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Miscellaneous - 65 HILLSIDE ROAD 4/30/2018
/ 65 HILLSIDE ROAD J 210/098.C-0105-oor Date A......... 10248 TOWN OF NORTH ANDOVER 10 PERMIT FOR PLUMBING (4 This certifies that................................... ....................................................... has permission to perform..... ........................ plumbing in the buildings .....of......... ... ...............................I...................... . .. ... . ...... at.....LS..... ......&(0............................... North Andover, Mass. .... ........ 2 ................ fee.�!O.:.1)13.....Lic. No. .........%2....... ................................... . ......... .............. PLUMBING INSPECTOR Check# r _ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK -�- � / J7 CITY I MA DATE ( PERMIT# JOBSITE ADDRESS OWNER'S NAME OWNER ADDRESS TEL ]FAX }, TYPE OR OCCUPANCYTYPE COMMERCIAL © EDUCATIONAL © RESIDENTIAL PRINT CLEARLY NEW: M RENOVATION:E] REPLACEMENT: PLANS SUBMITTED: YES® NO F-] FIXTURES 7 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 .1213 14 � BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM I ____.._1 DISHWASHER DRINKING FOUNTAIN I .--_-_--( ---____I .._____._I .__._f _____f __.___..__f. _._._.._I .___ _._.___► ..._..._I __-_._.t __._..._J __l. __......_f FOOD DISPOSER i .____... � ( .__..__i II ! .__._.__.._f -_�J f ..) FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK l __.� E LAVATORY ___ _._. _ ROOF DRAIN .-.-._J ._- -_---_( -_.__ --------ill- SHOWER . f _SHOWER STALL SERVICE/MOP SINK ' TOILET I - f URINAL WASHING MACHINE CONNECTION .... WATER HEATER ALL TYPES _l _f € _ ._ # i I _ i I ... _J WATER PIPING L -A OTHER 1s11�✓l Q� -._� I ► i ._..-.__.-_ INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES _._ TO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY © BOND Q 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 —i AGENT 10 cz:C- SIGNATURE OF OWNER OR AGENT S hereby certify that all of the details and information I have submitted or entered regarding this application aretru n ccurate to the best of my knowledge 5 and that all plumbing work and installations performed under the permit issued for this application will be in com ' n ent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. � PLUMBER'S NAME V I G I LICENSE# _l { SIGNATURE MP a JP n CORPORATION 9# � - _{PARTNERSHIP®# LLC COMPANY NAMEC/�f✓Ll-I� /µN L TZ ADDRESS CITY Iy. / ��OV� ;STATE _.( ZIP �� _ TEL I' r FAX f CELL � 3--- I EMAIL L� .) G I ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES i Date.. 1-�1- 3 �►onr#j qti op TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION ,g3�CHUS� JT�:�.�::...... .:.......:..............:...................: This certifies that ...... .... .. has permission for gas installation... ... in the buildings of...................:. .... .....!..::.......................................: at....x.......1-1 4 L L S\3 c�-.... MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY AN OVER• MA DATE/YI - _ 1 PERMIT# JOBSITE ADDRESS 65 HILLSIDE RD OWNER'S NAME FISCHER aG OWNER ADDRESS TE� FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YESE NO[] APPLIANCES I FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 `" 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE ,m,..,..F DIRECT VENT HEATER_ ®a wF , DRYER FIREPLACE FRYOLATOR FURNACE I _ .N GENERATOR � "� �' _ � � � � GRILLE _ M INFRARED HEATER ,..._ µ. LABORATORY COCKS N., MAKEUP AIR UNIT I. OVEN wear POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT ' TEST UNIT HEATER UNVENTED ROOM HEATER i WATER HEATE OTHER „ INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICYOTHER TYPE INDEMNITY BOND i 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 nd accurate Vthe best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in co m I' ce ith all ertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. / PLUMBER-GASFITTER NAME FJEFF HUTNICK 7 LICENSE#15212 j ( IGNATURE MP El MGF Dj, JP JGF LPGI CORPORATION # 3532 PARTN SHIP #=LLC # COMPANY NAME: CALLAHAN AC AN1 dHTG ADDRESS 91 BELMONT ST a CITY NORTH ANDOVER STATE _MA ZIP[----- TEL1845 978-689 9233 FAX CELL 978 423 6305 EMAIL PLUMBING@CALLAHANAC COM 1 _ 1 tiCOMMONWEALTH OF MASSCH AUSETTS - - � .. • .. r G; COMMONWEALTH OF,MASSACHUSETTS PLUM� RS ANL�:GASFITTERS=, • REGI�TERe-© AS ,q RtLUMB11�tG CORP ' y issuESOr P:L1MBERS AND .GASFITTERS ucENSE_To REGISTERED ASA PLUMBING CORP i ISSUES THE':ABOVE LICENSED . FREY P EiUTNIt Kzf CALLAHAN AIR:_ CO .DITIONING & &EL " 9I MONT ,T FiEA .tEFFREY ;HUTNICK x@� CA ND 'HE T N 05 L LAHAN A/C A A I G SERV Tr- NORTH ANDOU R x b0 PIYMOUTN ST M 018:45 23Q4 - - \\\^ 2840, /01/1 148I8 �fETt{UEN MA 018:44 425b f 3: 0 /0CENSE '1/1 -_, - • EXPIRATION _ _ t COMM©NWEALTH OF MASSACHUSETTS COIVlMOIVVYEALTH OF`MASSACHUSETTS -? .,: • - r - PLUt4iBEH,, ANL1 GASFITTERS PL t MBERS AND GASFITTERS . ttCEI ISED �5 q � S TER PLUMBER LfCEN� ED AS A JOURNEYMAI�t PLUMBER ISSUES THE AS VE LICENSE TO. r = ESSUES THE ABOVE CIGENSE TO £ JEFEY FRP f ►1TN_IC�" FFRE� P, HUT.NICK 6[] PLYMOUTH S.T ' .` PLYM:�UTH ..-ST s 3:0 . ME_THUE�t -MA .. .4--2,5,6MEIHUEN r 71844= ; MA: 0184:4 425& C 15212 /0 05 1 1/1.4 L478Q4 2188I /01/L4 47803 y/• -. a .. :..., ,,. ...' • y •, s „ ...i The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, NIA 02111 F www.ntass.gov/dia Vrkers' N.mpensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le2ibl I�ne (Business/Organization/Individual): ��Gf ��z �o 14-11,4 Address: i /iy7.14-Z' r it City/State/Zip: � - % �yi �2,f/� Phone : �. Y Are you an employer? Check the appropriate box: 1. 