' �] Alt.Tel.No.: *Per M.G.L.c. Id7,s. 57-61,security w rk requires I)epartn►cnt'o ublic Safety"S"License: Lie.No,� _ OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By n►y signature below,I hereby waive this requirement. I am the(check one)[]owner Own nt (]owner's agent. Signature � �_ Telephone No. I'LRn11T F,Eds: $ COMFaONWEA1.1I1 01 MASSAC,HUSE-11 S ' l'1M�� f1t1Uu!! tltA'u �1J't; �u� � z4Ti BOARD ELECTRICIANS EL REGISTERED MASTER ELECTRICIAN TYPI- SOLAKC r TY CURPORAT ION KEVIN S C,AGN014 A 17B STERLING RD 14 1111.LERMA MA 01802-2518 6577 20571 A 117131113 6577 COMMONWf.At.IfIOf MASSACIIUSE-t'1& ELECTRICIANS REGISTERED MASTER ELECTRICIANGUMIf,#OMWI:A1.II {.1F MA;bACFitiSt: � 14 L ECTRICIFINS •'1. ,' HATHAN 11 A*,lit AS A REG JOURNEYMAN ELECTRWAAN i i AVI.1 1 I11 Ft/1 FHAN A ii`.IiI lilc'lJ J OUs. F9A 1� 1 CI.eQ I13r, A li1:i QS7r,'te'r. LAVI'I I kll 1 '. (•kfllflt I tiA a► lr,i;p - 1, ,e 1 ! J3 r,I I1 The Commonwealth of Massachusetts Print Form ` Department of Industrial Accidents Office of Investigations 1 Congress Street,Suite 100 ." Boston, MA 02114-2017 www.mass.gov/dla Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly riame (Business/Organization/individual): SolarCity Corporation Address:3055 Clearview Way City/State/Zip:San Mateo, CA 94402 Phone #:650 963-5100 Are you an employer? Check the appropriate box: Type of project(required): 1.91 1 am a employer with 1500 4. Q i am a general contractor and 1 6. ❑ New construction employees(full and/or part-time).' have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g, ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp.insurance comp. insurance.: required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.]t c. 152, §1(4),and we have no Solar PV employees. [No workers' 1321 Other comp. insurance required.] kAny applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors 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 emplr7ver that is providing workers'compensation insurance for my employees Below is the pollcv and job site information. insurance Company Name:Zurich American Insurance Company Policy #or Self-ins. Lia#:WC96734670 Expiration Date:09/01/13 Job Site Address: S / W �G(]"/I Al d0Vr,(" A.- City/State/Lip: O/Sj q j- 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 cer u r the s n e hies o er'ury that thein orntadon provided above is true and correct. Sianature: _ - - - -- - Date Phone#:978-215-2358 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# ICssuing 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#: - - -- -- -- — -- — I /AC` 6;; DATE(MWODIYYYYI CERTIFICATE OF LIABILITY INSURANCE 08/16/2012 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 endorsoment s. PRODUCER 0726293 1-415-546-9300 CONTACTBrendaA Arthur J. callagher 4 Co. NAME- InsuranceQuinlan Brokers Plata, of California, Inc., License 40726293 WN.LRU:. I.1hicNe): One Market Plata, Speer Tower suite 200 - ••ADDRESS: brendan_quinlan*ajg.com --- San Francisco, CA 94105 INSURERS)AFFORDING COVERAGE MAIC i „ INSURERA: ZURICH AVER INS CO 16535- - Sola OrCity Corporation S _INSURER B: LIBERTY INS CORP 42404 ola - INSURERC_: UNDERWRITERS AT LLOYDS 32727 3055 Clearview Way INSURER D:. San kAteo , CA 94402 INSURER E: 1 INSURER F COVERAGES CERTIFICATE NUMBER: 26723200 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 REOUIREMENT,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_P_AID CLAIMS. INSR --• _ ADDL(SUBR1 POD Y EFF POLICY EXP phr Y1 0.BNIT8- -_ - TR TYPE OF INSURANCE POLICY NUMBER A GENERAL LIABILITY j :OL0967364404 09/01/1. 09/01/13 EACHOCCURRENCE =1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED P $ 2,000,000 1 REMISE$.