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HomeMy WebLinkAboutMiscellaneous - 65 STANTON WAY 4/30/2018 lass 'J BUILDING FILE 20.0' 16-2 \ EASEMENT \ �s\ EXISTING FND. BUFFER \\ ABS\ EL.=95.6' LOT 16-3 \ CV I M I \ \ i\ N 183.9' Q, i STANTON WAY EASEMENT om 113.8' OF Mass god MICHAEL 9�ym 16-4 J. SERGI No.33191 IgND SURA I CERTIFY THAT THE PRIMARY STRUCTURE'SHOWN CONFORMS TO THE HORIZONTAL SETBACK REQUIREMENTS OF THE LOCAL FOUNDATION AS-BUILT (THISICERTIFIZONING BY-LAWS IN EFFECT AN TION DOE NOT CONSIDERWHEN ANY OTHER CONSTRUCTED. RESTRICTIONS SUCH AS COVENANTS,WETLANDS,EASEMENTS, ORDERS OF CONDITIONS,ETC.)THIS DRAWING SHALL NOT BE USED BY THE CLIENT FOR ANY PURPOSE OTHER THAN THAT OUTLINED CLIENT: GREEN & COMPANY PERMISSION OF&ERGS NC.FURTHE MORE TTHIS DRAWING IS THE COPYR GHHTED" THIS CERTIFICATION IS MADE AND LIMITED TO THE ABOVE CLIENT PROPERTY OF CHRISTIANSEN&SERGI INC.AND ANY UNAUTHORIZED USE IS PROHIBITED.CHRISTIANSEN&SERGI TAKES LOCATION: NORTH ANDOVER,MA. NO RESPONSIBILITY FOR THE UNAUTHORIZED USE OF THIS DRAWING OR ANY INFORMATION CONTAINED HEREON. DATE:6/25/14 SCALE: 1"=100' PROFESSIONAL ENGINEERS & LAND SURVEYORS CHRISTIANSEN & SERGI INC. 160 SUMMER STREET, HAVERHILL, MASSACHUSETTS 01830 WWW.CSI-ENGR.COM TEL. 978-373-0310 FAX. 978-372-3960 DWG.NO.: 12007.001.012 i y Date.. .. ... ....1.................. NORTiy TOWN OF NORTH ANDOVER o s PERMIT FOR WIRING ;'"` -'ire•` 9 ,s`SACHU5�S 19A L This certifies that ....................................................................... PC has permission to perform ..1 ?.e.. .. ^-�" wiring in the bw' ding of............. P..4':+E.?......... \ C9 ................................... ( � - at ... ....................................... , . . North Andover,Mass. Fee.t ..:. Lic.No�-7 1 ` W NSPECTOR Check# r) Commonwealth of Massachusetts Official Use Only Permit No. ,w o Department of Fire Services Occupancy and Fee Checked aM BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07j (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(NMC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: City or Town of: NORTH ANDOVER To the Inspector of Wires: �1 By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) /j�(� Y+ Owner or Tenant t Telephone No./,0:3 Owner's Address 2,06,ex ,� p e6Ca Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization Nof�210�7 TJ - Existing Service Amps / Volts Overhead ❑ Undgrd i��o.lof Meters " New Service( 200 Amps 1.24) / o?9:IVolts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: L L/ L.- Completion of thefollowing table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Cell:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets O No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- ❑ o.o mergency ig tmg rnd. grnd. Battery Units No.of Receptacle Outlets I'f 0 No.of Oil Burners FIRE ALARMS No. of Zones No.of Switches No.of Gas Burners No.of Detection and 7J Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons No.of Waste Disposers Heat Pump I Number I TonsKW No.of Self-Contained Totals: .-"-................. Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local El Connection ❑ Other Connection No.of Dryers Heating Appliances Kir Security Systems:' No.of Devices or Equivalent No.of WaterNo.of No.of KW Data Wiring: Heaters C Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or E uivalent . OTHER: Attach additional detail if desired,or as required by the Inspector of ff7res. -Estimated Value of Electrical Work: 10,090 (When required by municipal policy.) Work to Start: ap Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE C V GE: 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 ❑ BOND ❑ OTHER ❑ (Specify:) I certify,itnder the pains and penalties of perjury,thin the information on this application is true and complete. FIRM NAME: - t 1 LIC.NO.: 17 7 Licensee: Signature LIC.NO.: 17 7 (If applicable,enter "exempt"in the license number It e) us.Tel.No.:Gyp s 07 6� Address: A1 ,3 see-,4e- �( I ( _ r f' /l t l� {-� 03a y Alt.Tel.No.: (,G,5�;s`" f 3 7 *Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.No. I'7 7 ! aR- 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/Agent 1P—k-R7M7,T FEE: $ Signature Telephone No. 