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HomeMy WebLinkAboutMiscellaneous - 550 BOXFORD STREET 4/30/2018 /�/ Date..... ........I......... ,4 RT#4 o .... TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING $sACHU This certifies that va� has permission to perform ...................... ...................................................................... ..... ....... ... .. . wiringin the building of................. ........................................S.............................................. at ....... .................... c .........North Andover,Mass. Fee 0. Lic.N ..........7:�o ................*...... ...........LECTIU-. C-. A-. L..... IN-........... SPECTO-........................ R Check# -34 1 Commonwealth of Massachusetts Official Use Only ' Department of Fire Services Permit No. Occupancy and Fee Checked g BOARD OF FIRE PREVENTION REGULATIONS [Rev.l/07] (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMRJ2.00 (PLEASE PRINT ININK OR TYPEALL INFORMATION) Date: 6911 City or Town of: NORTH ANDOVER To the Ins ector 4f Wires: By this application the undersigned gives no 'ce of his r her irate ion to perform the electrical work described below. Location(Street&Number) Owner or Tenant elephone No. ' Owner's Address Is this permit in conj unction with a building permit? Yes L®�No (Checic Appropriate Box) Purpose of Building Utility Authorization No.320 ®7 - Existing Service Amps / Volts Overhead ❑ Undgrd❑ No.of Meters New Service Amps/j3A) olts Overhead❑ Undgrd No.of Meters _,L— Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion of the follow'g table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total j/ Transformers KVA `JJ No.of Luminaire Outlets No,of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- ❑ o.o meLighting rnd. grnd. Battery Units � No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones Total No.of Switches No.of Gas Burners / No.of Detection and c InitiatingDevices No.of Ranges No.of Air Cond. Tons No.of Alerting Devices No.of Waste Dis osers Heat Pump NRm M..Tons KW No. of Self-Contained P Totals: Detection/Alerting Devices No.of Dishwashers S ace/Area Heating KW Local❑ Municipal ❑ Other P g Connection No.of Dryers Heating Appliances KW Security Systems:* N 3 No.of Devices or Equivalent !V 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 No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of ectr' aj WcLrk: '63�— (When required by municipal policy.) Work to Start: In ections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE VE GE: 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: 1NSURAt10E ❑ BOND ❑ OTHER ❑ (Specify:) .I certify,under th py a ins and P e s of er'ury,tI he i formation on this application is true and complet FIRM NAME: LIC.NO Licensee: Signature LIC.NQ0. (If applicable,en r"exe 'in the li nse lin ) Bus.Tel. Address: Alt.Tel. *Per M.G.L c. 147,s:-57-6t,securify work requires D artment of 15uMic Safe "S"Li nse: Lic. o. OWNER'S INSURANCE WAIVER: I am aware t1lat 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:$ Aj- 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 pen-nit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166,§32,an f electrical permit shall be issued to the person,firm or corporation stated on the permit application. Such entity shall be responsible for the R Y notification of completion of the work as required in M.G.L.c.143,§3L. fw 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/Date Closed: �Trench Ins ion ss M Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signal re: Date: SERVICE PECTION: Pass 0 Failed M Re-Inspection Required($.)❑ Inspectors Comments: . Inspectors Signature: XA 444 Date: 1- Zz-/ PARTIAL ROUGH INSPECTION: Pass(] Failed EN Re-Inspection Required($.)❑ Inspectors Comments: �I Inspectors Signature: Date: ROUGH INS CTION: Pass R Failed Re-Inspection Required($.)