Loading...
HomeMy WebLinkAboutMiscellaneous - 6 Royal Crest VIEW= 9-- Womm %Boo ommm goam- AOMMVA LA to Imn gene= ISIOM m Datel.bAA.0.111.5........ 11428 OF ORT#f TOWN OF NORTH ANDOVER 0 PERMIT FOR PLUMBING 14t 6. HU This certifies that bAOIPX.. ........................................... has permission to perform k�.-�.cA elz_.....�44 ........... .. ................................................ . plumbin g in the buildings of...........yy.. ............................................................... at.�.....e-0-1-AA..N-4.................................................. North Andover, Mass. Fee.J.6..........Lic. No.1j'b.(A3.... ................................................................................. PLUMBING INSPECTOR Check# MASSACHUSETTS UNIFORM APPLICATION.FOR A PERMIT TO PERFORM PLUMBING WORK i i CITY��^ (�JQ� MA. DATE PERMIT# , JOBSTE ADDRESS OWNER'S NAME❑�(��(� —��" OWNER ADDRESS: FAX: ( j fo RTOR .. OCCUPANCY TYPE: COMMERCIAL EDUCATIONAL PRT NT � ❑ RESIDENTIAL❑ CLE; RLy NEW:❑ RENOVATION:❑ REPLACEMENT:I$- PLANS SUBMITTED: YES Q NO FI3tUTRES Z FLOORS Bsmt 1 2 S 4 .5 6 7 8 9 BATHTUB 14: 11 12 13 14 CROSS CONN DEVICE DEDICATED SPECIAL WASTE SYS DEDICATED GASIOI /SAND SYS DEDICATED GREASE SYSTEM — DEDICATED GRAY WATER SYS I.DEDICATED WATER REUSE SYS DISHWASHER DRINKING FOUNTAIN FOOD WASTE GRINDER UNIT FLOOR J AREA DRAIN INTERCEPTOR INTERIOR KITCHEN SINK I ' LAVATORY .:,... . ....... ... ... SHOWER.STALL, SERVICE I MOP<SINK '• I . TOILET URINAL WASHING MACHINE CONNECTION. UVATER HEATER ALL TYPES ,WATER PIPING Fi Y INSURANCE COVERAGE I haue a current liability insurance policy or its substantial equivalent which meets the requirementsof,MGL.Ch.142 YES.# NO If you have checked YES,please indicate.the type of coverage by cliecldng the appropriate box below. LIABILITY INSURANCE POLICY ❑ OTHER TYPE INDEMNITY ❑ BOND ❑ OWNER'S INSURANCE WAIVER:I am aware that the licensee does not nave the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application.waiM this requirement. � CHECK ONE ONLY OWNER ❑ AGENT SIGNATURE OF pUVNEIt OR AGENT D I hereby certify that all bf the details and information i have submitted(or entered)regarding this application are true and accurate to e lie .of my Knowledge and that all plumbing work and installations performed under the permit issued for this a lication. bei. provision of the Massachusetts State Plumbing.Code and Chapter 142.o€.the Generai.La�vs. pp omplrance ath al .ert<nent PLUMBER NAME: - LICENSE MR40 1 SIGNATURE COMPANY NAME: ADDRESS: T' I CITY: STATE. ZIP: 01 FAX: TEL: 79'' -%� _5—I CELL EMAIL MASTER . JOURNEYMAN❑ CORPORATION[ # PARTNERSHIP❑#E�LLC❑# i � . i Date TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION CHU5� ! ......C CSR UV\ This certifies that .................................�:�.......c ..... .... has permission for gasAistallation .�........................ ........................in th buil -Ings of ..... ....:....MC ............................................................................... atP"Y ....... ... .