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HomeMy WebLinkAboutMiscellaneous - 55 MOODY STREET 4/30/2018 55 MOODY STREET 210/081.0-0008-0000.0 � n � Date..11....1.-I...f........ n j / v ,r TOWN OF NORTH ANDOVER F 9 PERMIT FOR PLUMBING 4' S'�CMU'Sfc ff This certifies that� '�� has permission to perform.................................. f' r- plumbing in the buildings of... ..ek g...!............................................................ at....... ' ..... 4.. ..A..................... North Andover, Mass. Fee.... ..........Lic. No. .............................................................. PLUMBING INSPECTOR Check# — MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY � � �-� � — _ MA DATE PERMIT# JOBSITE ADDRESS �._.. OWNER'S NAME _ I OWNER ADDRESS _ j TELj _ FAX[— ' _ w _ . I TYPE OR OCCUPANCY TYPE COMMERCIAL; EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: RENOVATION:0 REPLACEMENT: PLANS SUBMITTED: YES NO FIXTURES-1 FLOOR— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 i BATHTUB CROSS CONNECTION DEVICE - ...... DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN ,. INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY t ! ROOF DRAIN ,....... i...... SHOWER STALL r1••••---1— -- -- € SERVICE/MOP SINK : ..:._.. _...,, I... TOILET i URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES , WATER PIPING I__ 11_ !— OTHER ' �i l INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 13 NO 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 ONLY: OWNER E? AGENT III SIGNATURE OF OWNER OR 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 compliant ith a Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME mike ca Bless. LICENSE# 15 51 � SI ATURE MPf JP[j CORPORATION# IPARTNERSHIP!7 #=LLC D# . COMPANY NAME the bolter guy W�ADDRESS 160a pleasant st 1 CITY north andover STATE 1� ma ZIP !01845 TEL¢978-382-1017 FAX I 'I CELL F EMAIL ...................... Date........ TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ...............................i....................IJ Q IP ................... .................... has permission for gas installation ..��..!/, ....... inthe buildings of...........is... ............................................................................... . ... ....... at............55.......H..O..Ohl........ :ft: ........... North Andover, Mass. Feew.......... Lic. NoA�2+. ....... 110........................................................ GASINSPECTOR Check# MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY !v1 � �/��w MA DATE 1 w PERMIT# JOBSITE ADDRESS - �— OWNER'S NAME OWNER ADDRESSi TE < FAX � I.�.a.�....... ,. ._ . TYPE OR OCCUPANCY TYPE COMMERCIAL._ EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW:; .`, RENOVATION:.....,,. REPLACEMENT:;. PLANS SUBMITTED: YES NO w APPLIANCES Z FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER - CONVERSION BURNER §__.� :m , £ COOK STOVE DIRECT VENT HEATER i F � 3 DRYER ...4..__ FIREPLACE ........n .- ._... I .... ,t FRYOLATOR - .,. . . ._._. FURNACE GENERATOR GRILLE INFRARED HEATER --II --'-.,11F F-711 x: LABORATORY COCKS MAKEUP AIR UNIT I £ _ OVEN __ g POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT --, - [ TEST a _ J. I UNIT HEATER _ YI UNVENTED ROOM HEATER WATER HEATER _ - sI OTHER .4 <._.....,....w..:.....,�..www:............._...,...,wm..�w�,w:w,,:,.:.».w.n..ww».� ..,.....-, i i � `.�.....,... INSURANCE COVERAGE I have a current liabilityj insurance policy or its substantial equivalent which meets the requirements of MGL.Ch. YES , NO • 1 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 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 :. i SIGNATURE OF OWNER OR 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 Perti nt provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME LMn,CAPELESS LICENSE# 15851 SIGN URE MP,�_ MGF . _:Y JP JGF _fr LPGI CORPORATION PARTNERSHIP;,, #, LLC ... q _. ... n .:.1 COMPANY NAME:;THE BOILER GUY I ADDRESS 160A PLEASANT ST ____.__.W,,,,,,,,,,, CITY vNORHTaANDOVER .a STATE MA =ZIP.':01845 ITEL i 9783821017_ FAX� CELLF PEMAIL, - y The Commonwealth of Massachusetts , Department of Industrial Accidents Office of westigations 600 Washington Street Boston,MA.02111 qV -www mass gov/dia Workers' Compensation Insurance Affidavit:Builders/ContractorslElectricians/Plumbers Applicant Information Please Print Legibly Name(Business/organization/individual): /"! 1 l 4P,1 Address:_ City/State/ ��i'I 7r ,�C ���/vl�Ph�e# ���J��/U/ Y an employer?Check�E�e appropriate box: Type of project(required): [Arey am a employer with / 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part carne).* have hired the sub-contractors 2.[] I am a sole proprietor orpar[ner- listed on the attached sheet.I 7• ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working forme in any capacity. workers'comp.insurance. g_ El Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its 10.n Electrical repairs or additions required.] officers have exercised their 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),andwehaveno 12.❑Roofrepaizs insurance required.]i employees.