4Jam a employer with ,�i� 4. ❑ I am a general contractor and I Type of project(required): employees (full and/or part-time).` have hired the sub-contractors 6. E] New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodelincr ship and have no employees These sub-contractors have S. ❑ Demolitions working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.+ 9. ❑ Building addition required.] 5. ❑ We are a corporation and its 10.El Electrical repairs or additions J.❑ I am a homeowner doing all work officers have exe;cised their 11.❑ Plumbing repairs or additions myself: [No workers' comp. right of exemption per MGL insurance required.] T c. 152, 51(4), and we have no I?.[] Roof repairs employees. [No workers' 13.7 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 lure outside contractors must subirtit a new affidavit indicating such. 'Cont actors that creek 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 thein workers'comp.policy number. I all, an employer that is providing workers'compensation insurance for)ray employees. Below is the policy and job site information. � i Insurance Company Name:_ ._L f7JG�t'?t n Policy#or Self-ins.Lic. #: _ /2- lf� r^ 'Ll—] ./73 / Expiration llatQ;. Job Site Address: City/State"Zip: 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. I do hereby certify a der the pains and penalties o er'u that the information IP J r1' fo mahon provaderl above is true grad correct. Signature: Date: - Phone#: �7,P 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.BuBding Department 3. City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6. Other Contact Person: Phone#: 7 Date.....`��.. ��.' 0.� tt AORTN 3?0et"1` TOWN OF NORTH ANDOVER O P PERMIT FOR WIRING ,sS^CHUSEt L. This certifies that ..........!.1...(/40!5 . .�............................................. has permission to perform 54F# ..................... f wiring in the building of......—( ff�R. ....... ,North Andover,Mass. Fee.J .... ...... ................. s2 ELECTRICAL NSPE Check # 2 ,p. 57 `x' _ Official Use Only Commonwealth of Massachusetts /Permit No. .� `a. F. Department of Fire ServYAT Occupancy and Fee Checked BOARD OF FIRE PREVENTION REG [Rev. 11/99] leave blank APPLICATION FOR PERMIT TELECTRICAL WORK All work to be performed inaccordance with the al Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL0 TIOterCity or Town of: O the InspectM of res: By this application the undersigned gives notice of his or JV her,inte'tion to perform the electrical work described below. Location(Street&Number) . Owner or Tenant 1sc.,4aATelephone No. TW Owner's Address Is this permit in conjunctionith a b ilding perm i Yes ❑ No (Check Appropriate Box) Purpose of Building Utilityuthorization No. -3 3 Existing Service `DD Amps Za / vVolts 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: Completion of the folloi4ing table may be waived by the Inspector of Wires. No. of Recessed Fixtures No.of Ceil:Susp.(Paddle)Fans No. of Total Transformers KVA No.of Lighting Outlets No.of Hot Tubs Generators KVA No. of Lighting Fixtures Swimming Pool Above ❑ In- ❑ o.of Emergency Lighting rnd. grnd. Batte Units No. of Receptacle Outlets No.of Oil Burners FIRE ALARMS No:of Zones No. of Switches No.of Gas Burners o.of Detection and Initiating Devices No:of Ranges No.of Air Cond. Total. No.of Alerting Devices Tons g No. of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals:I. I I Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances .Kyr Security Systems: No.of Devices or Equivalent No. of Water No.of .No. of Heaters KW Data Wiring: Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiri.ig: No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability in rance including"completed operation"coverage or its substantial equivalent. e undersigned certifies that suchcover is in force,and has exhibited proof of s e to th permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) '✓%LIEUi (Expira ion D te) Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. I certify, under the ypain', d penalties of ppeer"jury, th/a�J the in ormation on this application is true and complete. FIRM NAME: �e.+1/{,t l� LIC.NOLicensee: �(/ Signature LIC.NO.- (If applicable, �t�g� m t"in 1 e cense nu linBus.Tel.No. 1� Address: �>bl )V? (, � b AAR Alt.Tel.No.: OWNER'S INSURANCE WAIVER• I am aware that the Licensee does not have the liability insurance coverage normally t required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑ owner ❑ owner's agent. Owner/Agent I Signature Telephone No. PERMIT FEE: f �r Generators Residential & c)each additional meter..$10.00 TOWN OF ANDOVER Commercial: Sewer Ejection Pump: $25.00. ELECTRICAL PERMIT FEES a) including photovoltaic& Signs: $25.00 each ballast (Effective March 12, 2003) generating Equip Per KVA $1.00 Smoke&Heat Detectors & MINIMUM PERMIT FEES: b) un-interruptible power systems, Initiating Devices: RESID ENTIAL $25.00 per KVA $1.00 Residential: $1.00 each COMMERCIAL $100.00 c) batteries over 100 amp. hours,per Commercial: $60.00 up to 10 NO SE CABLE ON ` cell $1.00 devices over 10- $1.00 each OUTSIDE OF BUILDING Heat Devices: $1.00 each Space Heaters: Air Conditioners: $40.00 each Heat Pumps: $40.00 each area heating$1.00 each Alarm Systems Security: (for fire Hydro-Massage Bathtubs/Hot Sub-Panel: $25.00 systems see smoke/heat detectors) Tubs: $20.00 each Swimming Pools: Residential: $40.00 Lighting Fixtures $1.00 each Residential: Commercial: up to 10 Devices Lighting Outlets: $1.00 each Above Ground:.