�:�.................................I North Andover,Mass. Fee................:... .Lic. No� 3...:.... ............:......................................................1. GAS INSPECTOR_ Check# MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING 1ttlORK i CITY: �\ --------_MA. DATE: JOBSITE ADDRESS: PERMIT# t' OWNER'S NAME: F OWNER ADDRESS: TYPE OR TEL: �J FAX: S PRINT OCCUPANCY TYPE; COMMERCIAL EDUCATIONAL ❑ RESIDENTIAL E]G'LEARLX Nom;❑ RENOVATION: ❑ REPLACEMENT: PLANS SUBMITTED: YES❑ NO APPLtAN.CEST FLOOR asrnt 1 2 BOILER 3 4 $ g BO ST 7 8 9 10 11 12 13 1.4 . ER CONVERSION BURNER COOIE'STOVE DIRECT VENT HEATER DRYER FIREPLACE F FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCK MAKEUP AIR UNIT OVEN POOL HEATER ROOM I SPACE HEATER ROOF TOP UN TEST UNIT HEATER UNVENTED.ROOM.l!TATER WATER THEATER ' I have a ccrrreni.liahili insurance policy or subs INSURANCE.COVERAGE 3 Po Y substantial which meets the requirements of MGL Ch.If You have checked YES Please indicate the YES ❑ NO ❑ type of coverage by .142 checking the appropriate box below: LIABILITY INSURANCE POLICY OWNER'S INSt1RANCE 1NAIVER t am aware ❑ OTHER TYPE INDEMNITY❑ BOND Massachusetts Genera! Y glhat the licensee does not have the insurance coverage required by Chapter 142 of the Laws;and that m signature on this permit application waives this requirement. SIGNATUREOF OWNER OR AGENT CHECK ONE ONLY: OWNER ❑ AGENT ❑ hereby certify that an of the details and informavon I'haus submitted(or entered)r Knowledge and that an pliunbing work and installations 1 egardin this application pptica6on are true and accurate to the best provision of the Massachusetts State Plumbing performed under the-permit issued forthis.application will. in compliance with all Gods and the 142 of the General Laws, nt PLUMBERIGASFITTER NAME: COMPANY NAME ltcLi' LICENSE# SIGMA nein ADDRESS: �.� �_r'S CITY:,; STATE: ZIP: p! FAX:a-S�_t�p4 7 CQ5? TEL:—11'— ?--fes�'c—CELL: EMAIL: MASTER JOURNEYMAN❑ LP INSTALLER.❑ .CORPORATION #. ( �. ,PARTNERSHIP❑# LX❑# 1 v) 1 I The Cornu mi0ea th of flanachmse& ZkoparftwM of hdo"dJAccidents E 600 washrnven Seek Bosfory MA 02111 www.mass.govIdle Workers'COMPensation Insurance Adams B cue i Ontractors/Bec immffllumbers Apel cant bafermation. �'.. se Priattegibly "Name( tt men/ommization4ndividual).' Maccomaek P1 iambi j T nc- Address: 17 bridge Sheet Ca'ty/•S at /' . Bllleraca ' MA 0182.1 . Phone Are you an employer?Check the appropriate Noxa Type ofprojpd(reqvized): 1.91 am a etnpluyer with 4. 0 I am a general contractor and I 6. Q Net#con taut ioa employees Gull and/or part;time),* have hired the sub-coutraclors 10:1 am a sole proprietor or partner- listed on the attached sheet 7. 0 Rmoddling ship and have no employees These sat-contractors have S. '0 Demolition working for me in arty capacity. employees and have workers' 9. Bu ' anion workers'comp.insurance comp,insurance il required. 5. Q We are a colpctratton and its 10. Blecultaf oz aclditluti 3,O I ati a homeowner doin all wort€ officers have exercised€heir 11.0 Plumb g. f. of, ort Ur utgt i`s ora ft ... my No worke&comp: 12.0 Roof repairs irlstrraxtce required]t c.152,§1(4),and we have ad I�:Q tither employees.[No workers' comp:.insurance requires/:.) *R»y atm mmatso fill out the section belowshmin #heirwozime vom f R0 �vuers arho subuzlkthis affdav3C indicating they we doing au work and am bile ouw&roafteton�swsi submli anew:a#l•Cdav3E i icata ,st�eh. tConuaams thatAecdc"box vwit attached ora additional sbeei showing the`tame of thoasb-cors and stao whetbsr ornot those eatitiex have employees-1tftsub-czutftctoss have anplo}ees.#iii must Foiride their wwkne eainp p4HoJ nurubnr. 170M an aWleyer that isprri3Yiding avorkers'eonWensadon lasurwice for any emptoya. Below is tkiepvl€cy=djvb site infarrnativn.. Insuraum Company Dame; AmGuard Insurance CotnMn 3 Policy 4 orSelf-in.Lie, RAWC578693 Expiration,Date 1011112015 Job Sift Address: Attach;s ropy r f Lite workerV compensation pulley declaraifion page;(shovdng the policy number and exph-Am Asiite). Failure to secure coverage as requir ad under Section 25A of.MGL c.152.c an lead to the imposition of miminalpenalt es of a rine up to$1,500.00 ardor one-year imprisonment,as well as civil penalties is 1he form of a STOP WORK ORDER and a fine of up to=0.00 a day against the violator. Be advised that a copy o'1his statement may be forwarded to the Office of Investigations ofthe IIIA for insurance.coverage verification. 