The URL can be used to link to this page

Home My WebLink AboutMiscellaneous - 47 HIGH STREET 4/30/2018 (4) 17 BUILDING FILE r7*rai ;at=ca==" X D Fat, :/,fmr.Tlacldi vamiavieApd douzl.cormJ�+{recordsj2Crz22 Town of North Andover,MA Q Search...__ i i 20222 i i *P Perrnt-2n:Covt &--n xkb a Bc5n:ig P ECS arResidaiddi i TIMELINE shi7arri ia�s reteiiu [ Yotr retest iis in program ItiAaq 9,�Di 6 �i$p^5 WtV 3a ynu Inm a,any updares via em-a Fee7'[reE to jJJ�•�� die&t e sus at any Jrne by= vna back w tiiis paw 0 Plumbing Permit Review 0 Permit Fee Pd)'rn.'t1t r Permit Issuance Do=urnent G4 !9 •r� __.. _ fix} �ca'.1}m-=rccooae f4pCCt�-nF Lac=an •1 Greene 43 HIGH STRE ,NORTH ANDOVER,MA Gwn±r RCC HGETH ANDD EIR fAU 5 ILLC ! t3i� -0T9H9Gl00I F-Mon-May-09-2016-18:28:.PDF Search tar iraur c wiTarmru%, sty search ba- Either the Iris 5 ilk cr Xk 4 1 u k- 2-01�, AwJ Monday,May 09,2016 02:28 PM ` Aug 2015 3:05PM E,T, O'Connell Insurance 9786817830 page 1 R ® DMID ATE IMDtYYYY) cvRo CERTIFICATE OF LIABILITY INSURANCE 08/25/2015 I HJS"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. It 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 endomement(s). PRODUCER CONTACT NAME: Barry T. OConnell Insurance Agency Inc. PHONE 19'78) 682-2896 FAX (978) 661-7830 252 Pleasant Street E-MAIL ,Info@btoconnellinsurance.com INSURERS AFFORDING COVERAGE NAIC tl Methuen MA 01844- wsURERA:NAT.IONAL GRANGE 14UTUAL INSURED eerie m GREE Gr Ja es D/B/A NE PLUMBING r INSURER 9: AND HEATING INSURERC: 74 BRIDGE STREET INSURER D: INSURER E: Salem NH 03079— 1 INSURER F: COVERAGES CERTIFICATE NUMBER: 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. I INSR ADOL SUER POLICY EFF POLICY EXP TR TYPE OF INSURANCE POLICY NUMBERDN LIMITS GENERAL LIABILITY 61PF0924P 7/06/2015 07/06/2016 EACH OCCURRENCE $ 1,000,ODO DAMAGE TO RENTED .)C COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrenceI $ CLAIMS-MADE F7 OCCUR / / / / MED EXP(Ary one person) $ 10,000 / / / / PERSONAL&ADV INJURY $ 1,000,000 / / / / GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: / / / / PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY PRO- LOC / / / / NOWND $ AUTOMOBILE LIABILITY / / / / COMBINED SINGLE LIMIT Ee acdda — ANY AUTO / / / / BODILY INJURY(Per person( $ ALL OWNED SCHEDULED / / / / BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED / / / / PROPERTY DAMAGE HIRED AUTOS AUTOS Per ac erR UMBRELLA LIAR OCCUR / / / / EACH OCCURRENCE $ EXCESS L1AB CLAIMS-MADE / / / / AGGREGATE $ DED I RETENTION WORKERS COMPENSATION / / / / WC STATU- OTH- A NDE MPLOYERS'LIABILITY 1111 ANY PROPRI ETD RIPARTNER/EXECUTIVE YIN / / / / E.L.EACH ACCIDENT S OFFICER/MEMBEREXCLUDED? F—] NIA (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ If yes,descrbe under DESCRIPTION OF OPERATIONS below / / / / E.L.DISEASE-POLICY LIMIT $ / / ! DESCRIPTION OF OPERATIONS/LOCATIONS!VEHICLES (Attach ACORD 107,AdcliUona1 Remarks Schedule,IT more space is rogWredl i CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of North Andover 1600 Osgood Street AUTHORIZED REPRESENTATIVE Bldg#20-sulte2035 North Andover MA 01845- ACORD 25(2010/05) 41988--2201100 ACORD CORPORATION. All rights reserved. INS025(2oioo5).o1 The ACORD name and logo are registered marks of ACORD Date..... TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING . .. This certifies that ....... ...... haspermission to 4 ........................................................................................ wiring in the building of......... �/........Z�..2...... ........ ................. ................... rr "7 at ......... ..Y ....... .......... .....:� . ........... ....................... /orth nclover,Mass. .............Lic.No. 11,3ry�.................. ......-, .... ... LEC ICAL&SPEcroi Check# 11877 1 commonwealth of Massachusetts Official Use Only - Department of Fire Services PerrmtNo. f 7-7 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 MR 12.00 (PLEASE PRINT IN MK OR TYPEALL INFORMATION) Date: �17-J" %3 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. 