(Eu opcurrancol I CLAIMS-MADE [Xi 0 OUR I MED EXP(Any one person) 3 20,000 X I Deductible: PERSONAL a ADV INJURY _ $ 2,000,000 GENERAL AGGREGATE ;f 2.000.00 0 GEN't AGGREGATE LIMIT APPLIES PER I PRODUCTS-COMPIOP AGG S 2,000,000 1 I{ s X POI ICY 1 PHO' Loc A AUTOMOBILE LIABILITY I iBAP902931702 1d 091017-13COMBINED SINGLE LIMIT s (Ea aaiden0 f 1,000,000 X_ ANY AU10 i BODILY INJURY(Por person) S ALL OWNED ([{ SCHEDULED AUTOS t AUTOS BODILY INJURY(Por ac idem $ X HIRED AUTOS i X AUTOS OWNED I j PFtUP&OY DAMAGE s (Per accideeQ i B 11 10MBRELLALIAS X OCCUR ( I 'TH7661066265012 09/01/1 09/01/13 EACH OCCURRENCE $10,000,000 E:CSSLIAO CIAIMS•MADEI i 7 JJ AGGREGATE 510,000,000 DED I X RETENTION$10,000 1 1 $ A WORKERS COMPENSATION WC STATU• OT H• AND EMPLOYERTLIABILITY IWC967346704 09/01/1 09/01/13 X' TORY LIMITS i 1 ER ANY PROPRIETORIPARINER"ECUTIVE YIN E.L.EACH ACCIDENY OFFICERIMEMBEREXCIUDED? [ijINIA; $ 1,000,000 (Mandatory In NH) E.L.DISEASE•CA FMpLOYEP,'s 1,000,000 If yysss,dcaa.bo under DESCRfPT1ON OF OPERATIONS below - E.L.DISEASE-POLICY LIMIT $ 1,000-000 C Errors and Omissions :80146LDUSA1204514 09/01/1 09/01/13 Limit of Liability 5,000,000 L ( I Aggregate 5,0001000 i Deductible 100,000 i I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORO 101,Additional Remarks Schedule,if more space Is required) Certificate issued as proof of coverage. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Evidanca of Insurance Only THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. ALITHORILED REPRESENTATIVE f___1 c�.- ®1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD goksan 28723200 N2j �� Date.......40 . .! ' 315 � A f NoDTM1 3?°.<�``..:•a"oo� TOWN OF NORTH ANDOVER ° PERMIT FOR WIRING This certifies that .....,/t...`P/...... � ......�' r.L..l..!.. !..................................... has permission to perform ............j .. f � r✓i�� ......... .: ....................................... %u ring in the building of.....�� ....x`..4.)4 ...(.�.� .�' .....4Azg./............. at...................:........ o....................... ......................,�,North Andover,Mass. eee.. ! l.�.(..e!. Lic.No.T'S. r f^j..( ...... ..... .. .. ............. / ELECTRICAL INSPECTOR Check # �7 WHITE: Applicant CANARY: Building Dept. PINK:Treasurer \ THECOIWONWEALIHOFAIAW4CHusu-ils Umce Use only i- DEPARTMFVTOFPUBIICSAFM Permit No. BOARD 0FFIREPREVEW0NRE6MTI0AN527CMR120 Occupancy&Fees.Checked UAVPPUCATTONFOR PERMIT TO PERFORM ELECTRICAL WORK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE,527 CMR 12:00 (PLEASE PRINT IN INK ORTYPE ALL.INFORMATION) D.ateLO�G���+O?7 D� Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location(Street&Number) /10 �� � � a Owner or Tenant ,�t'�d LL �,D,t'157�UC'77ac! Owner's Address � �� Is this permit in conjunction with a building permit: Yes[allo (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / —Volts Overhead Underground No.of Meters New Service 00Ampvx /a1Aolts Overhead © Underground No.of Meters / Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work� No.of Lighting Outlets No.of Hot Tubs No.of Transformers Total KVA No.of Lighting Fixtures Swimming Pool Above Below Generators KVA ground ground No.of Receptacle Outlets No.of Oil Burners No.of Emergency Lighting Battery Units No1of Switch Outlets No.of Gas Burners No.of Ranges No.of Air Cond. Total FIRE ALARMS No.of Zones Tons No.of Disposals No.of Heat Total Total No.of Detection and Pum s Tons KW Initiating Devices No.of Dishwashers Space Area Heating KW No.of Sounding Devices No.of Self Contained Detection/Sounding Devices No.of Dryers Heating Devices KW Local Municipal r7 Other Connections No.of Water Heaters KW No.of No.of signs Bailasis No.Hydro Massage Tubs No.of Motors Total HP OTHER-' - kmrarxeCA c18 F PlmatlotheieC]t erna1SCn3nalLaws Iha,.eaamtLdi*hn==PbiicynixkgCmVW C0ma8Dcr sWJst[WaPydlat YES NO a Ihawahritledvatidp udofsanetuthe09ix YES n NO If}wLa%edxdWY)S,pkmmdcetbet WcfwmaWbydtadr>gthe MURANICEo- >O o OVER o ) EvirAm D* Fst c V"dUmir cal Wcdc$ WokiDSw hspacticnD*ReVested Ralgh E>nal Signedtltxha'�ieP�ta)lie;ofpajtay E , � liar>,seNta. cjz FIRMNAME f Sig LiMnsee rlahlte L=l%b .