1do 3tereby eery under thepabu and panaMes ofperjury that the Mformuf ran prpvMzd above Is true axd cw7=L j Siartature: Date: Phone $-6I"i3-9530 (?,fJ iat'use onl, Do nvt write in this area,to be carx#e,ed by sly or town 6ffichd City or Town: PertnitlLxcease 9 . Issn'nrgAv&oriiy(circle one). 1.110"ard ofl eallh 1 Bu ding Department 3.City/Town Clerk 4.EIectrical Ftispeetor S.Plumbing Laspector 6.Hca' Contaet:�ersc+n: �h€esce#: OP ID-, CERTIFICATE OF L ABILI i"Y INSURANCE 10114/14 THIS CERTIFICATE IS ISSUED.AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS U . THE CERTIFICATE HOLDEN.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR.NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGEAt Ir0RDEI3 OY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A.CONTRACT BETWEEN THE ISSUING.INSURER(S),AUTHORTZZBQ REPRESENTATIVE-OR PRODUCER;AND THE CERTIFICATE HOLDER. IMPORTANT: If the:certificate holder Is an ADDITIONAL INSURED,the policy(ies)must be endorsed: if SUBROGATION 19 WAIVED,subject to the terns and conditions of the policy,certain policies may require an endorsemeft A statement on this certificate does not co -tothe certificate holder.in frau of such endorsem s). PRODUCER DeSanctis Insurance Agcy,Ino. Phone-781-9364480 100 Unicorn Park Drive Fa)c 781-933-5&45 Pso xt FAx Wobum,.MA 01801 a euuL . DREss: -gnus o MACCQ-1 fNSUREu MacCoi mask Pllambing Inc. tNSU INS)AFFORDING COVERAGE tralc 17 Bridge Street Suite 203 a+SURMA:American Southern Home 41998 Billerica,MA 01821 wsuRSRB:Plymouth Rock Assurance group 14737 i twRERc:Am card Insurance Compwy. 423811 INsuptexn-Nautilus Insurance Company 47370 INSURER E:Merchants Mutual Insurance Co 23329 INSURER-: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW TERM OHAVE BEEN ISSUED 10 THE INSURED NAMED ABOVE FOR THE POLICY PERIODINDICATED. NOTUMTHSTANDING ANY RERUIREMENT, R CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH-RESPECT TO NMiICH THIS 3 CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS ANDCONMONS OF SUCH POLICIES. JMTTS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS:. LTR TYPEOFIN$URANCE SURN POLICYNUMBER �E� -- Lim GENERAL LL46iLTlY EACHPOR .00Ct7RRENCE S 1,000 781 COWIGtEffC1AL V`FtdERAk uABiLRY1 A2C100D15ST 10H1114. 1DJtt/i"5' PREN $ jljq� CLAIW-MADE F OCCUR X Mkt Contractual. MED ENP A � i ar 10, X XCU Hazards PERSONAL&ADV INJURY ,$ 1,OM .: . GWERALACGRECATE S {1OO�Q0 Gm AseREGATEumrrAPPLIES PER: � PRODUCTS-comwoPAGc 4 21000, POLk;t X PRO- Loc I a auTomamLa'Lia»LtiY ; OMMINED SINGLE LIMIT & 9,000,0 0(1 ANYAUCO. BODlLY63JURYlPerpersortl; 'S ALL OWNED AUTOS BO6ILYINJURY (per acddent) $ B X xlRmiu>ras os RC00001063155 10E11n4 10/11/1:'S PROPERTYDAMAGE S - 3 i X NON-OWM AUTOS s $ X nMMM.LA UABX OCCUR EACH OCCURRENCE S E7{CESSLIAR CLAIMS-MADE ASGREGAlk I s 5,000,0 !1 T3P0001373 10t91F14 10199115 DEDUCTIBLE S X. RETENTION S 10,000 S WORIMISCOWEIiSAMON X_ .WC.STAT43- OTH- tiNDEBAPLDYERS'13ABILITY YtAI' ER C ANY.PROPiIETORI�ARTNERtEXECl1TNE WCS7$893 �. fliti1114 10111!15 E.LEACHACCtOENT $ 1;000.00. OFf7C>=RIFAEMBL�iEXCLUDED? �NJA (sendatory in NIH) III,NH),' F-LOISEASE-FAEMPLOYEES "I;00 I rc. desrx�eunaer s OF OPERATIONS below EL DISEASE-POLICY LIMIT $ %000,0II D Pollution Lfab 1083300 01130114 011301/8 Limits Sim Occ I Mold Coverage S2M DESWUPTION OF OPERATIONS 1 LOCATIONS f VEHICLES~ACORD 101,AdcManal Remarks SGsadute,it mom apace is req drem Evidence of Coverage CERTIFICATE HOLDER CANCELLATION. EVIDE-1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES EE CANCELLED BEFORE EVIDENCE OF INSURANCE THE exPli�►Tlom DAIS THEREOF. NOTICE WILL BE D� IN ACCOIWMcE VNTH THE POLICY PRavisiow AUTHOWZED.REPRIMMA - S ' 01888-2009.ACORD CORPORATION..AN rights reserved. ACORD 26(2408109y The ACORD name and logo are registered marks.of ACORD INQ �v MMCtNW�ALTW OFo IIAASS C IUS Tt�S' <v, IF WUM8�F35a ' ASF'�1TER" Y � tia C'_t Kt$�j f,3C+.}4 pp, (,�'} 'C�,. ',�iS, pj$^ S /� f`4k ,.�V �''3'�{u�{. 'S$,�& k roSr���y�`�/�' t{�} 5/ �7 �.!", < �Yd NDN` V S A MA'!> E;i{'P LUI�B' F � �acsy't' a�oMac GO�pMa KA' S v3 _ER ffiff z a �* rrf�u�y Jg t! t v�tee 1�t p�'"❑❑ ('� �'si q aia ' N o r S it 3Awi��t' �,,, z } , Ald Date..�'�2,`-...i .............. TOWN OF NORTH ANDOVER PERMIT FOR WIRING ss�CHu This certifies thatJ�` v �- " V 4 ............................�........................................... ............................................. has permission to perform 1..... \.. �kJ.1J ................................................. wiring in the building G'ti' I - at ...... ....:. `��`A.I.... .5 ......................i�T�I�A�'I'�SPECTOR Noh Andover,Mass. Fee.... . .....Lic. No. �....� .. `��c '" i` Check# I r a� -54 Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. 13 112- Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [R-ev.1/07] (leaveblank M APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MLC),527 CMR 12.00 (PLEASE PRINT ININK OR TYPE ALL INFORMATION) Date: D e C, o1% Ig City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electricalnwork d scribed below. Location(Street&Number) p (Z � ( Owner or Tenant AM,C r tuc�r t h r4 ry 'rJG1i� L-1.fes Tele hone o. Owner's Address 8 U n Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building Utility Authorization No. - Existing Service Amps / volts Overhead❑ Undgrd❑ No.of Meters New Service Amps / volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed EIectrical Work: r-kectL caneyot6LQ&- � �S ccnc ( ,rLv� �- b�t�luc�S ,red-rvNq kln e S , Completion of thefollowing table maybe waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA • No.of Luminaires Swimming Pool Above ❑ In- El0.0 Emergency Lighting rnd. rnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones No. of Switches No.of Gas Burners No.of Detection andInitiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices g Tons Disposers Heat Pump Number Tons KW No.of Self-Contained No.of Waste Dis p Totals: .�����.�����-.... Detection/Alerting Devices No.of Dishwashers S ace/Area Heating KW Local❑ Municipal E] Other p g Connection No..of Dryers Heating Appliances KW Sec Noo Systems:* es or Equivalent 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: 60 Attach additional detail if desired,or as required by the Inspector of Wires. Estimated"Value of Electrical Work: 0 (When required by municipal policy.) Work to Start: 1 Z'mA t lLt Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless 10 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. CIZECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) Icertify,under the pains and penalties ofper)ury,that the information on this application is true and complete. FIRM NAME: - A�t1 l�L P V 1 LIC.NO.: A 15-lq Licensee: ()A- j fd (� �{�(�,�p Signature (a Vim LTC.NO.:3 1 @)56 G (Ifapplicable,enter "exempt"in the license number line) Bus.Tel.No.: Address: (CAO D P I c S-'I-- Wcl-A riVA , 614: 1 Alt.Tel.No.:5 y l 1 *Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.No. 