$25.00 $60.00 additional devices over 10- Major Appliances: (not listed) Inground: $50.00 $1.00 each $20 each Commercial Pool: $100.00 Carnival Equipment: $50.00 each Motors: (per hp or fractional part Switches: $1.00 each Ceiling Fans: $1.00 each thereof) $2.00 Temporary Service: Oil/Gas Burners: Must have Utility Authorization Number Commercial New Construction or Residential $25.00 Alterations: Residential $20.00 each $100:00 per 1,000 Sq. Ft.of Commercial $20.00 each Commercial $100.00 Construction Space Office Furnishings: per circuit $10 Transformers: Commercial Service Change/ (Relocatable Partitions/Cubicles) a)capacitors,Per KVA $1.00 Repair: Outlets & Fixture: $1.00 each b)ducts,conduit& conductors Must hm,e Utility Authorization Number Ovens Built in/Counter Top Units: (Associated w/Padmount Transformers)$25 $100 (first 100 amperes or fraction,one $10.00 each c)each manhole$10.00 meter) Panel Change/Circuit Breaker: d)each handhold $5.00 a each additional 100 amperes Residential:$20.00 e)per KVA$1:00 f)primary feeders, $25.00 each(over capacity or fraction. $30.00 Commercial: $25.00 600 volts,non-utility owned) b) each additional meter$25.00 Phone Jacks: See g)vaults and equip. $25.00 each Commercial Temporary..Service: data/telecommunications p Iy $100.00 Ranges $15.00 each Washers: $15.00 each Must haveUtility Authorization Number Rece title Outlets: $1.00 each Waste Disposals: $5.00 each Commercial Repair and/or. Water Heaters: $30.00 each Recessed Fixtures: $1.00 each Maintenance Permit: (Blanket Re-inspection Fee: $25.00 Permit)up to 2 Electricians$150.00 Repair to Service Residential: *For Multi-Family & per pair of Electricians over 2 $50.00 $20.00 Large Commercial Project , Data/Telecommunication: Residential New Construction see Wiring in Inspectorector forResidential: $1.00 per port (Dwelling): 220.00 Commercial: $30.00 u to 10 pricing:u to 200 amps)over l0-$1.00 each e� Must have Utility Authorization Number Paul Kennedy (978) 623-8306 Dishwashers & Disposals: for services over 200 amps see below (Office Hours 8 am to 10 am) $5.00 Each a) for each 100 amps capacity or Dryers: $15.00 Each fraction add $20.00 *Inspection Schedule: Emergency Lighting(Battery Units) b) each additional meter$10.00 $ 1.00 each unit c) each additional panellsub panel 1 ROUGH Feeders or Sub-feeders: $25.00 1 FINAL each 100 amp capacity of fraction 1 TRENCH (if applicable) ` N': thereof Residential Additions/Alterations: Residential: $5.00 each $220.00 maximum Residential Service Change or ADDITIONAL _ g Commercial: $15.00 each i Under-round Service: X Gas/Oil Burners: b INSPECTIONS '$25.00 (if Residential: $20.00 each $40.00 applicable) � Must have Utility Authorization Number ; Commercial $20.00 each a) one meter, up to 100 amp capacity $40.00 (revised 09/04) b) each additional 100 amp capacity or fraction $20.00 .� Commonwealth of Massachusetts Official Use Only t� Permit No, Department of Fire Services Occupancy and Fee Checked 7 BOARD OF FIRE PREVENTION REGULATIONS [Rev. 11/99] leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL 0 TION) Date: City or Town of: �vhtlice `, ; Jl>r� To the Inspect o�' res By this application the undersigneof his or her intention to perform the electrical workescnbe� fl `. Location(Street&Number) r Owner or Tenant Telephone No. 6l�5 Owner's Address Is this permit in conjunctiTith a b ilding permit? Yes ❑ No (Check Appropriate Box)' Purpose of BuildingZ ij Utility uthorization No. 23b� Existing Service ` Amps / �� rd gVolts Overhead Und No.'of Meters ❑ New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Com pletion of thefolloAdng table may be waived by theInspector of Wires. No. of Recessed Fixtures No.of Ceil.-Susp.(Paddle)Fans No.of Total Transformers KVA No, of Lighting Outlets No.of Hot Tubs Generators KVA No. of Lighting Fixtures Swimming Pool Bove ❑ In- El 0'o mergency ig mg rnd rnd. Batte Units No.of Receptacle Outlets No.of Oil Burners `,. FIRE ALARMS No:of Zones O No.'of Switches No.of Gas Burners ;_ _ o.o etection an InitiatinLi Devices No. of Ranges No.of Air Corid. Total. g Tons No.of Alerting Devices No.of Waste Disposers Heat Pump I.Number Tons KW No.of Self-Contained Totals:I Detection/Alerting Devices No. of Dishwashers Spac&Area Heating KW," Local ❑ Municipal Q Other Connection No. of Dryers: Heating AppliancesKms, Security Systems: No.of Devices or Equivalent No. of Heaters KW No.of .No. of Data Wiring: Signs Ballasts No.of Devices or E uivaleiit No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: ._i Attach additional detail i desired or required e uired b 1 the Inspector• 4 Y loco Wires. INS a u INSURANCE COVERAGE: Unless waived b the owner,no ermit�for the he erforma . , p performance of electrical work may issue unless the licensee provides » Y p s proof of liability in rance including"completed o era Uon cove g. P P coverage or its substantia _ g l equivalent. e undersigned certifies that such cover is m force and has exhibited q bi ed proof of s e to t permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) `1V (Expira ion D te) Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. . I certify, under the pain d penalties of perjury, tha the information on this application is true and comP lete ' l� FIRM NAME: � U ,tiPe.s VG l LIC.NO.: � Licensee: ,>n Signature LIC.NO.: (Ifapplicable, aWm�ppt"in��j�??e cense nu lin ) Bus.Tel.No. �. Address: V N!G 1L n�C � b Alt.Tel.No. OWNER'S INSURANCE WAIVERVI am aware that the Licensee does not have the liability insurance coverage normally O required by law. By my signature below,I hereby waive this requirement. lam the(check one)❑ owner ❑ owner's agent., . Owner/Agent Signature Telephone No. PERMIT FEE: _ r i � ... . . Date. . . �. . . . . ... . . 