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HomeMy WebLinkAboutMiscellaneous - 47 PRESCOTT STREET 4/30/2018 47 PRESCOTT STREET 210/068.0-0008-0000.0 I , I Date...........1I.n................. OF NORTM,� TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION CHU This certifies that A......... ........ ............................................. . ............ has permission for gas . stallation ...YW-Ple-e....... ... ................ in the buildi, s Of'***"*"*'�ZJ4*e.,.)** at...,................ . ........ . ........ North Andover, Mass. Fee.....(P.C.)...... Lic. No. 1056+73- 41-4 4s- ......................... ..................................................................... GAS INSPECTOR Check# 09892 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK MA DATE`. JOBSITE ADDRESS OWNER'S NAME GOWNERADDRESS TE FAX TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL � �� CI'EARLY NEW:Q RENOVATION:DI REPLACEMENT:[ PLANS SUBMITTED: YES Q NO[ " APPLIANCES Z FLOORS-► BSM 1 -1 2T �3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER �- CONVERSION BURNER ar COOK STOVE DIRECT VENT HEATER DRYER _ FIREPLACE FRYOLATOR FURNACE GENERATOR — GRILLE INFRARED HEATER- ­­LABORATORY COCKS (`- �— MAKEUP AIR UNIT OVEN POOL HEATER _ I ROOM/SPACE HEATER ROOFTOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATfA, 1EATER OTHER fneTe a 6O OU t INSURANCE COVERAGE 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES [WO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY E;J� OTHER TYPE INDEMNITY BOND F 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: OW .ER AGENT SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I_have submitted or entered regarding this application are true d ccur e th t.of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be incom Iia th rti nt ovislon of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. 1 PLUMBER-GASFITTER NAME F, LICENSE# 156 K IGNATURE MP aMGF® JP ® JGF© LPGI El CORPORATION PARTNE HIP®# ( LLC EJ#= COMPANY NAME: ee Bro SE2�J ej ADDRESS — CITY STATE' /11 ZIP 2 i Z 2 TEL (7/ 7-- od r FAX CELL 5°2_gd6-Igg411EMAIL �eeae 6�� Lh � � i I I �� �� S�/� l� s���i� G��e�� MONW AdTF1=� �! • . • '��'a'S��iC1.1US TSS . PL'UMBEY s,y IS-S- T� x °SFITT'lS ,. �H F0L' O�JING � r z As L JW`E E A MASTaE NS ,. . SAV{Ig :,W �` x PLUMBEzRs,f ,F 24 RQK (?N 4htq 024 ' W 1 ,64 301 14g� ,r:: ;d , - 0I'/o 1 2264.42 :,GOMMONWEALTki OF MA-8-8 l3SETTS'"� S� s BO!�FAD QF >; PLUMBEIS� G�4SFIT1TERSt� k` EISSUE THE fOLLOW- ISl�,.d,O% CENSE z ts � �- RGff' TtRED AS A6 PLUMeuI' a �O�P� " pAUIx W GARF I ELDf` EFENEY BR0T-WB;R:5= SERVIfDE, LC ' z 2r1 WI��LOW ROCK1oN M 02301 36' ogYo 1/]6 #. 2 N413 4 i FEENBRO.01 SMORAN -_...-- DATE(MMIDDAYYY)-- ----- - ---------- �., CERTIFICATE OF LIABILITY INSURANCE 1/30/2015 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 Ileu of such endorsement(s). PRODUCER CONTACT NAME: Rogers 8,Gray Insurance Agency,Inc. PHONE FAX 434 Rte 134 ac No Ext: Arc No):(877)816-2156 South Dennis,MA 02660 ADDRESS: INSURER(S)AFFORDING COVERAGE MAIC A INSURER A:Old Republic General Insurance Corp. 24139 INSURED ENSURER B Feeney Brothers Services LLC INSURERC: 103 Clayton St PO BOX 220801 INSURER D: Dorchester,MA 02122 INSURER E: 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. INSR DD SBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER IMM1DD/YYYTL IMWDDNYYYILIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,00 CLAIMS-MADE a OCCUR A2CGO7501501 02/01/2015 02/01/2016 PREMISES(Ea occurrence) S 300,00 t.1 ED FXP(Anyone person) S 10,00 PERSONAL BADVINJURY $ 1,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 2,000,00 POLICY.P0 JEC LOC PRODUCTS-COMPIOPAGG $ 2,000,00 OTHER: $ AUTOMOBILE LIABILITY IBINED SINGLE IMIT Ea accident $ ANY AUTO BODILY INJURY(Per person) 5 ALLOV\NED SCHEDULED fid A BODILY INJURY( eraccen $ AUTOS AUTOS ) NON�OWNED ROPERTY DAMAGE HIREDAUTOSAUTOS Perseddent $ $ UMBRELLA LIAROCCUR EACH OCCURRENCE $ EXCESS LIAR HCLAAIS-MADE AGGREGATE $ DEO I I RETENTIONS $ WORKERS ANDEMPLO EM1RS'LIABILIITY YIN X STATUTE ERS A ANY PROPRIETORMARTNER/EXECUTNE A2CW07601601 02/0112015 02/01/2016 E•L.EACH ACCIDENT $ 1,000,00 OFFICERA.10.18ER