6 Location(Street&Number) fq!, 11/6411 'Ir. Owner or TenantijT,�Jf af� ��,fj`r��/ ( Telephone No. Owner's Address _ I7 lilhl04 Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) n' Purpose of Building 2e�z�� 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: Completion of thefollowing table may be waived by the Inspector of Wires. No.of Recessed Luminaires (Tpmingpool f CellrAbove Fans No.of Total Transformers KVA No.of Luminaire Outlets f Hot Generators KVA No.of Luminaires In- ❑ o,o mergency ig ting rnd. Batter Units No.of Receptacle Outlets 17 No.of Oil BurnersFIRE te of Zones No. ofSwitches No.of Gas Burgers o.oection and 11 Initiatin Devices No.of Ranges No.of Air Cond. Tons Total No.of Alerting Devices �v No.of Waste Disposers Heat Pum Number. Tons KW No.ofSelf-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 E uivalent No.of Water / No.of No.of Heaters ! KW signs Ballasts Data Wiring: No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or E uivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: en 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 W 13OND ❑ OTHER ❑ (Specify:) Icertify, under thepains and penalties ofperjury,that the information on this application is true and complete. FIRM NAME: _ �ll/Ir8 ®4 0-le LIC.NO.: Licensee: /�� LIC. LTC.NO.: (Ifapplicable,enter "exempt"in the licensep"n7ber / Bus.Tel.No.- . Address: 12 g'i/141Ch7 O V i fff�•Q�•�� Alt.Tel.No.: *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 agent. Owner/Agent Signature Telephone No. PERMIT FEE. $ 12,�' ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the provisions of M.G.L.C.143,§3L,the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166,§32,an electrical permit shall be issued to the person,firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L.c.143,§3L. Permits shall.be limited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012. ❑ Rule 8—Permit/Date Closed: .***Note:Reapply for new permit ❑ ❑Permit Extension Act—Permit/Datd C16"se0: . Trench Inspection Pass 0 Failed 0 Re Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: : . r PARTIAL ROUGH INSPECTION: Pass(] Failed Re-Inspection Required($.) ❑ r Inspectors Comments: Inspectors Signature: Date: ROUGH ECTION: Pass Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: i. Inspectors Signature: k.5 a Date: FINAL ECTION: Pass • . Failed 0 Re-,Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: o-11 u r^z Date: /!— 3' DEB WEINHOLD ...TOWN OF MERRI AC,MA. .......dweinhold@townofinerrimac.com J I The Commonwealth of Massachusetts Department oflndustriglAccidents Office of Investigations 600 Washington. Street Boston,MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organizationlfndividual): Address: City/State/Zip:^ Phone if: �� `�`��/7 Are ou an employer?Check the appropriate box: Typo of project(required): 1. I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(fall and/or part-time).* have hired the sub-contractors � p ) 7. Remodeling 2.❑ I am a sole proprietor or partner listed on the attached sheet.t ❑ g ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. g, ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.E]Electrical repairs or additions 3.F1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t employees.[No workers' 13.❑Other 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 aie doing all work and then hire outside contractors must submit anew affidavit indicating such. tContractors that checkthis box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workerscompensation insurance for my employees. Below is the policy and job site information. f..� Insurance Company Name:. Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder 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 sof 'Investigations of the DIA for insurance coverage verification. I do hereby certio under the pains andpenalties ofperjury that the information provided above is true and correct. - Simature: Date: Phone#: 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 d.EIectrical Inspector 5.Plumbing Inspector 6.Other - - Contact Person: Phone#: 1 ij r Information and Instruction's 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 ofhire, 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 e p ys p rsons to do maintenance,construction or repair work on such dwelling house or on the grounds or buildingappurtenant thereto shall not because of such employment To ment p y 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 ofpublic 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 numbers)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 maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the 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 permithicense 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 onl Y.submit one affidavit indicating current - policy information(ifnecessary)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. Anew affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Coax moi walth of Massarliusetts Department offadustdal Accidents • (?f�e�o�iu'�estigatio.�.� 600 Washington Street Boston?MA 021 X x TTL#617-727-4900 ext 406 or 1-$77,MASSAFE Revised 5-26-05 Fax#617-727-7749