`> � BtsitlessTel.Na �/S-(y6 r'� AItTeLNa �►�Z-�PS�7 — ---- OWNER'SINSURANCEWAIVER;I.amawa drttteLioense ori1s9*ki>lialegiK&rtastaqu Wby& %adu lfiGandLaws anddatmysigmtrsernlhisp=* MVMiresdtism*Zienat. (Please check one) Owner a AgentID i3AIlfTelephone No. PERMIT FEE (/ Location )p � 7 `P �°S � a No. 6 Date a MaRT� TOWN OF NORTH ANDOVER oft..e ,•ti' a ' Certificate of Occupancy $ S"cmust t� Building/Frame Permit Fee $ iso Foundation Permit Fee $ Other Permit Fee $ TOTAL $ / '9 S r C eck # f 13 j(- Building Inspector LOT 5 r,af- tL.EV, EXISTING FOUNDAr/0Al EASEMENT ,a LOT 4 �r IMAEL ERGI l`so ell) e3 -0049 t � .33121 0 TES' FOUNDATION LOCATION PLAN ,mas ov-a y cuErvr.• ,uxEs cARRor�. UST wm 1 11 � n a cannumm is WU AW MWM m�wwU,�wr w was ar w m wr �Odf rc ?W AaMM? OW MMM AMMM MMrr LOCAIM, SALEM SraErr LOr 5 e t MOM,,,q,+ in MOTH ANDOM, �6lA rir +�w+ Mw WOW are iweo� mNrum AW WW- or r r SCALE; 1'* x 80' DATEr APRk 3, 2001 CHR1SIMSEAt &SERI f " , IN x0a a.. Jw=d"m Nate raz ata-�r� aml Aw ammu■m DRAWING N0. DOOW016 Date.. . .. .. . . Of NORTH 02 �` TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION . 9 SA US This certifies that .. .. . ,�. . , , , , , , , . . . , , . has permission for gas installation . . . . . . . . .!'.'.'. � in the buildings of . .f.: .`�?H .�'. . .:: . . . . . . . . . . . . . . . . . . . . . . . at . . . . ./.: .!. �.'. :!. . . . . . . . . . . , North Andover, Mass. Fee. .). Lic. No.. . . . ... . . . . . . . . .�. .`� . . � .-� . . . . . GAS INSPECTOR i Check# / 4 73 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or T ) a Pmp",V�JAJ&AA) Mass. Date Permit*--4i2 1 Building Locatlaq '46 �Wec, Owner's Name t Type 01E g;ancy 1` N Renovation ❑ Replacement 101;0000" 'Pians Submitted: Yes❑ No❑ m m 39 'um m v Z ac fn m cce c o a W J d _ � 0: i c ` a =o a us 3 s m m r y m o — a W m m < �C m x m w z 4u "� '" m a m r Ira r. _ oC ix d aC is YI j a J }�}.. m d r J rr' �, r m .m 2 d Z °r O fA z ynt r at C oC tic to > aC W a Z• aC s 0 d Y U. 3 a O �.t v Y O G n0 6 i- SUB—BSMT. BASEMENT 1 ST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR STH FLOOR 6TH FLOOR 7TH FLOOR 8TH FLOOR Installing Company Name YANKEE GAS Check one: Certificate Address 140 SOUTH MAIN STREET ® Corporation 10 3 C MIDDLETON MA 01949 ❑ Paartnership Business Telephone 978-774-2760 ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter, WILLIAM R HARRIS INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes X3 No ❑ If you have checked yes. please Indicate the type coverage by cheddng the appropriate box A liability Insurance policy RX Other type of Indemnity❑ Bond O OWNER'S INSURANCE WAIVER: l am aware that the licensee does not have the Insurance overage required by Chapter 142 of the Mass. General taws. and that my signature on this permit application waives this requirement. Check one: OwnerO Agent❑ Signature of Owner or Owner's Agent 1 hereby certify that all of the details and information I have submitted(or entered)in above appt�cation e a r the best of my knowledge and that all plumbing work and installations performed under the permit for this ap i p ance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Laws. BY T of License: ureor as titer Title 3785 license Number N� 33 3 -37 Date........ TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING This certifies that ......kcn ......................................... has permission to perform ......Q.Vi .....k+.qm..e......... ....... .. . ....... wiring in the building of....... ...... ,F ................................ at....V..I ......... ........ North Andover,Mas;0' Fe?.3.11W Lie.No.l'fA.. . .........p......1.. CT OR JST ECTRICAL iNS E�� Check # WHITE: Applicant CANARY: Building Dept. PINK:Treasurer +DEPARTMF.IVTOFPVBLICSAFRY Permit No. 133- ' BOARDOFFMPREVEWONRWUMT1OAN527CMR]2.O —' Occupancy&Fees Checked APPUCATTONFOR PERMIT TO PEUORMELE=CAL WOYK ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS ELECTRICAL CODE,527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Dat , D Town of North Andover To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location(Street&Number) Owner or Tenant iZv / CST D Owner's Address 4� C I Is this permit in conjunction with a building permit: Yes[ No (Check Appropriate Box) j Purpose of Building Utility Authorization No. Existing Service Amps Volts Overhead Underground No.of Meters New Service G>d Ampsl&2,1 / v Volts Overhead M Underground No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work' . 701&1-.7 -07 '17-75 No.of Lighting Outlets No.of Hot Tubs No.of Transformers Total KVA No.ipf Lighting Fixtures Swimming Pool Above Below Generators KVA ground ground No.of Receptacle Outlets No.of Oil Burners No.of Emergency Lighting Battery Units 1�+ of Switch Outlets No.of Gas Bumers No.of Ranges No.of Air Cond. Total FIRE ALARMS No.of Zones Tons No.of Disposals No.of Heat Total Total No.of Detection and Pumps Tons KW Initiating Devices No.of Dishwashers Space Area Heating KW No.of Sounding Devices No.of Self Contained Detection/Sounding Devices No.of Dryers Heating Devices KW Local Municipal Other Connections No.of Water Heaters KW No.of No.of Signs Bailasis No.Hydro Massage Tubs No.of Motors Total HP G*fHER hst==Co�aaga RnstatbthetagtmanatscfMasssdmsmCmaWLaws Iha%eaamertLial*6m==PbtiWmduftCanVkje Ct a•Assdktttiata*aWat YES NO IImewbmitlaJvalidpoc(of==tDtheO i=YES M NO M IfycutmedxcWYESpkmmdc&tkteWofwmaWbydrdmgthe II�ISURAN ox f7 BOND OTI IQt (P(easespa*) F�uatirn Die Est¢t od ValuecrtBmftxd Wads$ WaktDStwt hVadmD,*RaVmWd Rogh Final Signedutx aTrPFiWWsofpa W FIRMNANIE l i Lid LiarneNa - �9 Z— Lioalsmti �v, `L�� SignatureZ— Bts¢IessTel.Na AftTel.Na �r59� OWNERSDWRANCEWAIVFR;I.arnawaceihattheLime theirlstramw=pa-itssr lecgmWatasrBgmWbyki%mdumCmcdLaws andditmyssgi s ,m ispanitappficMm alismpiement. (Please check one) Owner a Agent ❑ ° 6k Telephone No. PERMIT FEE �� o,HOR♦.14 0 ^ Town of ­0st`'• NORTH ANDOVER C BUILDING PERMIT INSPECTION REPORT 04- R PERMIT NO.: ®� PROJECT: ���`' �! I#3P1 DATE: "/ a UNIT NO.: FLOOR: WING: BUILDING NO.: 04C5 ' REMARKS: �� �eDo'v�? 3,6- 13ny4 8 ,S)4d 11 V'V j& C 'S"X 4 7;L / i Excavation-depth and soil conditions Framing- Other: Date: Date: Date: Inspector Inspector Inspector Footings and foundations and drains- Insulation- Other: Date: e`� C7/ Date: Date: Inspector .1 �� k (6` Inspector Inspector Electrical-rough- Plumbing and/or gas-rough- Other: Date: Date: Date: Inspector Inspector Inspector Electrical-final Plumbing and/or gas-final Other: Date: Date: Date: Inspector Inspector Inspector rare Dept- :lil burner,tank,stove,smoke detectors Final inspection Certificate of Use and Occupancy Date- Date: Date: -Cof 0# Inspector Inspector Inspector Form#995 Action Press,685-7000 i Town of North Andover o� TAO TH ,� .1 ,� Gt Mb• Building Department �, g..;�_ b o 27 Charles Street 0 P- North Andover, Massachusetts 01845 (978) 688-9545 Fax (978) 688-9542MID ACNUs�t�� APPLICATION FOR CERTIFICATE OF OCCUPANCY/INSPECTION ADDRESS LOT NUMBER SUBDIVISION f _ N(T�A 1'.