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance-with the provisions of M.G.L.c.143,§3L,the Permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166, §32,an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the L notification of completion of the work as required in M.G.L.c.143,§3L. Permits shall be limited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 17.3 of Chanter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter the Acts of 2012.The purpose of this act' p 238 of rP is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence"during the qualifying period beginning on August 15,2008 and extending"through August 15,2012. ❑ Rule 8—Permit/Date Closed: ***Note:Reapply for new permit❑ ❑Permit Extension Act—Permit/Date Closed: Trench Ins ection Pass n? Failed Q Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass M I Failed Re-Inspection Required($.) ❑ Inspectors Comme Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass 0 Failed Inspectors Comments: Re-Inspection Required($.)❑ Inspectors Signature: _ Date: [LOUGH INSPECTION: Pass Failed 0 Re-Inspection Required($.) ❑ Inspectors Commp ts: 1 Inspectors Signature: Date: INAL INSPECTION: Pass 0 Failed Re-Inspection Required($.)❑ nspectors Comments: 1 I i v i Inspectors Signature: j Date: :13 WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com a M ' ' The Commonwealth of Massachusetts - Department oflndustrigl Accidents Office Oflnvestigations 600 Washington Street .:Boston,MA 02111 -www.massgov/ilia Workers' Compensation bsurance Affidavit:Builders/Cont°actors/Electrxezans/Pliimberg Applieant information Please Print Legibly Name(Business/Organi'zation/Individual): cC- ` (K� Address: fT 3 ' ,P -cl J (.( �1- o'3 d4t41City/State/Zip: Phone#: 0-3 8 t� c) 4 S-4 Are you an employer?Check the appropriate box: 'Type of project(required): 1.❑ 1 am a employer with 4. ❑ I am a general contractor and I 6. []New construction employees(fall and/or part-time).* have hired the sub-contractors 2.0 I am a sola proprietor or partner- listed on the attached sheet.I 7. ]]Remodeling ship anTlave no.employees Theses ontractors have 8. ❑Demolition working forme in any capacity. wo rs'comp.insurance. 9. F]Building addition [No workers'comp.insurance 5. e are a corporation and its 10. Electrical repairs or additions required.] officers have exercised.their 3.❑ Z am a homeowner doing all work right of exemption per MGL 11.[(Plumbing repairs or additions myself.LWOworkers'comp. c.152,§I(4),andwehaveno 12.❑Roofrepairs insurancerequixed.]i employees.- workers' 13F1 Other comp.insurance required.] 'Any applicautthat checks box#1 mustalso fill outthe section below showingtheir workers'compensadonpoHoy information. i-Homeowners who submitihis affidavit indicatingthey a're doing all work and then hire outside contractors must submit anew affidavit indicating such. tContractors that cheekthis box must attached an additional sheet showingthe name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. I-- Insurance Company Name 0 C Policy#or Self=ins.Lic.