3� TOWN OF NORTH ANDOVER j p F i t - PERMIT FOR GAS INSTALLATION (/C.�L VJ l �e'. This certifies that . . . . . . . . . . . . . . . . .���� :��� �� has permission for gas installation . in the buildings of . ....!. . . . . . . . . . . . . at /Z... (. . . . . . �'. / , North Andover, Mass. Fee. . . . .r.�.. Lic. No.!... . . . . . . . . . . . . . . . . . . . . . . . . . . GASINSPECTOR Check# 4586 } MASSACHUSETTS UNIFORM APPLICATION FOR.PERMIT TO DO GASFITTING (Print or Type) NORTH ANDOVER 12/18/2003 Mass. Date 20 Permit# Building Location65 HILLSIDE ROAD Owner's Name MARK FISCHER Telephone. 979-975-7994 Type of Occupancy 1 Familv New D Renovation D Replacement ® Plans Submitted: YesD No D V C0 rn lZ Y Z ¢ W N C N U H W _ 0 W W U Z Z _ ¢ QQz m rn Q w 0 g a w ~ W W (a W Z Q W W I W 0 F _ Z H W i- Q W W 0 C > w W -� F- W it x o 3 0 5 $ M > o C ~ o sus-BSMT. BASEMENT 1 ST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR 5TH FLOOR 6TH FLOOR 7TH FLOOR STH FLOOR Installing Company Name Gerard Duff Check one: Certificate Address P.O Box 466 Mansfield MA 02048 D Corporation Partnership Business Telephone 508-454-5959 ® Firm/Co. Name of Licensed Plumber or Gas Fitter Gerard Duff INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivilant which meets the requirements of MGL Ch. 142. Yes ® No .71 If you have checkedems, please indicate the type coverage bychecking the appropriate box. Ai`liability insurance policy® Other type of indemnity D Bond D OWNER'S INSURANCE WAIVER: I am'aware that the licensee does not have the Insurance coverage required by ghapter 142 of the Mass. General Laws,and that my signature on this permit application waives this requirement. Check one: Owner D Agent D Signature of Owner or Owner's Agent I hear certify that all of the details and the information I have submitted(or entered)in the above application are true arjd accurate to the best of my knowledge and that all the plumbing work and installations performed under the permit issued for this application will in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the GeneralAre By Type of Licence: Title r Plumber Ci !Town ] Gasfitter City/Town Signature of Lice PI er or Gas Fitter APPROVED(OFFICE USE ONLY) Master License Number 1 Z ❑ Journeyman 25.00 + Date. TOWN OF NORTH ANDOVER 3? �� •�O0 PERMIT FOR PLUMBING SSACMUS� f / This certifies that a'. . . . has permission to perform . j1J . . ... . . �t.4�y ( . . . . . . . . plumhingri fi �uil'di gs of /1.� !/ --. ?% :.� . . . �. . .at . k, . . . . . . . . . . . . . . . ., North Andover, Mass. �J Fee�J.�.�... Lic. No. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . PLUMBING INSPECTOR Check !! J 15852 A MASSACHUSETTS UNIFORM APPLICATION FOR ERMIT TO DO PLUMBING (Print or Type) NORTH ANDOVER RA12/18/20.03 ass. Date f1 20 Permit# Building Location Owner's Name MARK FISCHER Telephone--91L-975-7994 ' 1 Family Type of Occupancy New 7 Renovation 7 Replace nt Plans Submitted: Yes? No z z z W 2 fn J > V Q z W W LLJQ D: Q O z_ it z_ z a N o m W = cc ¢ Q w cn Y 9 a " a a 3 <t W F Q CC W 0 Q W (� O LL M u- Z 8 Y W 3 Y g m ai o c g 3 = cog a Cr a 3 it m o SUB-BSMT. BASEMENT 1 ST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR 5TH FLOOR 6TH FLOOR M FLOOR 8TH FLOOR Installing Company Name Gerard Duff Check one: Certificate Address P.O Box 466 Mansfield MA 02048 ❑ Corporation Partnership Business Telephone 508-454-5959 Firm/Co. Name of Licensed Plumber or Gas Fitter Gerard Duff INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivilant which meets the requirements of MGL Ch. 142. A Yes ® No 7 If you have checked Yes, please indicate the type coverage bychecking the appropriate box. `TA liability insurance policy® Other type of indemnity 7 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 7 Agent 7 Signature of Owner or Owner's Agent I hear certify that all of the.details and the information I have submitted(or enter i the above applfapplin e and accurate to the best of my knowledge and that all the plumbing work and installations performed under ft issued for h ll be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 1 eneral Laws.Title Signature of licensed PlumberCity/Town Type of License:MasterJoumeym APPROVED(OFFICE USE ONLY) License Number 10349 25.00 i Date.. . . .. ..�, . . . .... .. ,� HORTM TOWN OF NORTH ANDOVER { - PERMIT FOR GAS INSTALLATION h CHO & This certifies that- .� i. . _. . has permission for gas installation . . . ...... . in the buildings of �f�'� 4�,- -2. 1 '/. . . . . . . . . . . . . at I K.. . . . . . . .. North Andover, Mass. Fee _, 51 Lic. No,! `?