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HomeMy WebLinkAboutMiscellaneous - 453 STEVENS STREET 4/30/2018 - S S r eee 7- - r Date.?/t!D/U..-r 9437 A 4 TOWN OF NORTH ANDOVER 3: .�� - • '•°oma ;�. PERMIT FOR PLUMBING ,SSACMUSf R 1��: _ This certifies that ! . . . . . . . . . . . . . . has permission to perform .5�f.G : . .. . . . . . . . . . . . . . . . . plumbing in the buildings of . . . . . . . . . . . . . . . at . �� ��/PNS --?�.. . Wrth er, ass. Fee ��. . .Lic. No.3m�?!- . °.� CT R Check # MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO DO GAS FITTING STATE:MA APPLICATION DATE. 7 1- ) CITYITOWN: do JOB ADDRESS:1 OCCUPANCY TYPE; COMMERGIAL7 RESIDENTIAL PLANS SUBMITTED. YES[] NO[] NEW[] ALTERATION[] REPLACEMENTO REMOVAUDEMOLITIONE] T NATURAL&LIQUEFIED PETROLEUM GAS: PIPING-EQUIPMENT-APPLIANCES-SYSTEMS "I ENTER TOTAL AMOUNT FOR EACH SELECTION(LIMITED TO FIVE(5)NUMERALS AIR ROTATION UNIT FURNACE: ALL TYPES TEMP HEATING EQUIPMENT —7-7 BOILER:ALL TYPES GAS PIPING THERMAL OXIDIZER BOOSTER F _7--] GENERATOR(STATIONARY ENGINE) TURBINE BROILER F ILLUMINATING APPLIANCE UNIT HEATER BURNER: ALL TYPES INCINERATOR WATER HEATER: ALL TYPES CO-GENERATION UNIT I INDUSTRIAL AIR HANDLER EQUIPMENT OVER 12,500MBH COFFEE ROASTER INFRARED HEATER .-OTHER NOT LISTED-1 COOK APPLIANCE HOUSEHOLD KILN i GLORY HOLE/CRUCIBLE F— COOK APPLIANCE COMMERCIAL LABORATORY COCKS DECORATIVE APPLIANCE MAKEUP AIR UNIT T- DIRECT VENT APPLIANCE MECHANICAL EXHAUST EQUIPMENT DRYER: ALL TYPES OVEN: ALL TYPES FIREPLACE:VENTED/UNVENTED POOL HEATER FRYOLATOR ROOF TOP UNIT FUEL CELL ROOM HEATER-VENTEDNENTLESS I PLUMBING GAS FITTING FIRM INFORMATION CHECK ONE ONLY ! , - - - 7--- "I'll ECorporation Business#E= NAME: AD D R E S S: 1�5�c- L Partnership Business#F-----7.- 6V El CITY: QQQ-t 002- STATE:J�MDA ZIP E!, LLC Business# '7 jo-7L�'53- --J EMA DBA Unincorporated TEL:1M - A FAX:i- ' -.' IL: NAME OF LICENSED PLUMBER I GAS FITTER: INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch,142 YES� NO If you have checked Yes,please indicate the type of coverage by checking the appropriate box below. A liability insurance policy Other type of indemnity BondEl 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. OWNER[]CHECK ONE ONLY AGENTE] Signature of Owner or Owner's Agent OWNER'S NAME:-. ---"------. TELL--�.--- FAX L-- I hereby certify that all of the details and information I have submitted(or entered)regarding this permit application is true and accurate to the best of my knowledge.I certify that all plumbing work and installations performed under thu permit issued,will be in compliance with all pertinent provisions of the Massachusetts Uniform State Plumbing Code,and Chapter 142 of the General Laws. (OFFICE USE ONLY) Type of License: Permit# OPlumber nGasfitter Signature of Licensed Plumber I Gas Fitter Inspector E]Master gJourneyman O Undiluted LP Installer License Number: Fee: O Limited LP Installer 4 ;s Jun 4 09 : 53 :27 2012 From: Hall,Larry To: 99786889542 Page 1 of 2 V.6South V![iLfvr.�� ■ �� �vra v� ��r�v��� ���vv�v ���v06/04/2012 M 978,887,4900 FAX 978.887.2404 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION F. Sennott Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Main Street HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P. 0. Box 457 Topsfiel d, MA 01983 INSURERS AFFORDING COVERAGE NAIC# INSURED Graham Archer INSURER A: Merchants Mutual Insurance Co. DBA: Archstone Plumbing & Heating INSURER B. 19 Pingree Farm Road INSURER C: Georgetown, MA 01833 INSURER D: INSURER E: COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. NSR ADD' POLICY EFFECTIVE 0 ICYEXP TION LTR INSR TYPE OF INSURANCE POLICY NUMBER DATE MMIDD DATE MM/DD LIMITS GENERAL LIABILITY BOPI043396 10/19/2011 10/19/2012 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence) $ 500,000 CLAIMS MADE Fi-I OCCUR MED EXP(Any one person) $ 15,000 A PERSONAL&ADV INJURY $ included GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY PRO LOC JECT AUTOMOBILE LIABILITY MCA7014929 10/19/2011 10/19/2012 COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ .1,000,000 ALL OWNED AUTOS BODILY INJURY $ A X SCHEDULED AUTOS (Per person) X HIRED AUTOS BODILY INJURY $ X NON-OWNED AUTOS (Per accident) r I PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO EA ACC $ OTHER THAN AUTO ONLY: AGG $ EXCESS I UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR E� CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION VVU�iIAIU- _T7 AND EMPLOYERS'LIABILITY YIN TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory inNH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT 1$ OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENTI SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN Town of North Andover NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL Attn: Plumbing & Gas Inspector IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR 1600 Osgood Street REPRESENTATIVES. North Andover, MA 01845 AUTHORIZED REPRESENTATIVE Peter Sennott/LAR ACORD 25(2009/01) FAX: 978.688.9542 ©1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Location �� No. Date 140^TM TOWN OF NORTH ANDOVER 41 • ; , Certificate of Occupancy $ ��s'+cNusEt� Building/Frame Permit Fee $ `3c' Foundation Permit Fee $ Other Permit Fee $ TOTAL $ X30 o-d Check # 20772 !. Building Inspector