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HomeMy WebLinkAboutMiscellaneous - 64 PRESCOTT STREET 4/30/2018 64 PRESCOTT STREET 210/082.0-0013-0000.0 1 i Date... 17.``x.. v:. �.................. °F NOw7M,h TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION Ss�CHU M~ This certifies that ... .E'�':�!!?I.............. has permission for g.s installation V1A : . -.:....... ..... ... ................ in the buildi gs of... .IPC':�..................................................................................... ( _,( ,,`` North Andover, Mass. Fee .............. Lic. No. . '5``.04c:. . ! '..................................................... GASINSPECTOR Check# 098 ; f •` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY iSoRTN..,r ram --771-MA DATE I5.- PERMT# JOBSITE ADDRESS 6t SY OWNER'S NAME 'A 19q4 iYP {'VI V OWNER ADDRESS TE FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CT'EA.RLY NEW:[Q RENOVATION:E] REPLACEMENT: '' PLANS SUBMITTED: YES 0 NO APPLIANCES I FI-66-RS-4 BSM 1 T 4 -3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER [-- CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR I , (� �— GRILLE _ INFRARED HEATER LABORATORY COCKS (�— MAKEUP AIR UNIT OVEN POOL HEATER R08M/SPACE HEATER ROOF TOP UNIT TES;fi - UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER *-te mcie ...3T INSURANCE COVERAGE I have a current liabilljy nsurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES [WO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY Ej BOND F 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. SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: 0 N R AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are tru a acqu e to a best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will he in co i a vA IP ent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME T as j&4 LICENSE# i56q ' SIG ATURE MP DMGF[3 JP EI JGF EI LPGI® CORPORATION�..3fa( -PARTN SHIP®# LLC Ej#= COMPANY NAME:U:,-,- gro (, Se2., e _ ADDRESS s — CITY A --]TEL7= OO q1 FAX — CELL EMAIL }eerie 6F� e VP i CO►yrMON ° WEALT F IW %j ° ° ® TTS "PLUMBERS ISSUESSFITTEfS, THE FOLLOWIW- L I�ITI�SEa qS A1-11rENSE MASTER PL--UMBER �A ARF1 X21 WlLLOW � � u OR l { k "ON 1564yO MA 0230.1 14 olio1/16 s 226442 COMMONWEALTH OF MASSAOHUSETTS w;� BOARD QE Y PLUMBERS Ah1b' GASF lTE7RS h ISSUES THE FOLLOWING`LICENSE :. �'` R..EGI STl{R1nD AS A PLlkhiB,l C CORP * QAlll W GARF I ELD' - ;EENE`Y BROT:RI=R SERVICE, LC }IL+ 21 WILLb,W 5`T f„t: 4 :r 9RbCKTbN MA 02301 `. 4 22113 :....::..... i ip `y I i FEENBRO.01 SMORAN DATE(M&VDDNWY) CERTIFICATE OF LIABILITY INSURANCE 1130/2016 THIS CERTIFICATE IS ISSUED AS A 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 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 pollcy(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 to the certificate holder In lieu of such endorsement(s). PRODUCER CONTACT NAME: Ro�ers&Gray Insurance Agency,Inc. PHONE FAX 43 Rte 134 Arc No Ext: Arc No):(877)816-2166 South Dennis,MA 02660 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC INSURERA:OId Republic General Insurance Corp. 24139 INSURED INSURER B Feeney Brothers Services LLC INSURERC• 103 Clayton St PO Box 220801 INSURER D: Dorchester,MA 02122 INSURER E. INSURER F: COVERAGES CERTIFICATE NUMBER: 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 CONTRACTOR 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. 1LTR TYPE OF INSURANCE DD SBR POLICY NUMBER POLICY EFF MWDD EXP LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,00 C4AIh1S•A}ADE a OCCUR A2CGO7501601 02/01/2015 02/01/2016 DAMAGE 10 RENThU PREMISES Ea occurrence S 300,00 MED EXP(Anyone Person) $ _ 10,00 PERSONAL&ADV INJURY S 1,000,00 GEN'LAGGREGATELIMIT APPLIES PER: GENERAL AGGREGATE S 2,000,00 POLICY EC Fx1 LOC PRODUCTS-COMPIOPAGG S 2,000,00 OTHER: $ AUTOMOBILE LIABILITY - COMBINED SINGLE LIMIT $ Ea actident ANY AUTO BODILY INJURY(Per person) $ ALLOAt4ED SCHEDULED BODILY INJURY(Per $ AUTOS AUTOS ( ) NONwOI%NEO PROPERTY DAMAGE HIRED AUTOS AUTOS PeraoCdenl $ $ UMBRELLA LIAROCCUR EACH OCCURRENCE $ EXCESS LIAR HCLAMIS.I.IADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATIONPER OTH- AND EMPLOYERS'LIABILITY YIN X STATUTE ER A AMY PROPRIETORIPARTNERIEXECUTNE A2CW07501601 02/0112015 02/0112016 E.L.EACH ACCIDENT $ 1,000,00 OFFICERWFLIBEREXCLUDEO? NIA (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,00 Ues,descnbe under SCRIPTIONOFOPERATIONS beae E.LDISEASE-POLICY LIMIT $ 1,000,00 I _L DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedulemayb , e attached If more space Is requTred) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1600 Osgood Street ACCORDANCE WITH THE POLICY PROVISIONS. North Andover,MA 01845 AUTHORIZED REPRESENTATIVE a, ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 26(2014101) The ACORD name and logo are registered marks of ACORD