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HomeMy WebLinkAboutMiscellaneous - 59 MEADOW LANE 4/30/2018 1 / 59 MEADOW LANE 21010451-0020-0000.0 Date..:'.Jz C)...I uk........................ 0*oon 74 o9 TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION ,$8'�CMU5fc This certifies tha`tl� .H. .4"—d �4 , `� ........... ....................................`......� ...... has permission for gas installation 54z...... .v.,� .. in the buildin s of....... at......E .....I ?Gt�cw) l--r?............................ North Andover, Mass. .. .................................................... Fee4• :SD... Lic. No.$5. ....... M! ...................................................... GASINSPECTOR Check# I MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY I N.Andover MA DATE 5/6/2014 PERMIT# JOBSITE ADDRESS 59 Meadow Ln OWNER'S NAME GOWNER ADDRESS Same TEC _ FAX TYPE OR OCCUPANCY TYPE COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL❑ PRINT CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT:❑ PLANS SUBMITTED: YES[] NOQ APPLIANCES 7 FLOORS, BSM 1 2 3 4 5 6 7 8 9 10 1 11 12 13 14 BOILER BOOSTER r CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE _ FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER Replace 1 Gas Meter x and Piping as Needed INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES Q 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 inpliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. / PLUM BER-GASF ITTER NAME Joseph Marino LICENSE# 8736 fSIGNATURE MP❑ MGF❑ JP❑ JGF❑ LPGI❑ CORPORATION Q# 3285C PARTISE SHIP❑# LLC®#� COMPANY NAME: RH White Construction Co ADDRESS L41 Central St CITY I Auburn I STATE MA IZIPI01501 TEL 1(508)832-3295 FAX 508-926-4347 JCELLI 508-832-4614 EMAILJMarino@RHWhite.com 0 4 ` ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES V f i r ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES i fell -G MW AL.TH OF MASS,�i` l :llS 1' - - - - - =1?LUfC�18RS AND GASF�T]'�.RS.. AG &'E® AS T � - 'A-Maw, R• ETM1R``-: _ SSUES T11E`{1BQUE LICENSE MA-R.INO - GTON 87 ~TifIIR:C 'S T`E R ' MA Q a 6 iJ--q=31:`0'x.- I /14 I COMMONWEALTH OF MAS SAC�#�3S:E'17S' `PLU]U1'13ERS AND GASFIT-T.-ERs:. . AS A JOURNEY I.i7A ABOV�'LICENSE T©: 3`'Fi4RR`T=NGTON ST. S-Tt R MA D 1G fl 4='3•I j , U4/03/Lt'J14 14:G4 OU003L0/O1 mn Wr11 I C IJUIVS I KUI,I r'HUC CIL/CIL �C ® DATE(MMlDD/yYYY) CERTIFICATE OF LIABILITY INSURANCE page y of 1 08/29/2013 THIS CERTIFICATE IS ISSUED ASA 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 DOLES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is nn ADDITIONAL INSURED,the policy(ies)muat 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 Cartif late does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER CONTACT Williq of Maseachudetts, Inc. PHONE C/o 26 C2ritury Blvd. -NO-EXT)• 877-945•-7378 FAX _NO): 868-46_ -237a P. 0. Box 305191 3 DD9ESS Cextifiaatep w•illia.com Nnghville, TN 37230-5191 INSURIaR(8 AFFORDINGCOVERAGE NA1011 INSURED INSURERA: The ChartOr Oak fixe lnauranCo Company 25615-001 R. X. White Construction Company, Inc. INSURERS.TraV0114 s Property Casualty Company 01 Am 25674-003 41 Central, Street INSURERC:National Union P iro Snsuranca Company o£ 1,9445-001 P. 0. Box 257 Auburn, MA 01501 INSURERD:Travelers Indemnity Company 25658-Dal INSURER F; INSURF,R F; COVERAGES CERTIFICATE NUMBER:20187680 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. i-MINSR TYPE Op INSURANCE DD SUB vuvn POLICY NUMBER POLICY EFF POLICY EXP LIMITS A GENERALLIABILIry VTC2000 977RS940-13 9/7./2015 9/1/2014 EACMOCCURRENCE F 2 000 0_00 X COMMERCIAL GENERALLIABII.ITY