❑ Inspectors Comments: 44 Inspectors Signature: Date: Zz l S FINAL INSP TION: Pass Failed M Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com The Commonwealth of Massachusetts Department of lndustriaZAccidents 1 Congress Street,Suite 100 _ d Boston,MA.o2114_2017 b ' www mass.gov/dia Wokkers'Compensation insurance Affidavit:Builder/Contractors/Electricians/Pluun exs. TO BE FILED WITH TBE PERMITTINGA.UTHORI�Y. EleasePrint Le 'bl A •licant informatiion / Name(Business/Organization/Individual): Address: � I City/State/Zip _ ` ro latebox: ��of •� ct(rcequired): Are you an employer.Checktb e app 1. I a a employer with employees(frill andlorpari-time). 1, ew'donstruotion 2 am a sole proprietoz or partnership and have no employees Working forma in 8. []R.emodel"* any capacity.proprietor workers'comp.insurance required.] 9, ❑DemolitiollL 3.E]I am a homeowner doing all workmyself..[No workers'comp.insurance required.]t 10E]Building addition 4.[]I am a homeowner and will be hiring contractors to conduct all work on my property. I will 11.0 Eleciaical re airs or additions ensure that all contractors eitherhave workers'compensation insurance or are sole �TLe Plumbing repairs or additions proprietors with no employees. $❑I am a general contractor and 1 have hired the sub-contractors listed on the attached sheet. 11[]Ro6f repairs These sub-contractors have employees and have workers'comp.insurance.t 14.0 Other 6.QWe are a corporation and its,officers,have exercised their right of exemption per MGL c. 152,§1(4),and ive have no employees.[No workers'comp.insurance required.] *Anyapplicantthat checks box#!.must also fd1 out the sectionbelow showing their workers'compensation policy information. i Homeowners who submit."affidavit indid hn additional a doing the all work andname en of the sub contractors and state wheth r or ne outside contractors must submit a now noot thoseentitt�have h tContractors that check ibis box must attach employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. X ane an employer that is providing workers'compensation insurance for my employees. Below is the policy and fob site information. Insurance Company Name • Expiration Date'. C� Policy#or Self-ins.Lic.#:. � City/State/Zip: lob Site Address: e showing the policy number and expiration date). Attach a copy of the�worl�exs' compens ion policy declaration page up to$1,500-00 Failure to secure coverage as required uadcr MGLalties in§he form of a STOP 25A is WORK ORDER a criminal-violation Iand a fine e by a ffilb f up to$250.00 a and/or one-year imprisonment,as well as l p day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DTA for insurance coverage verification. Ido hereby cert' er the at s dpenalties ofperjury that the information provided above is true and correct. Si ature: phone#: Official use only. Do not write in this area,to be completed by city or town official Permit/License# City or Town' Issuing Authoxity(circle one): 3.City/Tovvn Clerk 4.Electrical inspector 5.Plumbing inspector 1.Board of Healtb. 2.Building Department 6.Other Phone#: Contact Person: �pMMONW q 0 o CTH p efl US f 1 SSUE EE EC Acv a ETTS s THf .. Otto C REO 1.>ST FW/ ANS 'VARD EBEo MASTER G ��CENSE r oAY C fCTRIC CO ELECTRI. lC ANS i 700 WAgp x 1NCzf anti 88 ,a ER L �. 8648 a A, 38z� s 0088 7404 �_ a-. _ ; . COMMONWEALTH OF MASSACHUSETTS 0 0 0 • o 0 BOARC OF Epi ECT'R I C I ANS: 'k ISSUES.THE FOLLOWING: LICENSE 9 A SV A REG JOURNEYMAN 1LECTRI IC�1N Q a GARY'H WARD P.O. BOX $$ t l 100 .DE1 R DRIVE S11VER LAKE -NH 03$75 5403 17427E 07/31/15 ;`74048 Date............................................. NapTM �, TOWN OF NORTH ANDOVER p PERMIT FOR WIRING �s3gCHU5�� This certifies that .....: . '��G �?"'/��%� ` .................... has permission to perform ..................... }� ul S� wiring in the building of........... ........ F6 V 7- at /� ...................... Z25&* =INSPECTOR Mass.Fee, ... .........Lie.No. ................. .. ............ ............... �7 EL Check# f Gf 12999 —/ , t i Commonwealth of Massachusetts Official Use Only e Department of Fire Services Fern'itN°. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.l/07j (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code C), 27 CMR 12.00 (PLEASE PRINT WINK OR TYPE ALL INFORMATION) Date: City or Town of. NORTH ANDOVER To the I spec r of Wires: By this application the undersigned gives notice of ' ox her' ention t erfo the electrical work described below. Location(Street&Number) Owner or Tenant L, Telephone No. Owner's Address Is this permit in conjunction with a ilding permits Yes No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. - Existing Servic�G `�,� Amps /A� olts Overhead❑ Undgrd Ug-� No.of Meters�— New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity 01 0 Location and Nature of Proposed Electrical Work: Completion of the following table may be waived by the Inspector of Wires. r No.of Total No.of Recessed Luminaires No.of Cell:Susp.(Paddle)Fans Transformers KVA No.of Luminaire Outlets No,of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- ❑ o.o mergency Lighting rnd. grnd. Battery Units No.of Receptacle Outlets l No.of Oil Burners FIRE ALARMS No.of Zones No.of SwitchesNo.of Gas Burners No.of Detection and / Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices g Tons g No.of Waste Dis posers Heat Pump Number Tons KW No.of Self-Contained / p Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW SecuritNo.of Systems:* or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices orEquivalent 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 13lectriqal rk; (When required by municipal policy.) Work to Start:A&A, Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE C VE G : 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 colyepgCis in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE V BOND ❑ OTHER ❑ (Specify.) I certify,under the . and p t1 of r'ury, tat to n orntation on this application is true and complete. FIRM NAME: . LIC.NO.: �U Licensee: Signature LIC.NO.: (If applicable,e, r"ex t"in the a li ) Bus, —G Address: wa-:�Iy Alt.lic *Per M.G.L c. 147,s.57-61,security work requires D artment of Public Safety"S"License: o 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 PU MITFEE.-$fir_ 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 shallbelimited 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/Date Closed: Trench Inspection Pass 0 Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass N Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: . Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass R Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass M Failed Re-Inspection Required($.)❑ Inspectors Comments: w Inspectors Signature: Date: FINAL INSP CTION: Pass M Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com i k ,.The Commonwealth ofMassachusetts F Department of Industrial Accidents M .. �.:: 1 Congress Street,Sitite100 _ d Boston,MA 02114 2017 10 www.mass.gov/die Worker§'Compensationlnsurance Affidavit:Builders/Contxactors/Electricians/�lum ers. TO BE FILED`yJ1THE PERM1TT]NG AUTgO12ITY' please Print Legibly A, ''licantinformation ,y Name(Business/Oigan zationftdivi.dual): Address: Phone#: , City/State/Zip: Are you an emploper?Check the approp ate box: Type of roject'(required): 7. New`donstruction l❑I am a employer with employees(frill and/or part time).* 01 am a sole proprietor or partnership and have no employees Working for me in $, �Ren?odeliiig any capacity.[Noworkers'comp.insurance required.] 9, ❑Demolition 3.[JI am a homeowner doing all work myself[No workers'comp.insurance required.]t 10❑Building addition 4.FJ I am a homeowner and will be hiring contractors to conduct all work on my property.I will 11.[]Electrical xepaurs or additions ensure that all contractors either have workers'compensation insurance or are sole bin repairs Or additions proprietors with no employees. 12�[]Plum, g p • 11[]Ro6f repairs 5.❑I am a general contracto r and l have hired the sub-contractors listed on the attached sheet. These sub-contractors have employees and have workers'comp.insurance.t 14.Q Other 6.