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Home My WebLink AboutMiscellaneous - 57 VILLAGE GREEN DRIVE 4/30/20181-- /1,11_ Date..... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION Io This certifies that . 41. ... e_�t . has permission for gas installation ........... in the buildings of at .... ....... North Andover, Mass. Fee. Lic. No./�.9.3� GAS INSPECTOR 70, Check #OP TAJO, 5861 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Location 9/c -j 11�7 S Owners Namey` / `S ' Permit # Type of Occupancy J?C�J " �'+cJ J Amount New Renovation Replacement Plans Submitted Yes No FIRTMS (Print or type)/C C.c ��, Check one: Certificate Installing Company Name Corp. Address P Uc 1/ r 5�? Parhter. /' c< <4 7 72-1 c -7 j p Business Telephone 4 7 F 5 ' 5.7 f 6S � � Firm/Co. Name of Licensed Plumber. / C �- Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy L=J Other type of indemnity El Bond insurance Waiver. I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature IOwner ❑ 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 ins ti under Permit Issued for this application will be in compliance with all pertinent provisions of the Massg Code and Chapter 142 of the General Laws. ,D (OFFICE USE ONLY Type of Plumbing License cense NUMer Master 0 Journeyman Q/ DATE (MM/DDNWY) ' ACORQ CERTIFICATE SOF LIABILITY INSURANCE 10/10/2006 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION PRODUCER ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE CLOUTIER INSURANCE AGENCY } HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 1470 LAKEVIEW AVENUE SUITE #1 1 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. DRACUT, MA 01826 4° NAIC # 7 4881 FAX#: 978-957-7230 INSURERS AFFORDINGCOVERAGE PHONE #: 978-95 - INSURER A' PENN AME, INSURED LGC PLUMBING LYLE CARTER INSURER B: 63 VALLEY RD INSURER c: DRACUT, MA 01826 INSURER D: INSURER E: COVERAGES THE POLICY PERIOD INDICA,TED. NOTWITHSTANDING THE POLICIES OF INSURANCE LISTED BEN OF ANY CONTRACT OR OTHER DOCUMENT W TH RESPECTAVE BEEN ISSUED TO THE INSURED NAMED ABOVE TO ICH TICERTIFICATE RTIFIEXCLUSIONS AT D CONDITIONS OFSUCH MAY ANY REQUIREMENTI TERM OR AFFORDED MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO AL POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID C P IMS. EFFECTIVE POucY EXPIRATION LIMITS POLICY NUMBER DATE MM/D DATE MM/D �EAjCH OCCURRENCE $ 1,000,000 LTR NSR TYPE OF INSURANCE 08/21/2006 08/21/2007 A_ GENERAL LIABILITY PAC6613180 I E TO RENTED $ 1OO OOO X COMMERCIAL GENERAL LIABILI An one person) $ 5'000 CLAIMS MADE ❑ OCCUR 'EN'L AGGREGATE LIMIT APPLIES PEI X I POLICY n JE OT- LOC AUTOMOBILE LIABILITY ANY AUTO ALL OVJhED AUTOS SCHEDULED AUTOS HIRED AUTOS ' NON -OWNED AUTOS { GARAGE LIABILITY ANY AUTO EXCESSIUMBRELLA LIABILITY OCCUR CLAIMS MADE DEDUCTIBLE RETENTION $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY EXCLUDE�ECUTIVE �01FFICERIMEMBER yes, describe under PECIAL PROVISIONS belowTHER af" DESCRIPTION OF OPERATIONS / CERTIFICATE HOLDER CITY OF LOWELL. VEHICLES /EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL MED EXP ( Y PERSONAL & ADV INJURY $ 1,000,000. GENERAL AGGREGATE $ 2+000,000 PRODUCTS - COMP/OP AGG $ 1,000,000 COMBINED SINGLE LIMIT $ (Ea accident) BODILY INJURY $ (Per person) BODILY INJURY g (Per accident) PROPERTY DAMAGE $ (Per accident) AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ AUTO ONLY: AGG $ EACH OCCURRENCE $ AGGREGATE $ $ $ $ P �DISEASE ACCIDENT $ - EA EMPLOYEE -POLICY LIMIT $ Al CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. s AUTHORIZED REPRESENTi O ACORD CORPORATION 1988 ACORD 2S (2001/08)