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/AgentPERMIT 'EE:$. I Signature Telephone No. �71 /Workers, The Commonwealthof Massachusetts Department of Jndustr1glAccidents Office of Investigations 600.Washington Street Boston,MA 02X11 www.mass-gov/dia ompensation Insurance Affidavit:Builders/Contractors/El please Print umber ly Applicanormatlon Marne(Business/Organization/indiyidual): Address: �� 1 ta G City/State/Zip: ��g �(G1�1�/1 M� ®a 1 Phone#: Z)og s09 Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with �'f" 4. ❑ I am a general contractor and I g, ❑New construction employees(full and/or part-time).* have hired the sub-contractors Remodeling 2.❑ I am a sole proprietor or partner- listed on the attached sheet.* [J ship and'have no employees These sub-contractors have 8. F1 Demolition working for me in any capacity. workers' comp.insurance. g, F]Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions required.] officers have exercised their Plumbing repairs or additions 3.El am a homeowner doing all work right of exemption per MGL 11.❑ c. 152,§1(4),and we have no 12.❑Roof repairs myself. [No workers comp. o workers'insurance required.]i employees. kers' 13.❑ Other 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 this affidavit indicating they are doing all work and then hire outside contractors must submit a new 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. Y am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:, A L , �'j—z->v ro,V-) C "� Expiration Date: ( [ Policy#or Self ins.Lic.#: 5GO(0`6 � f-- Job Site Address. 5 6 1 0wc -' C)c<s-k– ':),(L Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as require 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. Y do hereb cert under the pains and penalties ofperjury that the information provided above is true and correct. Si ature: Date: y Phone 4: '(�B sok— cc eOfficial 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 Phone#: JContact Person: J COMMONWEALTH'OF°MASSACHUSETTS ROARI OF ELEE1RiCIAN! ISSUES THE FOLUOWING> Lf ENSE AS A REGISTERED MASTER :ELEtTRI C I AW." DRN:IEL Zi R VITALS IN s 190 DALE WA€THAM, MA .02451 3773; 15799 A 07/31116 : 35001 COMMONWEALTH;OFJMASACHUSETT:S ' i BOARD-0 I ELECTRIC ANS ; _ISSUES THE FOLLOWI�LG_ LICENSE AS A REG JOURNEYMAN <ELECTR I C I Alit + DANIEL P VITALE IJ 190 DALE: 5T Z' U J WALTHAM MA _02451-3773 31�5a E 07/31/16 35ooz ' b ya k • 4. liaco cy5CU / CERTIFICATE OF LIABILITY INSURANCE I8/26/14 a, OLDE EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES �cT1FICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE AUTHORIZED KATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, JV. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), ESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. ollc le, must be endorsed. If SUBROGATION IS WANED,subject to PORTANT: If the certificate holder is an ADDI110NAI- INSURED,the P y( ) she terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to e certificate holder in lieu of such endorsement(s). CONTACT LESLIE HANN ON NAME: FAX (978) 667-0587 PRODUCER PHONE (978) 667-6150 Al No: James O'Connell Insurance Agen EMAIL ,7IMINS@OCONNELLINS.COM ADDRESS: NAIC# 572 Boston Rd INSURE S AFFORDING COVERAGE Unit 7 INSURER A:merchants Billerica, MA 01821 INSURERB:A.I.M• Insurance INSUREDI NSU RER C DANIEL P VITALE ELECTRIC INSURER D 190 DALE ST MA 02451 INSURER E: WALTHAM, " INSURER F REVISION NUMBER: COVERAGES CERTIFICATE NUMBER: OR CONDITION OF ANY CONTRACT OR OTHER pOHEREEN IS SUB ECTWITH P O ALL THE TERMS, OD THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERI INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TER CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY T POLICIES OFFES DDE Cy EXP LIMITS EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED 1DY FF PAID 10 yY IMS. ILTR POLICY NUMBER $ 1 000 000 TYPE OF INSURANCE IN R WVD BOP9098053 9/12/14 9/12/15 EACH OCCURRENCE $ •500 OOO DAMAISES(RENTED A GENERALLIABILITY MED EXP(Arty one person) $ 15 000 x COMMERCIALGENERAL LIABILITY CLAIMS-MADE aOCCUR PERSONALBADVINJURY $ 1 OOO OOC GENERAL AGGREGATE $ 2 000 00C PRODUCTS-COMP/OPAGG $ 2%000,0_0( OO( GEN'LAGGREGATE LIMIT APPLIES PER COMBINEDSINGLELIMIT $ PRO- LOC Ea accident X POLICY T ' a AUTOMOBILE LIABILITY BODILY INJURY(Per person) BODILY INJURY(Per accident) $ ANYAUTO SCHEDULED PROPERTY DAMAGE $ ALLOWNED AUTOS Per accident AUTOS NON-OWNED $ HIRED AUTOS _AUTOS $ EACH OCCURRENCE UMBRELLA LIAB OCCUR AGGREGATE $---�- EXCESSLIAB CLAIMS-MADE STATU- OTH- DED RETENTION$ WC 10/11/13 10/11/14 X $ 100,0( WORKERS COMPENSATION WCCSOO 6538012009 E.L.EACH ACCIDENT B 11 AND EMPLOYERS'LIABILITY YIN 100 O ANY PROPRIETOR/PARTNER/EXECUTNE NIA E.L.DISEASE EA EMPLOYEE $ 500,0 OFFICER/MEMBER EXCLUDED? E.L.DISEASE-POLICY LIMIT $ (Mandatory in NH) If yes,describe under DESCRIPTION OF OPERATIONS below i if more space is requred) DESCRIPTION OF OPERATIONS 1 LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule, ELECTRICAL WORK i. CANCELLATION CERTIFICATE HOLDER SHOULD ANY OF THE ABOVE DESCRIBED F NOTICE BE BENCELLED DELIVEREDRED BEF i•. THE EXPIRATION DATE THEREOF, TICE ACCORDANCE WITH THE POLICY PROVISIONS. TOWN OF NORTH ANDOVER MA 120 MAIN ST / AUTHORIZED REPRESENTATIVE m e NORTH ANDOVER, MA 01845 J UC��✓ cJ� LESLIE HANNON ©1988-2010 A ORD CORPORATION. All rights re: c1� The AC ORD name and logo are registered marks of ACORD ACORD 25(2010105) Fax: E-Mail: IPhone: Date. . ...-.....�.Z.... L.. S NORTH � j�• �; TOWN OF NORTH ANDOVER.. o ' PERMIT FOR WIRING s + s + _'r • *,SSACMUs� _ 7�//c c a This certifies that has permission to perform ... G�/�Jll . to ri',eE wiring in the building of... :� at .11 .r... ..... �-' wli --.3,/f.. , orth Andover,Mass: � - ............. 3/ �%�! .dee '2Lic.No. . � �2... ELEGT cAL INSPECTOR � ;. lCheck # 4 10752 ti ( ommonwealth ol///aejackujetb Official Use Only Permit No. �l� 7;��- 2epartment of Jim Servicee Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(NEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: March 30 2012 City or Town of: North Andover To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) 50 Royal Crest Drive Building # 6 Apartment# 34 Owner or Tenant Royal Crest Apartments Telephone No.978-681-1822 Owner's Address 50 Royal Crest Drive North Andover, MA 01845 Is this permit in conjunction with a building permit? Yes ❑ No ❑X (Check Appropriate Box) g Purpose of Building Utility Authorization No. P Existing Service Amps / Volts Overhead ❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Kitchen rewire, Panel & Intercom Station Relocation Smoke & Heat Detector installations! Completion of the followingtable maybe waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires3 Swimming Pool ove ❑ n- ❑ o.o Emergency Lighting rnd. grnd. Battery Units No.of Receptacle Outlets 55 No.of Oil Burners FIRE ALARMS No.of Zones No.of SwitchesNo.of Gas Burners o.of Detection and $ 3 