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HomeMy WebLinkAboutMiscellaneous - 5 EMPIRE DRIVE 4/30/2018 i � , �1 �� <. --� 0 S erTab® Oversized-Tab folders 90%Larger Label Area ®® S M E A KEEPING YOU ORGANIZED No. 10301 PATENT PENDING SUFOR� FAN.RECYCLED INITI M CONTENTID% aian.awe W FIbw 8� POST-ONSUMER 3"1290 MADE IN USA GET ORGANIZED AT SMEAD.COM Date.... ............................ NORT/j TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING Hu This certifies that ..........Al-`....t�........ ............ ................................................ has perrmission to perform ....... ............. ......... e................. .......... wiring in the building of............% ......e............. .................. ... ............... ...... ............ firth Andover,Mass. Fee... Lic.No.15�.?f,. Check# 11577 Commonwealth of Massachusetts Official Use Only Permit No. -27 Department of Fire Services 1 ,�' ' Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/071 (leaveblank 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 ININK OR TYPE ALL MFORMATI019 Date: j~ /,? / 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. Location(Street&Number) _ .G .,Or _ Owner or Tenant , �r/-r'. c- r_ !nr^ Telephone N Owner's Address o- Box)—e- _ Is this permit in conjunction with a building pe mit? Yes No ❑ (Check Appropriate s Purpose of Building 4v �+� Utility Authorization No.��/'j 3Z S Z - Existing Service Amp / Volts Overhead❑ Undgrd❑ No.of Meters New Service Z Uy Amps -2-v/-2-5,14- Volts Overhead❑ Undgrd ® No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: L.� Completion of the following table maybe waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA N6.of Luminaires Swimming Pool Above ❑ In- 1:1 o.o mergency Lighting rnd. rnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Tons TotNo.of Alerting Devices No.of Waste Dis osers Heat Pump Number Tons J.M No.of Self-Contained p Totals: Detection/Alerting Devices No.of Dishwashers S ace/Area Heating KW Local❑ Municipal El Other P g Connection No.of Dryers Heating Appliances KW Security Systems-* Y No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Eg uivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: = 3-/ 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 force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE OND ❑ OTHER ❑ (Specify:) .I certify,under the pains and penalties ofperjury,that the information on this application is true and complete. FIRMNAME: , - S• Y l �L �� C.NO.: Licensee: _ Signature LIC.NO.: (If applica le,e er "exempt"inlefie license numbline.) Bus.Tel.No.: Address: vCr y K Alt.Tel.No.:Q7�-6J,-T- '�/�'0000, *Per M.G.L c. 147,s.57-61,se rity wor requires Department of Public Safety"S' License: Lic.No. OWNER'S INSURANCE R: 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 PERMIT FEE. $ Signature Telephone No. ❑ 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 Chanter 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 :Extension ermit/Date Closed: ***Note:Reapply for new permit ❑ ❑ Act—Permit/Date Closed: Trench Ins ection Pass 0 Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass Failed � � Re-Inspection Required($.)❑ Inspectors Comments: . Inspectors Signature: Date: PROUGH INSPECTION: Pass Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: S lb InspeasSature: Date: ., ROUGH INSPECTION: Pass 0' Failed 0 Re-Inspection Required($.) ❑ Inspect rs ents: I I' Inspector Signature: Date: 'INAE ECTION: Pass IN Failed � Re-Inspection Required($.) ❑ nspectors Com ents: Inspectors Signature: Date: =B WEINHOLD ...TOWN OF MERRIMAC.MA The Commonwealth of Massachusetts - Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le0bly Name(Business/Organization/Individual): Address: City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.EJI am a sole proprietor or partner- listed on the attached sheet. Remodeling ship and'have no employees These sub-contractors have 8. E]Demolition working for me in any capacity. workers'comp.insurance. g• ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its officers have exercised their 10.❑Electrical repairs or additions required.] 3.❑ I 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 12.0 Roof repairs insurance required.] employees.[No workers' q ]t 13.