ppqq TORENTF,D —Vol eocewanrcl _ 300_p00 CLAIMS-MADE OCCUR MED EXP(Anyone erten $ 10�000 PERSONAL&ADV INJURY $ 2 D00,000 GENERAL AGGREGATE $ 4,0000 000 GEN'LAGGREGATE LIP ITQAPPLIESPER; PRODUCTS-COMPlOPAGO J 0QO 000 POLICY LOC ]3 AUTOMOBILE LIABILITY VTJCAE 977R955A-13 9/1/207.3 9/1/2014 $ OMBINFJ151NGLF,I,IMIT $ 2,000,000 acc sent X AN.OWNE BODILY INJURY(Perpemon) $ ALI,QWNED SCHEDULED AUT08 AUTOS BODILY INJURY(Peraccidont) X HIREDAUTOS X NON-OWNED AUTOS araccident $ X CoIt I Ded X Co11 Ded C UMBRELLALIAO, OCCUR BE8766140 /1/2013 9/1/2014 EACHOCCURRENCE $ S.000,000 X EXCESS LIAR CLAIMS-MADE AOOREGATE $ $,QQO,000 DED $ RETENTION$ :L0,000S D WORKERS COMPENSATION AND EMPLOYrRa*LIABILITY yN VTRKUB 8205A1a5-13 9/1/2073 9/1/2014 X O - . r+,Y D ANY PROPRIETORIPARTNERIFXECUTIVE I NIA VTC2XUB 9203A71A-13 9/1./2023 9/1/203.4 E.L.EACH ACCIDENT $ 11000,000 OFFICERIMEMSEREXCLUDED? MvvendelonnrrinNH) E.L.DISEASE-EAEMPI:OYF.E $ 1,000,000 UE savhut%I�UN u d QPI:RAT1ON3 below E,L.DISEASE-POLICYLIMIT 3 11000,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(Attach Acord 101,Addltonel Remarke 5chodula,It more epeea la roqulrad) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF TWE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZEDREPRESENTATNE Etrxderice of InrRuzWrice • Y Coll:4197604 Tp1:1694012 Cert:20267680 ©1988-2010ACORD CORPORATION.All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD Date. . . .. . . . . .. . . . . .. . .. . ,,FORTH o? TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION S+'SC HusE� This certifies that . . . . . . . . . . . . . . . . :'. . . .!. .!. . . . . . . . . . . . . . . . . has permission for gas installation . . . . . . . . . . . ...... . ... .... ��. . . . in the buildings of . . . . . . . . . '. �_.. . . . . . . . . . . . . . . . . . . . . . . . . . . at . t. . ... . . . . . . .: . :. "f. �'"'"'�. . , North Andover, Mass. ), cT/nI Fee. . .,. . . .: . Lic. No.. . .% . . . .. . . . . . . . . -GAS INSPECTOR Check# JUS. � TO DATE/ ��. TIME AM PM P FROM�.� PHS ) � v CELL( j ) �/cl� OF T t __e__ FAX ( ) f E M F- S Q E-MAIL ADDRESS IstND' PHONED❑ gACK CALL RNED SEE YOUO AGAIN ALL AS I URGENT 0 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASF1-rT G Jam- (Print or Type) Ah- --,. ,. . , Mass. Date ` X Permit # �( Building Location Owners Name /", �o (� Type of Occupancy lel 7t N T i r� New ❑ Renovation ❑ Replacement Plans,Submitted: Yes❑ No ❑ N N W `ifl W W ¢ O Q C� = of J N W F' Z ¢ = C o0. t- W _ -C ¢ N 0 W < = Z t- H O CG �1 W N ¢ W Z V W N W < ¢ H H S W W Vl < _ ¢ ¢ ¢ W W y ¢ J W > U, i- V JUj • Z W < ¢ F- H to m 2 0 2 U, o M = ¢ = O d = u. O 3 G C J V ¢ > o a 1- O SUB-BSMT. BASEMENT 1ST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR STH FLOOR 6TH FLOOR 7TH FLOOR STH FLOOR Installing Company Name ('jAe T A • �51m MA TA r20 Check one: Certificate Address 3) L4o4 C H iyt r?.ty i-NI, ❑ Corporation n1 E T H U er,) r11 rl ❑ Partnership Business Telephone 9 (7-7 f 9--Firm/Co. Name of Licensed Plumber or Gas l=itter "Ro j3E P-T A• 5A M M 14 761 PL) -- INSURANCE COVERAGE: I have a current 1• b.lity insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142. Yes 2' No ❑ If you have checked Yes. please Indicate the type coverage by checking the appropriate box A liability insurance policy 0"' 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: 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 pe ed for this application vA be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of ne Laws. By T of license, G� Plumber n ure of cen u _ or fitter Title tter er License Number �33� City/Town Journeyman (OFFICEONLY)