[]We are a corporation and its,officers have exercised their right of exemption per MGL c. 152,§1(4),and we hage no empldyees:LNo workers'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-tbis affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such r• $Contractors that checkco °��hse tackedemploan addeY must sheets showing workers' comoftlpspolicy number.and state whether or not(hose entities have employees. If the suU loyees. Below is the policy and_rob site I am an employer that is-providingworkers'compensation insurance for my emp information. Insurance Company Name: • Expiration Date: Policy#or Self-ins.Lia#: City/Statelzip: iration date). Job Site Address: Ing the policy number Attach a copy of the workers'compensation policy 52,declaration 25A s a criminal violation punishable,by aafuie up to$1,500-00 Failure to secure coverage as requited under MGL o.152,§ of up to ER and a fine and/or one-year imprisonment,as well as m nt may be forwarded to the Officeil penalties in the form of a STOP IInnvO� of flus at ons of the DIA-for ins2uran e a day against the violator.A copy coverage verification. Ido hereby certi der the 'n and penalties perjury that the information provided ore S true and correct. Date: Si ature: a- r` Phone#: Official use only. Do notwrite in this area,to be completed by city or town official Permit/License# City or Town: Issuing Authority(circle one): 1.Board of Ifealth 2.Building Department 3.City/Tovtm Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Phone#: Contact Person' U 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 ofhlze, 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 receivet'or trustdd 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 applicantwho has not produced acceptable evidence of compliance with the insurance coverage ie,quuiired." 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=contractor(s)name(s),address(es)and phone number(s)along with their certificates)of insurance. Limited Viability 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 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' compensatiori 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 pormit/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.e.a dog license or permit to burn leaves etc.)said person is NOTrequired to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 Tel.#617-727-4900 ext.7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia Date... 11297 OF p►ORT�y,�O TOWN OF NORTH ANDOVER ° 9 PERMIT FOR PLUMBING ssACMU5� � y This certifies that....1Q .................. .. . ` has permission to perform................................... ,_,. ........................................... plumbing in the b ' dings of.......................... - ............................................. at....::.. ..�.......... ......�c �- ...., North Andover, Mass. Fee*S��Lic. No. Iu�Z5... ................................................................................. PLUMBING INSPECTOR Check# 32 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITYev-® NIA DATE a' 13'. PERMIT# JOBSITE ADDRESS S`�Q ®�'fGr OWNER'S NAME /I/0101's -� P OWNERADDRESS _ _ TEL I �--� FAX TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL ® RESIDENTIAL ) PRINT CLEARLY NEW:P-1 RENOVATION:® REPLACEMENT:® PLANS SUBMITTED: YES EI NO® FIXTURES I FLOOR- BSM 1 2 3 4 5 6 7 1 8 9 10 11 12 13 14 - BATHTUB CROSS CONNECTION DEVICE �I ` —�- DEDICATED SPECIAL WASTE SYSTEM _ DEDICATED GAS/OIUSAND SYSTEM I _� DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER _ =� DRINKING FOUNTAIN FOOD DISPOSER ; J FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN I - - - — ` — I _I — — -- i SHOWER STALL SERVICE/MOP SINK -- :� TOILET URINAL I Q ! I \ WASHING MACHINE CONNECTION _ WATER HEATER ALL TYPES WATER PIPING _ OTHER 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 CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE:APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY L BOND 0 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 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 co pliance ith all Partin nt provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. A PLUMBER'S NAME LICENSE# �' i SIGN URE MPO JP® CORPORATION #PARTNERSHIP®# LLC D# COMPANY NAME P1.U14I &HEA?ING,iNC. ADDRESS CITY1 NUT TING LAKE. ZIP TEL FAX CELL 1471F EMAIL_ f �,•`,n 20 pr"w Pr, >s. 6 r►J E np':P l C ' ��51 ?t �'/ �?l 1 � ! ,� Date.............8.... ............ NORTH TOWN OF NORTH ANDOVER IWO PERMIT FOR GAS INSTALLATION Thiscertifies that .................................................................. .... .......................................... has permission for gas installation .)�.k`-y..........64,--e...................... in the buildings of ................................................. .......... ...... .......+..A.......... at.........C350...... .........�5 ........... North Andover, Mass. .................. ....................... Fee.... Lic. No. )�2 ........................ ..................................................................... GASINSPECTOR Check# 1 LI � MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY Ald /6 ��. r MA DATE � i�i� =PERMIT# �I OO— • JOBSITEADDRESS J ® ` Q�'rO�� Jl' E OWNER'S NAME OWNER ADDRESS TEL FAX TYPE OR OCCUPANCYTYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO APPLIANCES 1 FLOORS BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER : f CONVERSION BURNERJ . COOK STOVE DIRECT VENT HEATER DRYER _.._ FIREPLACE FRYOLATOR FURNACE . .�. ._. •. f . ...' ._...__ .....a •.. . ,' ,..... . . .. .. ...__. . ... __, ._ GENERATOR GRILLE •-�_. - - W.. _ . INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT __ f OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT _ T TEST _ • . UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER Q I INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL,Ch.142 YES NO I 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 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 compliancq with all ertinen pro sion of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME /��rl /�+di/�'t� Z� LICENSE#/d 5 QQQ SIGNATU MP✓ MGF JP JGF LPGI CORPORATION*" # /i�G" PARTNERSHIP,-...# " .. LLC #" POWDERLY & SONS COMPANY NAME: PLUMBING&HEATING,INC. ;ADDRESS Boz 235 . . . CITY NG MA 01865 ZIP FAX � t978 663. 0164 MAIL r1 i�TYTE ...e§r/h'�r l „y. �. TEL ...... . 9-7X 5,27e) re i ne c,ommonwealtiz of Massachusetts I �. Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 100 t f Boston,MA 02114-2017 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual):POWDERLY AND SONS PLUMBING AND HEATING,INC. Address:PO BOX 235 City/State/Zip:NUTTING LAKE, MA 01865 Phone#:978-663-0164 Are you an employer?Check the appropriate box: Type of project(required): 1.❑✓ I am a employer with 1 ` 4. ❑ I am a general contractor and I employees(full and/or part-time). have hired the sub-contractors 6. ❑✓ New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8, ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp.insurance comp.insurance.: required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.[J Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.]t c. 152, §1(4),and we have no 13.❑Other employees. [No workers' 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 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 sub-contractors and state whether or 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:AMTRUST NORTH AMERICA Policy#or Self-ins.Lic.#WWC3112817 Expiration Date:10/31/15 Job Site Address: J'`5-4 166-YA City/State/Zip:A, �✓t�y�'���' ��� 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 cert nder the pains and penalties of p! uV that the information provided above is true and correct. Signature:E Z _ Date: Phone#:1 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#: « � . � • . 