� . . . . . . . . . . . . . . . . . . . . . . . . . . GAS INSPECTOR Check# ��✓ �/ ' 4568 MASSACHUSETTS UNIFORM APPLICATION FOR�PERMIT TO DO GASFITTING J (� (Print or Type) NORTH ANDOVER 12/09/2003 J Mass. Date 2C Permit# Building Location65 HILLSIDE ROAD Owner's Name MARK FISCHER U9 Telephone-923--K5,27994 ,F Type of Occupancy 1 Family New D Renovation Replacement HIK Plans Submitted: YesD No D G V M M W Y Z W rn N U X QQW W ¢¢ OLU U m F- _ 2 O W W O _ o� Z W M m W .O W d W H z W z Q = W�W M W W o w _ Z QW W WQ~ f- F- } fn O Z WO Z W = O C7 2 a Q m O W O W F=- 3 o c� g c� 2 > SUB-BSMT. I IT BASEMENT 1 ST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR 5TH FLOOR 6TH FLOOR 7TH FLOOR FF — 8TH FLOOR Installing Company Name Gerard Duff Check one: Certificate Address P.O Box 466 Mansfield MA 02048 D Corporation Partnership Business Telephone 508-454-5959 ® Firm/Co. Name of Licensed Plumber or Gas Fitter Gerard Duff INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivilant which meets the requirements of MGL Ch. 142. Yes F& No El If you have checked M,please indicate the type coverage bychecking the appropriate box. A liability insurance policy® Other type of indemnity :1 Bond :1 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: Si nature of Owner or Owner's Agent Owner ❑ Agent I hear certify that all of the details and the information I have submitted(or entered)in the above application are true and accurate to the best of my knowledge and that all the plumbing work and installations performed under the permit issued for this application well be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. By Type of Licence: Title Plumber City/Town ] Gasfitter Signature of Licensed Plumber or Gas Fitter APPROVED(OFFICE USE ONLY) Master License Number 10349 ❑ Journeyman Date 1�IWIK5 w V RT:'tic TOWN OF NORTH ANDOVER ' PERMIT FOR PLUMBING ,SSACHUS� /C This certifies that• . .4! .. . . . . . . . . . . has permission to perform . . . l. . . . . . . . . . . . . . . . . . . . . . . . plumb] gin tIQ buildings of .!.! .' �r. .. .. . at . . �1 /'�: . . ./. . . . . . . . . . . . . . . . North Andover, Mass. FeeOr.. G�3 . . . .Lic. No./ (. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Check �LLL- PLUMBING INSPECTOR 5838 MASSACHUSETTS UNIFORM APPLICATION FOR PE (Print or Type) RMIT TO DO PLUMBING � NORTH ANDOVER AA12/09/2003 �� ass. Date z 20 Permit# V Building Location ` Owner's Name MARK FISCHER Telephone—_928-975-7994 j � 1 Family Type of Occupancy New Renovation EReplacement iN Plans Submitted: Yes No zz W J U Q w w CO) Z 2 Q rt < t- 2 Z ('3 Q Xi O z m W = y V Q rn - a LL z z a 3 x ¢ Lu ~ W !CO W o a W 63 ° qa JQ Z a �p 0 tL p LL CO) �" z Z v w rn U = Z Y a w u. 3 Y g m ai o c g 3 i g c a 3 g m 0 SUB-BSMT. BASEMENT 1 ST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR i STH FLOOR 6TH FLOOR 7TH FLOOR 8TH FLOOR H7-1 Installing Company Name Gerard Duff Check one: Certificate Address P.O Box 466 Mansfield MA 02048 ❑ Corporation El Partnership Business Telephone 508-454-5959 Firm/Co. Name of Licensed Plumber or Gas Fitter Gerard Duff INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivilant which meets the requirements of MGL Ch. 142. Yes X No I,d you have checked Yes, please indicate the type coverage bychecking the appropriate box. A liability insurance policy.9 Other type of indemnity :1 Bond QWNER'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 71 Si nature of Owner or Owner's Agent I hear certify that all of the details and the information I have submitted(or entered)in the above application are true and accurate to the best of my knowledge and that all the plumbing work and installations performed under the permit Issued for this application in Hance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General ws. By Title Signature of Licensed Plumber City/Town Type of License:Master X Journeyman '-1 APPROVED(OFFICE USE ONLY) License Number 10349 1l NUMBER °' � COMMONWEALTH OF MASSACHUSETTS BHP-2017-0543 North Andover FEE $100.00 _°a t BOARD OF HEALTH r�.Y'r4Wu ;Ah Michael John Colo nbosian NAME 65 HILLSIDE ROAD ------------------------------------------------------------------------ ADDRESS IS HEREBY GRANTED A PERMIT Trench Permit Trench work to repair blocked sewer This permit is granted in conformity with the Statutes and ordinances relating thereto, and expires Dec-ember-0-82-201-7------ - unless sooner suspended or revoked. ---------------------------------------------------------------- September 08, 2017 BOARD OF -------------------- - --- -- - - - - HEALTH ------ -�-��- - - ---- (--------- ------------------------------------------------------------------ BOARD OF HEALTH CHAIRMAN NUMBER 01P COMMONWEALTH OF MASSACHUSETTS BHP-2017-0543 '01• . . • �,. North Andover FEE $100.00 BOARD OF HEALTH Michael John Colombosian ------------------------------------------------------------------------------------- NAME 65 HILLSIDE ROAD ------------------------------------------------------------ ------------------------------- ADDRESS IS HEREBY GRANTED A PERMIT Trench Permit Trench work to repair blocked sewer This permit is granted in conformity with the Statutes and ordinances relating thereto, and expires ------------December-0-82-201-7-----------unless sooner suspended or revoked. ----- ----- -- - - - - September 08, 2017 --------------------------------------------------------------- BOARD OF - ---------------------------------------------------------------- HEALTH f -- - ----- - ----------------------------------------------------------------- BOARD OF HEALTH CHAIRMAN ® /� 0 TOWN OF NORTH ANDOVER Permit Number ® 5 NORTH ANDOVER,MASSACHUSETTS 41845 Date Issued J. ®e,� 0,,+6 Oo74 Expiration Date 4Z x 4 RECEIVED � �rQ s.ewi� y SEP 0 8 2017 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT Jackie's Law — Permit Application Pursuant to G.L. c. 82A §1 and 520 CMR 7.00 et seq.