Initiatin Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons No.of Waste Disposers Heat Pump Num er Tons KW..._...... No.of el-Contained P ..... tion/Alertin Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ other Connection No.of Dryers Heating Appliances KW Security ystems: No.of Devices or Equivalent No.o aterKms, o.o o.o Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications iring: No.of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of YVires. Estimated Value of Electrical Work: $ 2,829.00 (When required by municipal policy.) Work to Start: 3/30/2012 Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: 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: INSURANCE ❑X BOND ❑ OTHER ❑ (Specify:) 7 certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: The Electricians & Co. Inc. A LIC.NO.: A10737 Licensee: Michael J. Parziale Signature C.NO.: E20269 (If applicable,enter "exempt"in the license number line.) Bus.Tel.No.: 781-322-9344 Address: 50 Branch Street Malden, MA 02148 Alt.Tel.No.: 781-322-3100 *Per M.G.L.c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.No. SS CO 001021 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 a ent. Owner/Agent PERMIT FEE. $ Signature Telephone No. I e' e f �; ��- � � C2 e �' ., IV The Commonwealth of Massachusetts F Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): The Electricians & Co., Inc Address: 50 Branch Street City/State/Zip: Malden, MA 02148 Phone#: (781) 322-9344 Are you an employer?Check the appropriate box: Type of project(required): 1.0 I am a employer with 15 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. F-1 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 g. ❑Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers'comp.insurance comp.insurance.$ required.] 5. ❑ We are a corporation and its 10.❑X Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑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 employees. [No workers' 13.0 Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. '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: Hanover Insurance Company Policy#or Self-ins.Lic.#: W H N 6055762 02 Expiration Date: 09/01/2012 .lob Site Address: 50 Royal Crest Drive Bldg 6 Apt 34 City/State/Zit):-North Andover, MA 01845 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. 1 do hereby certify under the pains and pe lties perjury that the information provided above is true and correct. Si nature: Date: March 30 2012 Phone#: (781 322-9344 U 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#: 08/31/2011 18: 33 5709982831 LAYLONCONST PAGE 02/02 08/31/2011 WED 7:29 FAX . Baal/aol &JvSHEA cONCRETE gRODUCT5 New England's Premier PreCllster 800-696-SHEA (7432) Amesbury,MA • Wilmington,MA • Rochester, MA . Nottinrjhpm, NH 8/30/11 To:Dave Laylon LQylon ConstruCtion 8878 LYComing Creek Rd Cogan Station, PA 177281 Re.Stair Replacement SO Royal Crest Dr N.Andover,MA Dear Mr. Laylon. Per YOUr request,enclosed please find Shea Concrete's recommended procedure for pouring and plaCemont of concrete pad to support the precast stairs to be delivered to the above referenced address. I. Remove any loam or organics from area of pad. 2. Gravel or%"stone compacted material. 3. Length and width of pad should coincicie with thick. foot-print of stairs and at least S" 4. Concrete should be minimum 4000 p.s.i. 5. #4 rebar 12"O.C.both ways. 6. Top of pad should be set at height to keep rise consistent(Le.7" or 7.511), If you have any other questions or Concerns, please calf. Sincerely, -4(4ef. Bob Flores General manager Shea Concrete Products,iNC