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HomeMy WebLinkAboutMiscellaneous - 58 VILLAGE GREEN DRIVE 4/30/2018 (2)MOW / � 0 Datef�! . r�... . i, TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that .. u.--.... C ►..... -.......... . �,�- has permission to perform . �.��.. .f. .t! . .... . 6414 plumbing in the buildings of .r�! ," ..�r7" ..�! 1,/: at ..��i,�� f- -..41-1 !! el............ , North Andover, Mass. Fee 257'� Lic. No.. t//...... Z 1 nn PLUMBING INSPECTOR ��ck 1 (A, of .� MASSACHUSETTS UNIFORM APPUCATON FOR PERMIT TO DO GAS FITTING (Type or print) Date 6� NORTH ANDOVER, MASSACHUSETTS Building Locations se /0 yj/4 f C (� wee � Permit # �/ q Amount $ %l Owner's Name New ❑ Renovation ❑ Replacement a Plans Submitted ❑ (Print or type Check one: Certificate Installing Company Name 4%�� �s' ��� ❑ Corp. Address P &A // e,% �� C n Partner. ,Arzr-, iness cff 0/.P" Name of Licensed Plumber or Gas Fitter Al le- rcl, 1- c �— ❑ Firm/Co INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ❑ No ❑ If you have checked Les, please indicate the type coverage by checking the appropriate box. Liability insurance policy D/ 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 Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ 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 Permit Issued for this application will be in compliance with all pertinent provisions of the Massachus$t�; Sta* Gas Cod�e,and Chgter 142 of the General Laws. By: Title City/Town APPROVED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter Plumber /%Cl?46, Gas Fitter License Number Master a E, a a z z O z > d z a w w �- O Cw7 H z H z x w w O > H a w z w Q x F �- d m z o z a o x d w > w z a d d O O w O w F cG x O x w O 3 a V w U z > SUB-BASEM ENT BASEM ENT 1ST. FLOOR 2ND. FLOOR 3RD. FLOOR 4 T H. F L O O R 5TH. FLOOR 6 T H. F L O O R 7TH. FLOOR 8TH. FLOOR (Print or type Check one: Certificate Installing Company Name 4%�� �s' ��� ❑ Corp. Address P &A // e,% �� C n Partner. ,Arzr-, iness cff 0/.P" Name of Licensed Plumber or Gas Fitter Al le- rcl, 1- c �— ❑ Firm/Co INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ❑ No ❑ If you have checked Les, please indicate the type coverage by checking the appropriate box. Liability insurance policy D/ Other type of indemnity ❑ Bond ❑ Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachus$t�; Sta* Gas Cod�e,and Chgter 142 of the General Laws. By: Title City/Town APPROVED (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter Plumber /%Cl?46, Gas Fitter License Number Master A_ CERTIFICATE -,0F LIABILITY INSURANCE DATE (MMIDDIYYM ' 10/10/2006 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION PRODUCER ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE TIER INSURANCE AGENCY �. CLOU TIER INSURANCE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 1470 AVENUE SUITE #1 3 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. DRACUT, MA 01826 PHONE#: 978-957-4881 FAX#: 978-957-7230 1 INSURERS AFFORDING COVERAGE NAIC # INSURER A PENN AMERICA INSURED LGC PLUMBING LYLE CARTER INSURER B: 63 VALLEY RD INSURER C: DRACUT, MA 01826 INSURER o: INSURER E COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR ANY REQUIREMENT, TERMOR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH MAY PERTAIN, THE INSURANCE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. POLICIES. AGGREGATE POLICY EFFECTIVE POUCY EXPIRATION uMrrs LTR NSR TYPE OF INSURANCE POLICY NUMBER DATE MM/D DATE MNVD EACH OCCURRENCE a 1,000,000. A. GENERAL LIABILITY PAC6613180 08/21/2006 08/21/2007 DAMA E R NTE S 100 000 X COMMERCIAL GENERAL LIABILITY MADE OCCUR 5,000 MED EXP (AnY one Person) $ CLAIMS PERSONAL 6 ADV INJURY S 1,000>0� GENERAL AGGREGATE PRODUCTS - COMP/OP AGG $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: X POLICY Eo- LOC AUTOMOBILE LUU3ILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO ALL OWNED AUTOS BODILY INJURY $ (Per person) SCHEDULED AUTOS HIRED AUTOS ' I BODILY INJURY $ (Per accident) NON -OWNED AUTOS PROPERTY DAMAGE $ _ (Per accident) AUTO ONLY - EA $ GARAGE LIABILITY $ OTHER THAN ' ANY AUTO AUTO ONLY: $ EACH OCCURRE$ US IABILITY EXCESSIUMBRELn CLAIMS MADE AGGREGATE $ OCCUR DEDUCTIBLE RETENTION $ TORY LIMITS ER WORKERS COMPENSATION AND E.L. EACH ACCIDENT $ EMPLOYERS' LIABILITY ANY PROPMETOR/PARTNER/EXECUTIVE E.L. DISEASE - EA EMPLOYEE S OFFICER/MEMBER EXCLUDED? !` E.L. DISEASE - POLICY LIMIT $ M yes, describe under SPECIAL PROVISIONS below OTHER OF OPERATIONS 1 LOCATIONS 1 VEHICLES 1 EXCLUSIONS ADDED BY ENDORSEMENT 1 SPECIAL PROVISIONS DESCRIPTION CANCELLATION CERTIFICATE HOLDER " SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION CITY OF LOWELL. 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._ _ AUTHORIZED REPRESENTAT��l� © ACORD CORPORATION 1988 ACORD 25 (2001108) s i a.