6' • � . Z � AOMMONWEAL H OF & &d§BSE & % � : . . . ■ ,■ �T•, . � \ : < . . \. � . . r \ m < Rvy�alw _ \ 6MBEMI ` 7 ( S-RE FOLLOW[ . wx::: L C O /� f MASTER. P U B \ « < K N Hg ,POWDER: \ K / ® 0R 4 ¢ \ (fugG)LAKE yfA} 18,65 © 2 / / .v® » . • u 12 d/ . , . . - ra» .m AgoQaq < ! , - � � � Date.. 6..1IZI....i......... ................... NORrH TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION CHU This certifies that ..... C�C-A 6, .................................... ................................................... has permission for gas installation ..- etOe:,� - ..........................C..........t.-..-................I ............... in the building's of ................. ........... ........ at6x--V�-CQ ............... North Andover,Mass. 3...6......... Fee * - *............... .. *i*c.'*N'o*. . ... —........ L ......................... ..................................................................... GAS INSPECTOR Cheek# 10245 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY: S&L HOMES MA. DATE: 10/21/2015 PERMIT# jq-q� JOBSITE ADDRESS: 550 BOXFORD STREET OWNER'S NAME: S&L HOMES GOWNER ADDRESS: TEL: 978-265-8352 FAX: TYPE OR OCCUPANCY TYPE: COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL PRINT _ / CLEARLY NEW: IBX RENOVATION ❑ REPLACEMENT: ❑ PLANS SUBMITTED:YES ❑NO 1 APPLIANCES FLOOR Bsmt 1 2 3 4 5 6 7 8 9 10 11 12" 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE C� DIRECT VENT HEATER DRYER 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 IL A 43 to 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. LIABILITY INSURANCE POLICY 0 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 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 the permit issued,will be in complian5q with all Pertinent provisions of the Massachusetts Uniform State Plumbing Code,and Chapter 142 of the General Laws. C� 2 PLUMBERIGASFITTER NAMF,�I Z LL&ySf4.,) LICENSE# /3� SIGNATURE COMPANY NAME:OSTERMAN PROPANE LLC ADDRESS: 321A Merrimack St CITY: Methuen STATE:MA ZIP:01844 FAX:978-738-0118 TEL: 800-368-9956 CELL: MAIL:INFO OSTERMANGAS.COM MASTER El JOURNEYMAN OLPINSTALLERVORPORATION E]# PARTNERSHIP E]# LLC ❑ � 5- 26-3 11,r �6)-A� -� �0� ��� � �V s--f-c -Q- 1 �, .� f l ��l�/ rl�/ ' The Commonwealth of Massachusetts • Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 s" www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Osterman Propane, LLC Address: One Memorial Square City/State/Zip: Whitinsville, MA 01588 Phone#: 508-234-1573 Are you an employer?Check the appropriate box: Type of project(required): 1.® I am a employer with 2 75 4. ❑ I am a general contractor and I 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. 1 7. ❑Remodeling 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 S. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 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.❑Roof repairs insurance required.]t employees. [No workers' 13.2 Other LP Gas Install & Repair 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 are doing all work and then hire outside contractors must submit anew affidavit indicating such. TContractors that check this 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 the policy and job site information. Insurance Company Name: Insurance Company of the State Of PA Policy#or Self-ins.Lic.#: 1NC01 5883775 Expiration Date: 06/30/2016 Job Site Address: All Loc2flons In. North Andover 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 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. Ido hereby certify under the py ' and penalties of perjury that the information provided above is true and correct. Si nature:a�6& Date: 07/01/2015 Phone#: 508-234-1 73 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 Cleric 4.Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: AC<>R0CERTIFICATE OF LIABILITY INSURANCE DATE(MM 06/29/291/ YYY) Page 1 of 1 2015 THIS CERTIFICATE IS ISSUED ASA MATTER OF INFORMATION ONLYANO 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 tothe certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAMP Willis of Texas, Inc. PHONE 877-945-7378 FAX 888-467-2378 c/o 26 Century Blvd. P.O. Box 305191 A "RE-MAILS. certificates@willis.com Nashville, IN 37230-5191 INSURER(S)AFFORDING COVERAGE NAIC4 INSURERA:Lexington Insurance Company 19437-000 INSURED NGL Energy Partners, LP INSURER B:The Insurance Company of the State of Pen 19429-100 6120 S. Yale Avenue INSURERC: Suite 805 Tulsa, OR 74136 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:23299818 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 TYPEOFINSURANCE DL SUB POLICY NUMBER POLICY EFF POLICYEXPI TO LIMITS A X COMMERCIAL GENERAL LIABILITY 034205248 6/30/2015 6/30/2016 EACH OCCURRENCE $ 2,000,000 ppOpN�,1pRGGEJ7 ENTED CLAIMS-MADE X OCCUR PREMISESQEaoccurence) $ 100,000 MED EXP(Any one person) $ PERSONAL&ADV INJURY $ 2,000,000 GEN'LAGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE S 4,000,000 X POLICY 171PRO- JECT [7LOC PRODUCTS-COMP/OPAGG S 4,000,000 OTHER: S B AUTOMOBILE LIABILITY CA4584397 AOS 6/30/2015 6/30/2016 COMBINED SINGLE LIMIT 5,000,000 (Ea accident) $ B X ANYAUTO CA4584396 MA 6/30/2015 6/30/2016 BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ HIREDAUTOS NON-OWNED PROPERTYDAMAGE AUTOS (Peraccident) $ A X UMBRELLA LIAB X OCCUR 015881338 6/30/2015 6/30/2016 EACH OCCURRENCE $ 51000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $ 5,000,000 DED I X RETENTION$ 10,00 $ B WORKERS COMPENSATION WC015883775&079331530 6/30/2015 6/30/2016 X PER oTHSTAT FIR - AND EMPLOYERS'LIABILITY ANY PROPRIETORfPARTNER/EXECUTIVEY7 N/A E.L.EACH ACCIDENT $ 11000,000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 f yes,describe under DESCRIPTIONOFOPERATIONS below I E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additonal Remarks Schedule,maybe attached if more space is required) 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. AUTHORIZED REPRESENTATIVE Town of North Andover 120 Main Street N. Andover, MA 1845 Coll:4718034 Tpl:1970970 Cert:2 9 18 (61988-2014 ACORD CORPORATION.All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD S NGL Retail Supply NGL Retail Supply, LLC NGL Supply Terminal Company, LLC NGL Supply Wholesale, LLC NGL Water Solutions, LLC NGL-MA, LLC NGL-NE - — Osterman Propane,_LLC Osterman Propane, LLC dba Anthem Propane Exchange _ Osterman Propane, LLC dba Down east Energy -- _Osterman Propane, LLC dba Lessig Oil and Propane Osterman Propane, LLC dba Thompson's Oil and Propane Thompson Oil- - - ------- -- -- - i I I I I II Insured Includes: -- AntiCline Disposal, LLC i Centennial Energy, LLC Hickgas, LLC dba DeLuca_ Hickgas, LLC dba Enviro Hickgas, LLC-Lincoln --i Hicksgas, LLC Hicksgas, LLC - Blackstone — u -- Hickgas, LLC - Bloomington Hicksgas, LLC - Braidwood Hicksgas, LLC - Decatur ---- Hicksgas, LLC - DeKalb Hicksgas, LLC - Kankake Hicksgas, LLC - Kankakee _ Hicksgas, LLC - Lowell — _— -- — i Hicksgas, LLC -_Monticello H ksci gas, LLC - N. Pekin — — Hicksgas, LLC - Oakwood i Hicksgas, LLC - Renesselaer Hicks as,_LLC - Roberts --I Hicksgas, LLC -Toluca Hicksgas, LLC -_Urbana Hicksgas, LLC -Vandalia !�Hicksgas, LLC dba DeLuca Hicksgas, LLC dba Enviro Hicksgas, LLC dba Global Propane -- Hicksgas, LLC dba Indiana Hicks Hicksgas, LLC dba Liberty Propane Hicksgas, LLC dba Pacer Propane _Hicksgas, LLC dba Pittman Propane — Hicksgas, LLC dba Rocket Propane `Hicksgas, LLC_dba Rocket Supply, Inc_ Hicksgas, LLC dba Service Gas Hicksgas, LLC_dba_Urbana Hicksgas, LLC-Utah LP — -- High Sierra Crude Oil & Marketing, LLC - 1 High Sierra Energy, LP _NGL Crude Logistics NGL Crude Transportation, LLC L NGL Energy Operating, LLC NGL Energy Partners, LP i NGL Liquids, LLC NGL Propane, LLC LNGL Propane, LLC dba Brantley Gas NGL Propane, LLC dba Propane Central -� NGI Propane LLC dba Propane Energies Group (PEG) — NGL Propane, LLC dba North Georgia Propane _ _ — NGL Propane, LLC dba Pro-flame NGL_Propane, LLC dba_RB's Gas NGL Propane, LLC dba Woodstock Gas ,s<::COMMONWEAM OF M40bHUSETTS { • 0=0 • • I flLUMBERS .;SF ITTERS I ISSUES THE;: HS FBLLOWING SE LI1rN ;I 3 . 1ICENSED A, AN LP GAS INSTALLER I_ MI CML A BRYS0 SR i rf , $ ARB0R CT , ,, � fz W fit . .LYNN MA 01902-111 93301/16 223720