[i Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. I Homeowners who submit this affidavit indicating they ire doing all work and then hire outside contractors must submit anew affidavit indicating such. $Contractors 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 workers'compensation insurance for my employees. Below is thepolicy and job site information. 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 of insurance coverage verification. Investigations of the DIA.for g g I do hereby cert 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: P ermit[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#: Information and Instructions 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 of hire, 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 persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment 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 of public 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-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the 4 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 may be 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 permit/license 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 only submit one affidavit indicating current policy information(if necessary)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. A new 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 (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 Commonwealth of Massachusetts Department ofhadustrial Accidents Office of Investigations 600 Washington Street Boston,MA 0.2111 Tel,#617-727-4900 ez t 406 or 1.-877rMASSAFB Revised 5-26-05 Fax##617-727-7749 www.Mass,govldia Date . . . . . . . . . . . . . TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that . .6.`.i.`" r,:-t l. . Pl�.. .�� .�'E t . . . . . . . . . has permission for gas installation . .VA i;P . . . . . . . . . . in the buildings of. . .C_7 `-�^`fir 0.Il l t`S.-I"-- at . . . . . . . . . .North Andover, Mass. Fee i PO.9t4 . . Lic. No.�9.3 L(J. . 1. .. . . . . . . . . . GASINSPECTOR Check# -760 1 8666 3 Of Date P.b� LFiYJ�a^: TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that . . .G 1v sv . . . -'^^�'" � . 1( . has permission to perform . . �3�q --. . . . . . . . . . . . . . . . . . fes. plumbing in the buildings of. . . .�J� � . at . . . . . :mow F� a': -. . . . . . . . . . . . . . .North Andover, Mass. Fee . Lic. No. iA7P`<.� PLUMBING INSPEftbR Check# 7& f MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK � CITY AfIG�I "ill�& MA. DATE y ' l SbJ 3 PERMIT# JOBSITE ADDRESS OWNER'S NAME 0I(LLt4_W" V t(-LV mzr POWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE: COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL PRINT NEW: RENOVATION:❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO ❑ CLEARLY FIXTURES 7 FLOOR- BSMT 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYS DEDICATED GAS/OIL/SAND SYS DEDICATED GREASE SYS DEDICATD GRAY WATER SYS DEDICATED WATER RECYCLE SYS DRINKING FOUNTAIN DISHWASHER FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER INSURANCE COVERAGE: I have a current liabili insura t nce policy or its substantial equivalent which,meets the requirements of MGL Ch. 142. Yes(RrNo❑ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY ❑ BOND ❑ 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 BOX ONLY: OWNER ❑ AGENT ❑ Signature of Owner or Owner's Agent I hereby certify that all of the details and information I have submitted (or entered) regarding this application are true and accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and C pter 142 of a General Laws. PLUMBER NAME STEF'4150 C_ GALIOSKY SIGNATURE LIC# J 0,311 S MP pr JP❑ CORPORATION X# 319(- PARTNERSHIP ❑# LLC ❑# COMPANY NAME GAuNSKY PLUMOJA L, *- OVAT' LIG- ADDRESS: P.O. GQX 17011 CITY HA VCaVtII.1L STATE M.A- ZIP 01831 EMAIL Www• rnf_PlumbegWI , cowl TEL 17+11 CELL 50-50-59014 FAX 97$-Sat-,4131 I ROUGH PLUMBING INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES �5/2, C-14- 3?— MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY: t+O crvw h cWo -{r MA. DATE.q —( 0' `U-3 PERMIT# JOBSITEADDRESSk, ,�/1111�I1 A &A) %he_ OWNER'SNAME: © V�LJL*dyo Cj OWNER ADDRESS: ��� TEL FAX: TYPE OR OCCUPANCY TYPE: COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL. PRINT CLEARLY NEW:[ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ APPLIANCES-1 FLOOR Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER 1 FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCK MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER I INSURANCE COVERAGE I have a current liabili insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 9 NO ❑ If you have checked YES,please indicate the type of coverage by checking the appropriate box below. LIABILITY INSURANCE POLICY [�r OTHER TYPE INDEMNITY ❑ BOND ❑ 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: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT F eby certify that all of the details and information I have submitted(or entered)regarding this application are true and accurate to the best of my wled e and that all lumbin work and insta9 p g llations erformed under the ermit issuep p d for this application ill b in pliance with all Pertinent ision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUM BER/GAS FITTER NAME:- STFPyEN C. GALINSKY LICENSE# 103WS SIGNA COMPANYNAME: C>ALltS3Kq Pf.00810(, + 9C-*t4J& ADDRESS: P.O. Zox 1701 CITY: MAu'ERNiL.L• STATE: i'n.A- ZIP: 01831 FAX: ` 71- 521-14ISi TEL: 97K- 7y— i7y3 CELL: jog - 5ozj— 590q EMAIL: iN1N'W• tArplumbeffc� xol c,a,M MASTER JOURNEYMAN❑ LP INSTALLER❑ CORPORATION[�# ?�i iib PARTNERSHIP❑# LLC # ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ S/'-/Z9 FEE: $ PERMIT# PLAN REVIEW NOTES Date—5.. .. ,40RTH TOWN OF NORTH ANDOVER 41 '6'6 p` O PERMIT FOR MECHANICAL INSTALLATION �" H S 4 u J a � J 9 9SSACHUSEt s 9 This certifies that . . . . . . ... . • • • • • • has permission for mechanical installation . ... . . . . . . .'' . in the buildings of . . .. . . . . . . . . . . . . . . . at . . . . ... . . . ?fes�� . `. �` .v.: . North Andover, Mass. Fee�,1 . . . . . Lic. No.. .� . . . . '. . . . . . . .c =.! . . GASINSPECTOR WHITE:Applicant CANARY: Building Dept. PINK:Treasurer r Commonwealth of ylassachusetts Sheet Metal Permit Dam: ? ()4 Estirnucz� lob Cost'. 5 Per-nil Fee: 3 Z a,00 Plans 5ubmiae--L YES NO P,2ns R.cvie��c�. 1'Ej yp i�usiness mice^sc = �;i:ani �iccnsc " ���� Jl1S::1.55/LntO CiI14t:OC; �:��C'C;r 'J`.�t;C' 00 :.czat or IIlTO^T'l1llOR: P' oto ic�_ C cc, c['?hc-c N•O -c ��...rae :-s� r cs o; ac._ _.,..me-_._. U:; :c :{071Qeniia1: i�...'v ��I;ll1I:-.�^-ri, ,- .....`.sic Q,VI'] S'E .. _Cc_..II SRC_......., —_,.0 iiC.,,..... �Qr11'C *00t3Q^. und=. , roc' �li7^..`.0r S: to ts: ?:cet me:al w_r4; be c maiecec: -,cL•i.... ;ctai._,, desc: - .,,., „_ :r�... :o .,.. dcr._. s, f t � INSURANCE COVERAGE: I have a current liability Insurance policy or its equivalent,which meets the requirements of M.G.L Ch. 112 Yes �/ No If you have checked Yes,indicate the type of coverage by checking the appropriate box below: ❑ Liabirdy Insurance Policy I ❑ Other type of indemnity ❑ Bond OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 112 of the Massachusetts Gene I Law d that my signature on this permit application waives this requirement Signature of Owner or Owner's Agent I Owner I ❑ Agent By checking this box I hereby certify that ail of the detaiis and information I have submitted(or entered)regarding this apoiication are true and accurate to the nest of my!mowiedge and that all sheet metai work and installation performed under this permit issued for this application will be in compliance with all pertinent provision of the Massachusetts Building Code and Chanter'12 of the General Laws. Duk inspection reawrec prior to insuiation installation:Yes No Progress inspections Date Comments Sinai inspec--ion Date Comments Type of License BV: I Master i tie: I ❑ Master-Restricted ❑ Joumeyperson Permit T. .. Joumevoerson-restricted Fee S: ❑ Inspector Signature of Permit Approval Signature of Licensee License#: SHED METAL PERMIT 0219.11 r AcoRo® CERTIFICATE OF LIABILITY INSURANCE ) F12/28/2012 THIS NERTIFICATE 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 pollcy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to endorsement. A statement on this certificate does not confer rights to the s and conditions of the policy,certain policies may require an n the term P Y 4 P Yr certificate holder In lieu of such endorsement(s). ONTACT PRODUCER NAME: FAX NORTH ANDOVER INSURANCE AGENCY, INC. Ig,'1.e, Ertl: (978) 686-2266 IAA. Not (978) 656-6410 M.J. FOSTER INSURANCE SERVICES ADDRESS: cfernandez@nafins.com 163 MAIN STREET CUSTOMER o qR.A . Mechanical, Inc. NORTH ANDOVER Imo. 01845-2508 INSURER(S)AFFORDING COVERAGE I NAIC s INSURED INSURER A MERCHANTS INSURANCE CO R.A . Mechanical, Inc. INSURER B :L umm INSIJRALQCE 16 Lpmar Park INSURER C Suite 1 INSURER D • INFIIPFR F Pepperell M& 01463— 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. P15R POLICY EFF POLICY E%P LTR TWE OF INSURANCE IINSR IVWD POLICY NUMBER (MNV00/YYYY) IIMNVDD/YYYYI UMTS A oenenw� �wo�rrr I Y 1/OS(201D O1/OS/2019 rrnevl�X434 � I EACH OCCURRENCE $ 1,000,000 JAMA ''rttICU 100,000 �,COMMERCIAL GENEPAL LIABILIT)' I ! ! I ! ! ISR MISES(Ea nocurrenre! S I CLAIMS40ADE U OCCUR I ! / ! ! MED EXP(.4nv one person) 15,000 1,000,000 ! ! ! ! GENERAL AGGREGATE S 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER ! ! ' ! ! PRODUCTS-COMP/OP AGG -S 2,000,000 X I POLICYPRO LOC E6LIA $ A AUTOMOBILE LIABLRY j NCA0000005 p1/01/2013 01/01/2014 COMBINED SINGLE LIMIT $ 1,000,000 (Ea acc,aent) I t ANY AUTO BODILY INJURY(Per person; I S t—Ell ALL OWNED AUTOS I v INJURY(.D � � BODI ar accident) $ 2E,SCHEDULED AUTOS / / / / PROPERTY DAMAGE $ I�X II HIRED AUTOS (Per accident) i X I NON-OWNED AUTOS A X I UNSRELLA LIAB OCCUR ; �UP9145434 pl/01/2013 1/01/2014 EACH OCCURRENCE S 1'000'-000 EXCESS uae F--I Ci_AIM.S.mADE I ! ! ! ! AGGREGATE $ 1,000,000 r)FnUCT1FI F I RETENTION S ! ! ! ! $ B IWORKERS COIwENSATION RAWC466048 1/01/2013 b1/01/2014 X I WC STA IT- GTF- AND EMPLOYERS' LIABILITY T ANY PPOPRIE70I1PMTNER/D(ECU nVE YIN E L EACH ACCIDENT $ 500,000 OFFICEPMEMDBG Ev CUJ DEO ❑ N/A (Mantlatory In NH) ! ! ! / E.L DISEASE-EA EMPLOYE $ 500,000 II yes.describe under DESCRIPTION OF OPERATIONS below I ! ! ! ! E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS VEHICLES (Attach ACORD 101. Addibonal Remarks Schedule. r more space is Mqurod) 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. R.A. b=HANCTpT., INC. 16 LOMAR PARK AvmoUaO RerFu aeF'rwrre SUITE 1 PEPPEREIM MA 01463- ACORD 25(2009/09) ©1988-2009 ACORD CORPORATION. All rights reserved. INS025(200909) The ACORD name and logo are registered marks of ACORD .t:�— -:L:.':...ayi_�..:_.--~+.:. - rn�.::u:,� _ :r,'-... ...•�'�',:,er-.:.r'Su:l_:•�b.:r.�^ - .. I 5:5ACHZ,T$ETTS DRIVERS LICENSE OF EMS I, -............ .. - DOa...-..... —_ — ........ — MAµ µ07H RD BaS u _ -- DRAC':lT.MA 01826.13d_ COMMONWEAL-7-H OF MASSAC'HLSE-77 S SHEc T Mc I AL ANO K� S A.S A ViiASTE—M-UNRcSTR1CTEJ iSSUL-.i ••C ABCVE—ICENSC C: J J 4 DONALC C:;ELLFT_� r 657 MAMMOTH RD DRACUT MA 01826-449 4688 07/28/14 22�i39 N • Y• _ t r Mj� '• � � 1\L.�`1.�� f r--....•sad Ci�c�t i I Ir �U i I - I A i I A t Jab T: R, MEr'NANICAL INC 74 F-erfarmed far. azge t rf� / 16 LGMAR PARK Rigrn-Suttt°�Unrve^_a� crt-As.; ,1.17 Rsu1=0, Phone 97842-IS5t i Fax 9 8.42=4S O oiaLc 11:21:'28 ��; n � - rame�:antc3l�aal.cm C'�acmme:nd..rmnq: M..- 1 tEi�rj ir, ..r _I. � �I Vii• t •'• 11/vi c c� II ; it i The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations C 600 Washington Street • `—' = Boston, AM 02111 j www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): E i� H �_ro C`/z,-Iz 1 Address: - / z, City/State/Zip: 1a�," °�;i :; Phone '�- Are you an employer? Check the appropriate box: Type of project (required): 4. 1 am a general contractor and I I.� I am a employer with ❑ 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 g. ❑ Demolition working for me in any ca achy. employees and have workers' p 9. ❑ Building addition [No workers' comp. insurancecomp. insurance.t required.] 5. 71We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their 1 1.❑ Plumbing repairs or additions myself. [No workers' comp. richt of exemption per MGL I2.❑ Roof repairs insurance required. c. 152, b l(4), and we have no employees. [No workers' 13.❑ Other comp. insurance required.] *Anv applicant that checks box 91 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 subcontractors and state whether of 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 job site information. Insurance Company Name: 1_7 u Expiration Date: Policy+ or Self-ins. Lic. ,,�,y� Job Site Address: (iy'L City/State/Zip: %J, 4.7� 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 ce under theandVenaltiesof perjury that the information provided above is true and correct eils Si ature: 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 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: I