�� DATE REQUEST FILED t 0 . DATE READY FOR INSPECTION FIVE (5) DAYS NOTICE PRIOR TO CLOSING DATE IS REQUIRED ALL WORK AND SIGN-OFF'S MUST BE COMPLETED WITHIN THIS TIME FRAME. A RE-INSPECTION FEE OF TWENTY-FIVE($25.)DOLLARS WILL BE CHARGED IF THE STRUCTURE DOES NOT MEET ALL APPLICABLE CODES. SIGNATURE OFFICIAL USE ONLY ROUTING r CONSERVATIDATE102— PLANNING_ DATE D.P.W. -WAJR METER DATE 5 - to -0 2 D.P.W. MUST INDICATE THAT THE WATER METER HAS BEEN INSTALLED PRIOR TO THE INSPECTION REQUEST DATE. 'QST AT'IJRE WMAUTHORIZATION v .ptONTM 3a d.yr, •-.• o O p N t w ;9sSAC�1� CERTIFICATE OF USE & OCCUPANCY TOWN OF NOR'T'H ANDOVER Building Permit Number _IA4— Date S"6 THIS CERTIFIES THAT THE BUILDING LOCATED ON 7u MAY BE OCCUPIED AS IN ACCORDANCE - WITH THE PROVISIONS F T MASSACHUSE S STATE BU DING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. CERTIFICATE ISSUES TO �4v '�� oijQ&'- ,;,AIss Building Inspector Va^Aot- I, NpRTM Town of 4Andover /O VO LA o dover, Mass. L? 4917-oPc9yJ COCMIC HEWICK 1 ADRA7ED APa��S S 4 BOARD OF HEALTH PERMIT T iD Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT. .......Q..... .....AN..0.100r*....... rA Cp� •............ ...... ........ .............................. Foundation ld'i//{l6-- has permission to erect................/.................... buildings on O� i� C AJ////j to be occupied as j.#.RO..Q...1.!�'l./..��5...Ba�.:../..,I/ 1./�a// fl.*dfr.....52A/s... �� � �/1( himney✓19�79[(�i r� provided that the person accepting this permit shall in every respect conform to the terms of lication on file in. in 6 this office, and to the provisions of the Codes and By-Laws relating to the Ins pe tion, Alteration and Construction of Buildings in the Town of North Andover. M `� p!y /Q ��� PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. f� ou 7-2—d1 PERMIT EXPIRES IN 6 MONTHS UNLESS CONSTRUCTI T"11 T LECTRI AL E 0 ou ......... ............. ..................... ...................................................... Service BUILDING INSPECTOR 6. �� FinAlp Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove RoughJ�g , /G No Lathing or Dry Wall To Be Done Until Inspected and Approved by the Building Inspector. FIR DEPARTMENT Burner Street No. SEE REVERSE SIDE Smoke Det. ; Town of North Andover NORTH OFFICE OF 3?�y`S t�E /e 141 COMMUNITY DEVELOPMENT AND SERVICES f- A 27 Charles Street WII,LIAiv1 J. SCOTT North Andover, Massachusetts 01845 X97 CHUS���h Director (978)688-9531 Fax(978)688-9542 CHIMNEY APPLICATION AND PERMIT DATE 536,D PERMIT # D� C-1 LOCATIONS OWNER'S NAME f 1. PW-�&71"y &C pi ' I BUILDER'S NAME �rj-r" MASON'S NAME ( aLy. 0 tn1- o � MASON'S ADDRESS _a. — hI (fir o r MASON'S TELEPHONE MATERIAL OF CHIMNEY EX cLk QYV INTERIOR CHIMNEY EXTERIOR CHIMNEY V, NUMBER AND SIZE OF FLUES �,� �. X k THICKNESS OF HEARTHt7'� ' I Will chimney or fireplace conform to requirements of the code and j have rules and regulations been received: DATE SIGNATURE OF MASON :Rlat.9/.���rr � „�,✓ CONTR. LIC. # CS 0�3! �j j EST. CONSTRUCTION COST/CONTRACT PRICE 5C)oC)L PERMIT GRANTED � FEE ROBERT NICETTA, BUILDING INSPECTOR INSPECTED REMARKS SOLID BRICK REQUIRED THIS PERMIT MUST BE DISPLAYED ON THE PREMISES BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 Location No. �0f Date OR TOWN OF NORTH ANDOVER 41 s + ; . Certificate of Occupancy $ �'�s •Eta CMU s Building/Frame Permit Fee $ sA Foundation Permit Fee $ Other Permit Fee $ � TOTAL $ Check # 6 / 46� Building Inspector