#: Expiration Date: Job Site Address: LJ57 Si &-TDA WACity/State/Zip: 131f/ iW Attach a copy of the workers'compensation-policy de ration page(showing the policy number and expiration date). F ilure to secure coverage as regpked.under Section 25A ofMGL o.152 can lead to the imposition of criminal penalties of a fins up to$1,50 0.00 and/or one=year imprisonment,as well.as civil penalties in the form of a STOP WORK ORDER and a fine otup 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. Ido hereby cert urtcler the pains and enalties ofperjury that the information provided above is true and correct. - Si afore• Date: Phone#: Official use only. Do not write in this area,to be completed by city or tort official City or Town: Permif/Lzcense# 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#: i �. L 'i Information and Instruction Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to flus statute,an employee is defined as",..every person iu the service of another under any contract ofhire,• express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a-deceased employer,or the receiver or,trustee of an individual,partnership,association or other legal entity,employing employees. however the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be,deemed to be an employes." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth fora applicant g . any ppli ant who has not produced-acceptable evidence of corn fiance t ,, � p with the insurance coverage required.,, Additionally,MGL chapter 152,§25C(7)states `Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance ofpublic work until acceptable evidence of compliance with,the insurance requirements of this chapterhave beenpresented tot the contracting authority." Applicants Please fill out the workers'coznpensalzon affidavit completely,by checking the boxes that apply to your situation and,if n.ecegs*,supplysub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,axe not required to carry workers'compensation insurance. If au LLC ox LLP does have employees,apolicy is.required. Be advised that thisaffidavit maybe submitted tothe Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printedlegibly.'The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office ofInv str atie ' ons has to con g tactou regarding e y g g th applicant. Please be-sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant thatmust submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(ifnecessary)and under"Job Site Address"the applicant should write"all locations in (city or town:)."A-copy of the affidavit that has been officially stamped or marked by the city or town maybe provided to the applicant as proof that a valid affidavit-is on file for future permits or licenses. Anew affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. � The Office of Investigations would like to thank you in advance for your cooperation and should you have any ctuestions, please do not hesitate to give us a call. The Department's address,telephone and fax number: Tho Co owealth o SVlassarl�u P - Dapartment ofI dust W A,ccxdmits Offjiee QUIRvestiga-0oin 600 WasWv&j.i Street Boston?MA,42111 Tei, 617-7-21.7, 900 end 406 or 1-8,7 -:N�ASSAkF, Revised 5-26-05 `ax, 617-727-7749 WWW.zztass.gc v dia Q. COMMONWEALTH OF MA "&H` I)SETTS BOAAA.D'OF ' i ELEC.TRtCIANS ISSUES TRE FOLLOWING LICENSE AS A: REG`JOURNEYMAN ELECTRICI`AN� W,. � MATTHEW K PITKIN 137 BEEO.E HI Lt ROAD F.4 EMONT NW: 03o44-3202 ` x :.: 177 14, 0731/ 6 j2481 Date ........ 10640 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING LQ_ LA� This certifies that..................... ................. .........................y.94.....4 .. -.)...................... ...... has permission to perform........ .......... .............................................. plumbing in thetuildings of..G62e? ....4...Cp,....................................... at......(11QP:a....... . ......:.... *­­­­­***­­*........ .... .................. North Andover, Mass. Fee.(,.01;1..