[No workers' 131i i Other comp.insurance required.] *Any applicant that checks boxfil must also fill out the section be16w showingt heir warkers'compensation policy information. t'Homeowners who submit this affidavit indicating they a're doing all work and$hen hire outside contractors must submit a new affidavit indicating such. t'Conhactors that checkthis bogie must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. lam an employer that&providing workers'compensation insurance for my employees: Below is thepolicy and job site information. - Insurance Company Name: Policy#or Self-ins.Lie./#: Z_/ ` , _ / ExpirationDate: Job Site Address: City/State/Zip: Attach a copy of the workers'con tionpolicy$eclaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL o.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 maybe forwarded to the Office-of Investigations of the DIA for insurance coverage verification. X do lierehy certify under the pa7aNdenalties perjury that the in farmatior2 provided abov s trnd cosrec - Si afore• �Date.:� /J.177/v__ Phone#• Offrc&Z use only. Do not write in this area,to he 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 i I I AC`OR" CERTIFICATE OF LIABILITY INSURANCE °Aiiilv2014Y' 1110w - 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(ies)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 endorsement(s). PRODUCER CONTACT Matthews Insurance Agency Inc PHONE FAX 182 Parker St ac No E.0; (978)681-1112 ac No:(978)685 3855 E-MAIL ADDRESS: Lawrence,MA 01843 INSURERS AFFORDING COVERAGE NAIC# INSURERA: Atlantic Casualty INSURED Michael Capeless INSURER B: Arbella 105 Tyler St Methuen,MA 01844 INSURER C: INSURER D: 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 CY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WVD SUER POLICY NUMBER MM DPOLID/YYYY MM DD/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000 TO RENTD COMMERCIAL GENERAL LIABILITY L143000684 08/07/2014 08/07/2015 PAR Ea occuErtence $ 100,000 j CLAIMS-MADE F—IOCCUR MED EXP(Any one person) $ 1,000 j PERSONAL&ADV INJURY $ 2,000,000 I GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY I ' OLOC LOC $ AUTOMOBILE LIABILITY HC357357 08/30/2013 08/30/2014e Ea aB tleDtSINGLE LIMIT $ ANY AUTO HC357357 renewal 08/30/2014 08/30/2015 BODILY INJURY(Per person) $ 300,000 ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ 300,000 NON-OWNED PROPERTY DAMAGE $ 300,000 HIREDAUTOS AUTOS Per accident E $ UMBRELLA LIAB [77 OCCUR EACH OCCURRENCE _ $__ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION WC STATOR,LIMU- OTH- AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N 890911-0937696 02/13/2014 02/13/2015 E.L.EACH ACCIDENT $ 100,000 OFFICER/MEMBER EXCLUDED? ❑ N/A (Mandatory in NH) E.L.DISEASE-EA EMPLO16EEI$ 100,000 If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) Heating or combined heating and air conditioning systems or equipment,installation,servicing or repair,plumbing 1407 Great Pond Road in North Andover CERTIFICATE HOLDER CANCELLATION L.. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE E:au�r ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD NO a tCHA . td cPIT LES '0 TYLf� Sl ME HU'N MA O l844 i�� Date 0It ""O RT TOWN OF NORTH ANDOVER p PERMIT FOR PLUMBING s s u J'"t9 SACMUSE� This certifies that 1.4f.'. .. • • . • . . . . has permission to perform . . . . . . �. . . . . . . . . . . . . . . . . . . . plumbing in the buildings of . . AP,! e`... . . . . . . . . . . . . . . . . . ' _ , North Andover, Mass. Fee.31. .' .Lic. No.. �>. . . .`. . . . . . . . ( . . Vii:.. . . . . . PLUMBING INSPECTOR Check # '? t 5421 72 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO"00 PLUMBING (Print or Type) p _ Mass. Date ~ r� Permit # S _Q Building Locations '1011 A J Owner's Name( 2c / -MUl l' Type of Occupancy Residential New (_J Renovation U Replacement K Plans Submitted: Yes ❑ No ❑ FIXTURES rArL � ,n X F- H O i W n' Z Lj W Y J N z N Z - W Z N O. 'I'1 49 'J n z c•� a K � — o N w N (n x Q r- c) w Y c a 2 a c 3 rd riS rd Z rr Co a N W 0 a QCC a x x l •-i o :3q ur ~ ~ w N Q J M ¢ J — o w Wo k I1 }� IU u F o = a � z o o yr x z w o t� N N Q "t O 4 J J a (L CL c a O Q 4J 1-1 3 x J m In o o J 3 r r N LL u a a 3 ¢ m 3 3 SUB—BSMT, BASEMENT 1 1ST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR 5TH FLOOR 6TH FLOOR 7TH FLOOR 8TH FLOOn Installing Company Name IIeri tage Htg. &Plg. Co. Inc. Check one: Certificate Address_ 35 Pleasant Street CX Corporation 714 Stoneham, Ma 02180 F.] Partnership Business Telephone_. 781� $_7 7 7 6 171 Firm/Co. _ Name of Licensed Plumber Gordon Switzer INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes N] No C] If you have checked yes, please indicate the type coverage by checking the appropriate box. A liability insurance policy l Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVEFI: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner ❑ Agent❑ Signature of Owner or Owner's Agent I hereby certify that all of the details and information I have submitted(or entered)in above 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 provisions of the Massachusetts State Plumbing Code and Chapter 142 o e General Laws. -- --- re 1: ns d lumber Title _ ------- Type of License: Master tX Journeyman❑ City/Town8 3?.2 APPROVED OFFICE USE ONLYj^ License Nurnbor___.______.____ BELOW FOR OFFICE USE ONLY FINAL INSPECTIONS SKETCHES PROGRESS INSPECTIONS FEE_ NO. i APPLICATION FOR PERMIT TO DO PLUMBING NAME&TYPE OF BUILDING LOCATION OF BUILDING PLUMBER f i PERMIT GRANTED DATE 19 PLUMBING INSPECTOR � s•