(as amended) THIS PERMIT MUST BE FULLY COMPLETED PRIOR TO CONSIDERATION Name of Applicant Phone Cell 111 i Lk e-� �"�1�,o %y PrQ t 7G L(A%f 9 79 Street Address .f City/Town MA ZIP AAn�ptic TTA �1 'a ll7 Name of Excavator(if different from applicant) Phone Cell Street Address ) Y:ziP-\ _ CiWrown MA ZIP Name of Owners)of Property_ Phone Cell Street Address 65 t—1LL5iDr= ROAD City/Town MA ZIP eog AWN N 0k%45�-537 Other Contact Permit Fee Received No Yes Description,location and purpose of proposed trench: Please describe the exact location of the proposed trench and its purpose(include a description of what is(or is intended)to be laid in proposed trench(eg;pipes/cable lines etc..)Please use reverse side if additional space is needed. Insurance Certificate 55 o� d a./ /0 Co Name and Contact Information of Insurer- Policy Expiration Date: o% Dig Safe#: Name of Competent Person(as defined by 520 CMR 7.02): Massachusetts Hoisting License# License Grade: Expiration Date: BY SIGNING THIS FORM, THE APPLICANT, OWNER, AND EXCAVATOR ALL ACKNOWLEDGE AND CERTIFY THAT THEY ARE FAMILIAR WITH, OR, BEFORE COMMENCEMENT OF THE WORK, WILL BECOME FAMILIAR WITH, ALL LAWS AND REGULATIONS APPLICABLE TO WORK PROPOSED,INCLUDING OSHA REGULATIONS,G.L.c.82A,520 CMR 7.00 et seq.,AND ANY APPLICABLE MUNICIPAL ORDINANCES,BY-LAWS AND REGULATIONS AND THEY COVENANT AND AGREE THAT ALL WORK DONE UNDER THE PERMIT ISSUED FOR SUCH WORK WILL COMPLY THEREWITH IN ALL RESPECTS AND WITH THE CONDITIONS SET FORTH BELOW, THE UNDERSIGNED OWNER AUTHORIZES THE APPLICANT TO APPLY FOR THE PERMIT AND THE EXCAVATOR TO UNDERTAKE SUCH WORK ON THE PROPERTY OF THE OWNER, AND ALSO,FOR THE DURATION OF CONSTRUCTION,AUTHORIZES PERSONS DULY APPOINTED BY THE MUNICIPALITY TO ENTER UPON THE PROPERTY TO MONITOR AND INSPECT THE WORK FOR CONFORMITY WITH THE CONDITIONS ATTACHED HERETO AND THE LAWS AND REGULATIONS COVERING SUCH WORK. THE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO REIMBURSE THE MUNICIPALITY FOR ANY AND ALL COSTS AND EXPENSES INCURRED BY THE MUNICIPALITY IN CONNECTION WITH THIS PERMIT AND THE WORK CONDUCTED THEREUNDER,INCLUDING BUT NOT LIMITED TO ENFORCING THE REQUIREMENTS OF STATE LAW AND CONDITIONS OF THIS PERMIT,INSPECTIONS MADE TO ASSURE COMPLIANCE THEREWITH,AND MEASURES TAKEN BY THE MUNICIPALITY TO PROTECT THE PUBLIC WHERE THE APPLICANT OWNER OR EXCAVATOR HAS FAILED TO COMPLY THEREWITH INCLUDING POLICE DETAILS AND OTHER REMEDIAL MEASURES DEEMED NECESSARY BY THE MUNICIPALITY. THE UNDERSIGNED APPLICANT,OWNER AND EXCAVATOR AGREE JOINTLY AND SEVERALLY TO DEFEND,INDEMNIFY,AND HOLD HARMLESS THE MUNICIPALITY AND ALL OF ITS AGENTS AND EMPLOYEES FROM ANY AND ALL LIABILITY,CAUSES OR ACTION,COSTS,AND EXPENSES RESULTING FROM OR ARISING OUT OF ANY INJURY, DEATH, LOSS, OR DAMAGE TO ANY PERSON OR PROPERTY DURING THE WORK CONDUCTED UNDER THIS PERMIT. APPLICANT SIGNATURE v.-. DATE q-7— L7 EXCAVATOR SIGNATURE(IF DIFFERENT) DATE OWN R'SGNA /�J� D RENT) V DATE: 7 ,� _\FFA•. � � `" _,_ ,�=-. .�-t_�,�., .�-,� �=�_ .";`�.c•r�"�"ti=-��''•r���...s-'-.��';�`'^�'��',',1.?��_w�..=t,..G:�," .tet`,x,'..•C=�'�-w.�t'' y�:�,^v:c'=''`�"�%.``i�s..: z. " _ n✓�.,. ��. h:�`,�F-c,�-=: .w�'o-'='. .nom_ - "" M NO _..-o.,,._,......._...•=,.:_....-..�:...�fr..<«_ir-.,.,.�> _�. r__-'; xr� .-�"..-.zr,_..r1=:E. ._mac_✓i__:r.,:Fr?-r_.c-..:r. .r,.�:::. ..,�' =.Y.:_..:�: CONDITIONS AND REQUIREMENTS PURSUANT TO G.L.C.82A AND 520 CMR 7.00 et seq. (as amended) By signing the application,the applicant understands and agrees to comply with the following: i. No trench may.be excavated unless the requirements of sections 40 through 40D of chapter 82,and any accompanying regulations,have been met and this permit is invalid unless and until said requirements have been complied with by the excavator applying for the permit including,but not limited to,the establishment of a valid excavation number with the underground plant damage prevention system as said system is defined in section 76D of chapter 164(DIG SAFE); Trenches may pose a significant health and safety hazard. Pursuant to Section i of Chapter 82 of the General Laws,an excavator shall not leave any open trench unattended without first making every reasonable effort to eliminate any recognized safety hazard that may exist as a result of leaving said open trench unattended. Excavators should consult regulations promulgated by the Department of Public Safety in order to familiarize themselves with the recognized safety hazards associated with excavations and open trenches and the procedures required or recommended by said department in order to make every reasonable effort to eliminate said safety hazards which may include covering, barricading or otherwise protecting open trenches from accidental entry. Persons engaging in any in any trenching operation shall familiarize themselves with the federal safety standards promulgated by the Occupational Safety and Health Administration on excavations:29 CFR 1926.650 et.seq.,entitled Subpart P"Excavations". iv. Excavators engaging in any trenching operation who utilize hoisting or other mechanical equipment subject to chapter 146 shall only employ individuals licensed to operate said equipment by the Department of Public Safety pursuant to said chapter and this permit must be presented to said licensed operator before any excavation is commenced; V. By applying for,accepting and signing this permit,the applicant hereby attests to the following:(1)that they have read and understands the regulations promulgated by the Department of Public Safety with regard to construction related excavations