—Lic. No. f ..........M ...................................................................... PLUMBING INSPECTOR Check# It ZA I MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY I NORTH ANDOVER MA. DATE 7-15-14 PERMIT# 11 "t ID JOBSITE ADDRESS 65 STANTON WAY OWNER'S NAME GREEN AND COMPANY P -- OWNER ADDRESS: POBOX 1297 NORTH HAMPTON NH 03862 TEL: 800 429 8615 FA.X: TYPE OR OCCUPANCY TYPE: COMMERCIAL❑ EDUCATIONAL PRINT ❑ RESIDENTIAL❑■ CLEARLY NEW:❑■ RENOVATION:❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑ FIXUTRES-1 FLOORS- Bsmt 1 2 3 4 5 6 7 8 1 9 10 11 12 13 14 BATHTUB 2 CROSS CONN DEVICE 2 DEDICATED SPECIAL WASTE SYS DEDICATED GAS/OIUSAND SYS DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYS DEDICATED WATER REUSE SYS DISHWASHER DRINKING FOUNTAIN FOOD WASTE GRINDER UNIT FLOOR/AREA DRAIN INTERCEPTOR INTERIOR KITCHEN SINK LAVATORY 1 3 ROOF DRAIN SHOWER STALL 1 SERVICE/MOP SINK TOILET 1 2 URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES 1 WATER PIPING 1 SPIGOTS 2 INSURANCE COVERAGE J have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ❑■ NO ❑ If you have 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 AGE Elt- SIGNATURE OF OWNER OR AGENT 1 I hereby certify that all of the details and information I have submitted(or entered)regarding this application e t and cc at o the best of my 1 Knowledge and that all plumbing work and installations performed under the permit issued for this applica' n wi e' o is a with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER NAME: MIKE BURKE =LICENSE# 13127 GNATURE COMPANY NAME: POWERHOUSE PLUMBING AND HEATING CORP ADDRESS:I PO BO 896 CITY:I PLAISTOW STATE: NH ZIP: jg3w FAX: 16033780040 TEL: 116033780020 CELL:119784909385 EMAIL: J.LAURENCIO@POWERHOUSEPLUMBING.COM MASTER❑■ JOURNEYMAN❑ CORPORATION❑■ # 2482 PARTNERSHIP❑#[= LLC❑# 0 r ROUGH PLUMBING.INSPECTtON NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES / 1 Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ `` a�� FEE: $ PERMIT# PLAN REVIEW NOTES i 1 I Date.....t..t.b,.0 1.' ..................... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION Hus� This certifies that ' . ..... $ has permission for gas installation .......`y?Q. ........ . ......................................... in the buildings,of...... .P.. N..... ..e.�........................................................... at t 2�.... ....\,,Jc-1. ..................... North Andover, Mass. Fee.. W."..:..... Lic. No. ,�12 .... .TI�'" .................................................................... GASINSPECTOR Check# hl MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY I NORTH ANDOVER I MA. DATE 7-1514 1 PERMIT#M I l- JOBSITE ADDRESS 65 STANTON WAY OWNER'S NAME GREEN AND COMPANY GOWNER ADDRESS: I PO BOX 1297 NORTH HAMPTON NH TEL: 8004298615 FAX: TYPE OR OCCUPANCY TYPE: COMMERCIAL❑ EDUCATIONAL ❑ RESIDENTIAL FE PRINT CLEARLY NEW:❑■ RENOVATION:❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NO❑ FIXUTRES Z FLOOR- Bsmt 1 2 3 4 5 6 7 8 9 16 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM 1 SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER c INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ❑■ NO ❑ 1 If you have checked YES,please indicate the type of coverage by checking the appropriate box below. LIABILITY INSURANCE POLICY 0 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 hereby certify that all of the details and information I have submitted(or entered)regarding this application rue ang urate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this applic 11 be' m ' nce with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER/GASFITTER NAME: MIKE B JRKE LICENSE# 13127 SI R COMPANY NAME: POWERHOUSE PLUMBING AND HEATING CORP ADD SS: PO 0 896 CITY: PLAISTOW STATE: NH ZIP: 03866 FAX: 6033780040 TEL: 6033780020 CELL: 9784909385 EMAIL: J.LAURENCIO@POWERHOUSEPLUMBINGAND HEATING.CO MASTER❑■ JOURNEYMAN❑ LP INSTALLER❑ CORPORATION❑■ # 2482 PARTNERSHIP❑#=LLC❑# - Y t ROUGH GAS INSPECTION-NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ /4 FEE: $ PERMIT# PLAN REVIEW NOTES The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations 1 Congress Street, Suite 100 Boston,MA 02114-2017 M v www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Ledbly Name (Business/Organization/Individual): POWERHOUSE PLUMBING CORP Address:PO BOX 896 City/State/Zip:PLAISTOW, NH 03865 Phone#:6033780020 Are you an employer?Check the appropriate box: Type of project(required): 1.0■ I am a employer with 6 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. Q New construction listed on the attached sheet. 