EXCLUDED? NIA (Mandatory (Mandatory In NH) E.L_04SEASE-EA EMPLOYEE S 1,000,00 lyyes descnbeunder DES(RIPTIONOFOPERATIONSbeaN E.L-DISEASE-POLICY LIMIT S 1,000,00 L -I DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may attached If mote space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1600 Osgood Street ACCORDANCE WITH THE POLICY PROVISIONS, North Andover,MA 01845 AUTHORIZED REPRESENTATIVE ' t) ©1088-2014 ACORD CORPORATION. All rights reserved. ACORD 26(2014101) The ACORD name and logo are registered marks of ACORD _ , PO Box 55098 Boston,MA 02205-5098 617-951-0600 Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS, Ch. 139, Sec. 3B To: Building Commissioner or Board of Health or Inspector of Buildings Board of Selectman City Hall City Hall NORTH ANDOVER, MA 01845 NORTH ANDOVER, MA 01845 7 RE: Insurc&, WCHAEL-RODDEN and CHRISTINE RODDEN IIS Property Address: 47 PRESCOTT STREET,NORTH ANDOVER,_MA Policy Number: HMA 0276553 Claim Number: BOS00054597 Date of Loss: 2/21/2015 Company: Safety Indemnity Insurance Company Claim has been made involving loss, damage or destruction of the above-captioned property, which may either exceed $1,000.00 or cause Mass. Gen. Laws, Chapter 143, Section 6 to be applicable. If any notice.under.Mass. Gen. Laws, Chapter 139, Section 3B is appropriate,please direct it to the attention of the writer and include a reference to the captioned insured location, > policy number, date of loss and claim number. Eric Yablonski Claim Examiner 3/11/2015 Safety Insurance Company Homeowners Claims Unit P. O. Box 55098 Boston, MA 02205-5098 Phone: (617) 951-0600 EXT 3.550 Fax: .(617),531-6650 Email: EricYablonski@Safe�tylnsurance.com Tne CERTIFICATE VF LIABILITY INSURANCE DATE �VO�D11/13/21 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMAL PRODUCER ONLY AND CONFERS NO RIGHTS UPON THE CER71FIC NORTH ANDOVER INSURANCE AGENCY, INC HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND 9 WAVERLY ROAD ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW INSURERS AFFORDING COVERAGE NORTH ANDOVER MA 01845-2415 INSURED INSURER A:NATIONAL GRANGE MUTUAL Michael Rodden INSURER B:TRAVELERS PROPERTY & CASUALTY 47 Prescott Street INSURER C: INSURER D: North Andover NA 01845— INSURER E COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDIN REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PEI THE INSURANCE AFFORDED BY TETE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POI AGGREGATE LIMITS SHOWN MAY HAVE'SEEN'REDUCED BY PAID CLAIMS. (NSR TYPE OF INSURANCE POLICY NUMBER POLICYEFFECTIVE p DATE MM/DD/YY DATH TKMN LIMITS LTR MM/DD A GENERAL LIABILITY / / EACH OCCURRENCE $ 1.,00 X COMMERCIAL GENERAL LIABILITY FIRE DAMAGE(Any one fire $ 50 CLAIMS MADE OCCUR NPP37395 02/01/2003 02/01/2004 MED EXP An one person) $ 1 PERSONAL&ADV INJURY $ 1,00 / GENERAL AGGREGATE $ 2,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,00 POLICY JEPR LOC AUTOMOBILE LIABILITY / / / / COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ ALL OWNED AUTOS / / / / BODILY INJURY SCHEDULED AUTOS (Per person) $ HIRED AUTOS / / / / BODILY INJURY NON-OWNED AUTOS (Per accident) $ PROPERTY DAMAGE (Per accident) $ GARAGE LIAB1LI7Y AUTO ONLY-EA ACCIDENT $ ANY AUTO /_ / / OTHER THAN EA ACC $ AUTOONLY: AGG $ EXCESS LIABILITY / / / EACH OCCURRENCE $ OCCUR FICLAIMS MADE AGGREGATE $ DEDUCTIBLE / / / $ RETENTION $ $ WORKERS COMPENSATION.AND / X TORY LI ITS T EMPLOYERS'LIABILITY - ER E.L.EACH ACCIDENT $ 1C 849K419 01/01/2003 0101/2004 E.L.DISEASE-EA EMPLOYEE$ iC E.L.DISEASE-POLICY LIMIT $ 5C OTHER DESCRIPTION OF OPERATIONSILOCATIONSIVEHICLES(EXCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS CERTIFICATE HOLDER ADDITIONAL INSURED;INSURER LETTER: CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFOI EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TC 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LE TOWN OF NORTH ANDOVER FAILURE TO DO-SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND OF INSURER,ITS AGENTS AOR REPRESENTATIVES. -----------AW ,ORI PR S -- -- - --- North Andover MA 01845- -- ACORD 25S(7/97) i O ACORD CORPORATI INS021S IS9,01,01 ELECTRONIC LASER FORMS,INC.-(800)327-0545 _