and trench safety; (2)that he has read and understands the federal safety standards promulgated by the Occupational Safety and Health Administration on excavations:29 CMR 1926.650 et.seq.,entitled Subpart P"Excavations"as well as any other excavation requirements established by this municipality;and(3)that he is aware of and has,with regard to the proposed trench excavation on private property or proposed excavation of a city or town public way that forms the basis of the permit application,complied with the requirements of sections 40- 40D of chapter 82A. vi. This permit shall be posted in plain view on the site of the trench. For additional information please visit the Department of Public Safety's website at www,mass.gov/dpi 3Page Summary of Excavation.and Trench Safetu Regulation(520 CMR 14.00 et sea.) This summary was prepared by the Massachusetts Department of Public Safety pursuant to G.L.c.82A and does not include all requirements of the 520 CMR 14.00. To view the full regulation and G.L.c.82A,go to www/mass.gov/dps Pursuant to M.G.L. c. 82,.§ 1,the Department of Public Safety,jointly withthe Division of Occupational Safety, drafted regulations relative to trench safety. The regulation is codified in section 14.00 of title 520 of the Code of Massachusetts Regulations. The regulation requires all excavators to obtain a permit prior to the excavation of a trench made for a construction-related purpose on public or private land or rights-of-way. All municipalities must establish a local permitting authority for the purpose of issuing permits for trenches within their municipality. Trenches on land owned or controlled by a public(state)agency requires a permit to be issued by that public agency unless otherwise designated. In addition to the permitting requirements mandated by statute, the trench safety regulations require that all excavators,whether public or private,take specific precautions to protect the general public and prevent unauthorized access to unattended trenches. Accordingly,unattended trenches must be covered,barricaded or backfilled. Covers must be road plates at least V thick or equivalent;barricades must be fences at least 6'high with no openings greater than 4" between vertical supports; backfilling must be sufficient to eliminate the trench. Alternatively, excavators may choose.to attend trenches at all times,for instance by hiring a police detail,security guard or other attendant who will be present during times when the trench will be unattended by the excavator. The regulations further provide that local permitting authorities,the Department of Public Safety,or the Division of Occupational Safety may order an immediate shutdown of a trench in the event of a death or serious injury;the failure to obtain a permit; or the failure to implement or effectively use adequate protections for the general public. The trench shall remain shutdown until re-inspected and authorized to re-open provided, however,the excavators shall have the right to appeal an immediate shutdown. Permitting authorities are further authorized to suspend or revoke a permit following a hearing. Excavators may also be subject to administrative fines issued by the Department of Public Safety for identified violations. Summary of 1926 CFR Subpart P-OSHA Excavation Standard This is a worker protection standard,and is designed to protect employees who are working inside a trench. This summary was prepared by the Massachusetts Division of Occupational Safety and not OSHA for informational purposes only and does not constitute an official interpretation by OSHA of their regulations,and may not include all aspects of the standard. For further information or a full copy of the standard go to www.osha.gov. Trench Definition per the OSHA standard: o An excavation made below the surface of the ground,narrow in relation to its length. o In general,the depth is greater than the width,but the width of the trench is not greater than fifteen feet. • Protective Systems to prevent soil wall collapse are always required in trenches deeper than 5',and are also required in trenches less than 5'deep when the competent person determines that a hazard exists. Protection options include: o Shoring. Shoring must be used in accordance with the OSHA Excavation standard appendices,the equipment manufacturer's tabulated data,or designed by a registered professional engineer. o Shielding(Trench Boxes). Trench boxes must be used in accordance with the equipment manufacturer's tabulated data,or a registered professional engineer. o Sloping or Benching. In Type C soils(what is most typically encountered)the excavation must extend horizontally 1 %2 feet for every foot of trench depth on both sides, 1 foot for Type B soils, and%foot for Type A soils. o A registered professional engineer must design protective systems for all excavations greater than 20'in depth. continued • Ladders must be used in trenches deeper than 4'. o Ladders must be inside the trench with workers at all times,and located within 25'of unobstructed lateral travel for every worker in the trench. , o Ladders must extend 3'above the top of the trench so workers can safely get onto and off of the ladder. • Inspections of every trench worksite are required: o Prior to the start of each shift,and again when there is a change in conditions_ such as a rainstorm. o Inspections must be conducted by the competent person(see below). • Competent Person(s)is: o Capable(i.e.,trained