7. 0 Remodeling 2.❑ L am a sole proprietor or partner- ship and have no employees These sub-contractors have 8. 0 Demolition workingfor me in an capacity. employees and have workers' Y P h'• 9. E)Building addition [No workers' comp. insurance comp. insurance.: required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3.0 I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL 12.0 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#I must also fill out the section below showing their workers'compensation policy information. t 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:HARTFORD UNDERWRITERS INSURANCE COMP Policy#or Self-ins.Lic.#:04WECIT2480 Expiration Date:7-28-14 Job Site Address: 65 Stanton Way City/State/Zip: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 d y against Pe violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of t DIA fo surance coverage verification. I do hereby ce • un r e ins and penalties of perjury that the information provided above is true and correct. Signature: Date: 7-15-14 Phone#: 0337 290 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#: } "EAU Of BUiLOING SAFETY&CONSTRUCTION PLUMBING SAFETY S CTION 31NAME MICHAELV1l BUR' LI ar: C 3$01 M a 'r• EXPIRES: 05/31/2 1 0 5 �tG►YE��t�Nl�i "4ii _ j ,�s«ru+taer+w�a. - State of New Hampshire A Voluntary Heating Technician I • NAME MICHAEL BURKE x � � PLURItRt� OAR0 OF ,. .., ,, V- , ENDORSEMENTS H10iN SO. R tATSTERED AS" '' P C1j I DATE ISSUED 02rtS/2014 � DATE EXPIRES: 02/2912016 =MiAEL'.i F>�tlRlCEr � ; ;—*OW ERROUSlr P �e. s.; r`>T Nri COR LICENSE#: HT 1400207 �AtiERHi,LL � .� Dl$ O I, Commortwcrattn of Massachusetts n , Department of Public Safety (hi Burmrr Technicinn E eltrfi�tr• License- SU4 9572 r' AGCHARL W BURKH dl CORI= I Haverhill MA 01830 Expiration Cotmwsmonef 05126/2018 • AC40RVCERTIFICATE OF LIABILITY INSURANCE1 7Ai16MiZO14 ' 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 policy(ies)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 NAMEACTKathleen biller, CISR, CPIW Insurance Solutions Corporation PHONE (603)362-4600 FAX Nok(603)382-2034 60 Westville RdE-MAILAppgEss.kmiller@isc-insurance.com INSURERS AFFORDING COVERAGE NAIC N Plaistow NH 03865 INSURER A)4erchants 23329 INSURED INSURER B.Hartf ord Underwriters Ins. Co. POWERHOUSE PLUMBING & HEATING INSURERC: CORP INSURER D: PO BOX 896 INSURER E: PLAISTOW NH 03865-0896 INSURER F: COVERAGES CERTIFICATE NUMBER:CL1471617536 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. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LTR POLICY NUMBER MMIDD/YYYY MM/DD LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE OR N E A CLAIMS-MADE Fx_1 OCCUR BOPI065497 /1/2014 /1/2015 PREMISES(Ea occurrence) $ 500,000 MED EXP(Any one person) $ 15,000 PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 X POLICY PRO- irr-T 17 LOC $ AUTOMOBILE LIABILITY Ec O aclrNNdBD SINGLE LIMIT 11000,000 A X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED CAPI058154 /1/2014 /1/2015 BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS Per accident $ Medical payments $ 5,000 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATION WC STATU- 0TH- AND EMPLOYERS'UABIUTY Y/N DRYANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100,000 OFFICER/MEMBER EXCLUDED? ] NIA (Mandatory In NH) 04WECIT2480 /28/2013 /28/2014 E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space Is required) CERTIFICATE HOLDER CANCELLATION (978)688-9542 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of North Andover ACCORDANCE WITH THE POLICY PROVISIONS. 1600 Osgood St AUTHORIZED REPRESENTATIVE North Andover, MA 01845 Keith Maglia/KLMACORD 25 25(2010/05) ©1988-2010 ACORD CORPORATION. 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