and knowledgeable)in identifying existing and predictable hazards in the trench,and other working conditions which may pose a hazard to workers,and o Authorized by management to take necessary corrective action to eliminate the hazards. Employees must be removed from hazardous areas until the hazard has been corrected. • Underground Utilities must be: o Identified prior to opening the excavation(e.g.,contact Dig Safe). o Located by safe and acceptable means while excavating. o Protected,supported,or removed once exposed. • Spoils must be kept back a minimum of 2'from the edge of the trench. • Surface Encumbrances creating a hazard must be removed or supported to safeguard employees. Keep heavy equipment and heavy material as far back from the edge of the trench as possible. • Stability of Adjacent Structures: o Where the stability of adjacent structures is endangered by creation of the trench,they must be underpinned,braced,or otherwise supported. o Sidewalks,pavements,etc.shall not be undermined unless a support system or other method of protection is provided. Protection from water accumulation hazards: o It is not allowable for employees to work in trenches with accumulated water. If water control such as pumping is used to prevent water accumulation,this must be monitored by the competent person. o If the trench interrupts natural drainage of surface water;ditches,dikes or other means must be used to prevent this water from entering the excavation. • Additional Requirements: o For mobile equipment operated near the edge of the trench,a warning system such as barricades or stop logs must be used. o Employees are not permitted to work underneath loads. Operators may not remain in vehicles being loaded unless vehicles are equipped with adequate protection as per 1926.601(b)(6). o Employees must wear high-visibility clothing in traffic work zones. o Air monitoring must be conducted in trenches deeper than 4'if the potential for a hazardous atmosphere exists. If a hazardous atmosphere is found to exist(e.g.,02<19.5%or>23.5%,20% LEL,specific chemical hazard),adequate protections shall be taken such as ventilation of the space. o Walkways are required where employees must cross over the trench. Walkways with guardrails must be provided for crossing over trenches>6'deep. o Employees must be protected from loose rock or soil through protections such as scaling or protective barricades. 5 Page Client#: 8614 MJCOLOMBO ACORD- CERTIFICATE OF LIABILITY INSURANCE 9DATE /08/2017NYYY) PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Doherty Insurance Agency,Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE P.O. Box 1985 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 21 Elm Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Andover, MA 01810 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: Arbella Protection Ins Company M.J.Colombo Landscaping, Inc INSURER B: The Hartford Michael Colombosian INSURER C: 48 Argilla Rd INSURER D: Andover, MA 01810 INSURER E: COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD' TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LTR NSR DATE MM/DD/YY DATE MM/DD/YY LIMITS it A GENERAL LIABILITY 9520040469 06/28/17 06/28/18 EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE AMAG ETO RES tEaNTEDPREMIoccurrence) $300OOO CLAIMS MADE 51OCCUR MED EXP(Any one person) $5-10-0-0— PERSONAL 5OOOPERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE s2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG s21000,000 X POLICY PRO- JECT LOC A AUTOMOBILE LIABILITY 1020008792 11/15/16 11/15'5/17 COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $1,000,000 ALL OWNED AUTOS BODILY INJURY X SCHEDULED AUTOS (Per person) $ X HIRED AUTOS BODILY INJURY X NON-OWNED AUTOS (Per accident) $ PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ DEDUCTIBLE RETENTION $ B WORKERS COMPENSATION AND 08W ECIS7301 05/28/17 05/28/18 X WC STATU- oTH- EMPLOYERS'LIABILITYFly ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $500 OOO OFFICER/MEMBER EXCLUDED? If yes,describe under E.L.DISEASE-EA EMPLOYEE $500 OOO SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $500 OOO OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT!SPECIAL PROVISIONS Covering operations usual to M.J.Colombo Landscaping,Inc... CERTIFICATE HOLDER CANCELLATION 10 Days for Non-Payment SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Town of North Andover DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL In DAYS WRITTEN Health Dept NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL 1600 Osgood St., IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR Bldg 20, Unit 2035 REPRESENTATIVES. North Andover,MA 01845 AUTHORIZE I PRESENTATIV ACORD 25(2001/08)1 of 2 #S35809/M35786 v 0ACORD CORPORATION 1988 IMPORTANT If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. i I ACORD 25-S(2001/08) 2 of 2 #S35809/M35786 5 e AORTN 8001 Town of North Andover :. HEALTH DEPARTMENT ,SSACHUSt� CHECK#: -DATE: LOCATION: 6 5 H/O NAME: CONTRACTOR NAME:1V1< To117 4 Type of Permit or License: (Check box) ❑ Animal $ t. ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ k ❑ Offal(Septic)Hauler $ r ❑ Recreational Camp $ 4 ❑ Sun tanning $ ❑ Swimming Pool $ r, t. ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ k ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ t, ❑ Title 5 Inspector $ �t ❑ Title 5 Report $ '�; Other:(Indicate) 00 Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer