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Miscellaneous - 777 GREAT POND ROAD 4/30/2018
Date. ........ "NON, TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLAMON This certifies that'....40, has permission for gas installation .. r"!?.'....- .............. . in the buildings of d !.. , el .................. at V .................. North dover, Mass. Fee. ��`�'` Lic. No..$�� �.. ��4! rc.�; /,.2 . .. GAS INSPECTOR Check # 1t�o 7854 Q/co W W W � a MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING C1ty/Town: ,/� r > MA. Date: Permit# Building Location: IPYZ ¢�" 419 A.lr Owners Name: Type of Occupancy: Commercial ElEducational ❑ Industrial E]Institutional E]Residential Q v/ New: Alteration: ❑ Renovation: ❑ Replacement: ❑ Plans Submitted: Yes ❑ No ❑ Q/co W W W � a to N U v/ ,! / Z X 0 z O W} co z to o z W w u5 w U) W g F) W m 0 W D W W O Q H W> to U w m m O W to Cl -O O a W o= z W �• w v) J H a F- O a m z J 0 W O z u_ 0 H= m�> w Z W W I- _ v o o caa cm7 =_ O a F>>> O SUB BSMT. BASEMENT 1 FLOOR 2 FLOOR 3 FLOOR 4 TH FLOOR r)TH FLOOR 6 IHFLOOR 7 FLOOR 8 FLOOR Installing Company Name: ..��''� � � i C..��t�'y��- Check One Only Certificate # '� Address: _�rik.�i"' y/Town: y�2 �� State: ©..Corporations , Business Tel: Fax: ❑ Partnership r_. -•r Name of Licensed Plumber/Gas Fitter: ❑Firm/Company INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes 0 No ❑ If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy ❑ Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only ❑ Signature of Owner or Owner's Agent Owner El Agent By checking this box ❑; I hereby certify that all of the details and information I have submitted (or entered) regarding this application are true and --- - - - - • -• •••, ••••�•• ��y` a••w • .• P..,."..,IU WUFr anu msiauations pertormea unser the permit issued for this application wilt be in -- - -- - - • �••• r••••C 4-00-11YJellD dale rlumnmg %,oae ana cnapter 942 otthe General Laws: Type of License: s ey h ® ❑ Plumber G�as Fitter - Title 2 / ❑ D G stSignature of Licensed Plumber/Gas Fitter L City/rown ❑Journeyman License Number: ��+�~ APPROVED OFFICE USE ONLY F-1LPInstaller . 11/21/2011 11:04 978-521-5127 COSTELLO INS. PAGE 01/01 k. ATE (MMIDDiYYYY) CORP,, CERTIFICATE OF LIABILITY INSURANCE P10/21/2011 THIS CERTIFICATE 1S 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 poriey(les) must be endorsed. If SUBROGATION 13 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 -IPNAME; COSTELLO INSURANCE AGENCY AIC, Ext; 978.3%4.6352 AIC,No'978.521.5127 2 South Kimball St. ADDRESS: PO BOX 5248 INSURER(S) AFFORDING COVERAOI= NAIC It Bradford, MA 01835 M$URERA: Merchants Ins. Co. INSURED Joseph A Dipietro Heating & Coo ting, Inc. INSURER 5: Peerless Insurance 24198 5 South Summer Street INSURER C: Bradford, MA 01835 INSURER D: I INSURER F DVERAGES CERTIFICATE NUMBER: Master, 2011-2012 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED N INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITIC -N OF ANY CONTRACT OR OTHER DOC CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORC 'ED BY THE POLICIES DESCRIBED HER FYr:I I IGIaNs AND CONOITIONS OF SUCH POLICIES. LIMITS SHOWN MAY 1,- AVE BEEN REDUCED BY PAID CLAIMS, TYPE OF INSURANCE INSR WV POLICY NUMI: GENERAL LIABILITY BO MERCIAL CLAIMS -MADE GENERAL OCCUR F_1 DESCRIPTION OF OPERATIONS I LOCATIONS /VEHICLES (Attach ACORD 101, Addleonal Pemarks Schedule, If more space Is required) CERTIFICATE HOLDER FAX: 978.688.9542 Town of No. Andover Attn: Mary 1600 Osgood St. No., Andover, MA 01845 ACORD 26 (2010103) CANCELLATION rd11MRER' ZM— ED ABOVE FOR THE POLICY PERIOD .1MENT WITH RESPECT TO WHICH THIS .IN IS SUBJECT TO ALL THE TERMS, LIMrrs EACH OCCURRENCE $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER; 100,000 MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ POLICY 7 iRCT F7 LOC GENERAL AGGREGATE $ 2,000,000 PRODUCTS. COMP/OP AGG $ 2,000,000 AUTOMOBILE LIABILITY 11000,00 BODILY INJURY (Par per80n) $ B BODILY INJURY (Par occidenn S ANY AUTO (Per acoidant $ EACH OCCURRENCE s B ALLOWNEOX SCHEDULED s X TORY LIMITS ER 2,000,000 E.L. EACH ACCIDENT S AUTOSAUTOS NON.OWNEO X X E.L DISEASE - EA EMPLOYEE $ 500,000 E,LDISEASE- POLICY LIMIT $ 500,000 HIRED AUTOS AUTOS UMBRELLA LIAB OCCUR B EXCESS LIAR CLAIMS -MADE DED X RETENTION S 101 00 WORKERS COMPENSATION H AND EMPLOYERS' LIABILITY Y f N ANY PROPRIETORIPARTNERIDCECUTIV B OPFICERIMEMBER EXCLUDED? N N I A (Mandatory In NH) Ifyc- describe under DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS /VEHICLES (Attach ACORD 101, Addleonal Pemarks Schedule, If more space Is required) CERTIFICATE HOLDER FAX: 978.688.9542 Town of No. Andover Attn: Mary 1600 Osgood St. No., Andover, MA 01845 ACORD 26 (2010103) CANCELLATION rd11MRER' ZM— ED ABOVE FOR THE POLICY PERIOD .1MENT WITH RESPECT TO WHICH THIS .IN IS SUBJECT TO ALL THE TERMS, LIMrrs EACH OCCURRENCE $ 1,000,000 PREMISES Ea occurrence s 100,000 MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 1,000,113 GENERAL AGGREGATE $ 2,000,000 PRODUCTS. COMP/OP AGG $ 2,000,000 i a a9N- s 11000,00 BODILY INJURY (Par per80n) $ BODILY INJURY (Par occidenn S (Per acoidant $ EACH OCCURRENCE s 2,000,000 AGGREGATE 5 s X TORY LIMITS ER 2,000,000 E.L. EACH ACCIDENT S 500.000 E.L DISEASE - EA EMPLOYEE $ 500,000 E,LDISEASE- POLICY LIMIT $ 500,000 SHOULD ANY OF THE ABOVE DESCRIDPD POLICIES Sr CANCELLED SECORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED Ben Cott -e io O 1888-2010 A The ACORD name and lDgo are registered marks of ACORD reservec Date.. /� ! U 1 i •�;:_'�,o TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING 1 �,SSACNUS�t This certifies that ... r.. V has permission to perform ........ -...................... . plumbing in the buildings of.................. . at ..... Nort.�. !.. �T %? .`.�':?....�o ": `� h .� , h Andover, Mass. Fee. 3!Q .... Lic. No...1" J........ �t PLUMBING INSPECTOR Check # / y a HIR City/Tbwn:/L)-t/- J Ar),AVIer MA. Date Building Location. -2.2-2 CSL+✓ d—i90 d al Eel Permit#f 0 Z () Owners Name: Dvqy c zb l � Type of Occupancy: Commercial Q Educational ❑ industrial Q' Institutional Q Residential E' New: [j alteration: E] Renovation: j Replacement: Flans Submitted: Yes Q No 0 CIVYf rune INSWRANCE COVERAGE: 1 have a current liabii" insurance policy or its substantial equivalent which meets the requirements of MGL. Ch.142 Yes No El If you have checked,Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy Other type of Indemnity 0 Bond OVVNER'S INSURANCE WAPVER: i, am aware that the licensee does not have the insurance coverage required by Chapter 442 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement Check One Only Rinnatl IM of rh.in— — rS.....e.'- A,,,,.,. Owner ❑ Agent ❑ i hereby codify that an of the details and information t have submitted for entered) regarding this apprication are true and accurate to the best of my Knowledge -and that ail plumbing Work and installations performed under the permit issued for this aQDGcation will ho In. rnrnnH.— ,.I1+6 .11 .. ,......Q... j— .....a.. v. um masyacnuseu5 Jiaie- 1-1ulmoing Code and Chapter 142 of the General Laws. By Type of License: -role LV] . mber Signa of Licensed Plumber Cityfrown [�!a �j APPROVED IOFFICE USE ONLYI []journeyman License Number: k t 2 s , -EENM �®���®®ice®�������� MM MM WM e , - -®M® ®MMM®®Installing ®® Company r - ♦ . Address: Cltyfr•... state: Business Tel:�_ i` / r r t% to • < I 1 . r Name of Licensed Plumber: Y'4izet— INSWRANCE COVERAGE: 1 have a current liabii" insurance policy or its substantial equivalent which meets the requirements of MGL. Ch.142 Yes No El If you have checked,Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy Other type of Indemnity 0 Bond OVVNER'S INSURANCE WAPVER: i, am aware that the licensee does not have the insurance coverage required by Chapter 442 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement Check One Only Rinnatl IM of rh.in— — rS.....e.'- A,,,,.,. Owner ❑ Agent ❑ i hereby codify that an of the details and information t have submitted for entered) regarding this apprication are true and accurate to the best of my Knowledge -and that ail plumbing Work and installations performed under the permit issued for this aQDGcation will ho In. rnrnnH.— ,.I1+6 .11 .. ,......Q... j— .....a.. v. um masyacnuseu5 Jiaie- 1-1ulmoing Code and Chapter 142 of the General Laws. By Type of License: -role LV] . mber Signa of Licensed Plumber Cityfrown [�!a �j APPROVED IOFFICE USE ONLYI []journeyman License Number: Dae ..... ........7—..l.S7-.........-/6 ......... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ..... &IL zzc. ............ .............. has permission to perform .............................................................. -T--P 3 P) / 7�5-0,,7 wiring in the building of ................................................. v ................................. ..... ... ... .... k ........ 7.77 ... 124 North Andover, Mass. ..................................... ......... ......... Lic. No. .......... .. . .............. .............. ELEemcAL INsPE Check # LoV"1111V11WCdIL11 U1 1'1CI.bb91L►ILIDCLLJ --- - -- - Department of Fire Services Permit No. 1 Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: !7 h4l lo 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) Owner or Tenant Z Owner's Address Telephone No.97g—U6 - 3si5 Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building Q-Q.S ?v e)g rl h 1 Q 1 Utility Authorization No. 9 'a® 1 -I -g 0 Existing ServiceAmps c b4AVolts Overhead Undgrd ❑ No. of Meters New Service /cNo Volts Overhead Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: e 0402 b0 L- N ���1 � � r S�-r n5 �c��le vr-, -�•n C�P�a c ✓1 Completion of the following table may be 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- ❑ rnd. rnd. o. o Emergency Lighting 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 and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Number .......................................................... Tons KW No. of Self-Contained Totals: Detection/Merting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security o Devices 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 Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: % (When required by municipal policy.) Work to Start: lI 6 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 ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under the ams and penalties of perjury, that the information on this application is true and complete. FIRM NAME: v 6 C C vr. /► LIC. NO.:W Licensee: (� 9�y� ignature LIC. NO.: S O (If applicable; enter "ex' t" in a license number ine.) Bus. Tel. No.- Address: 3 b A- 0 17 C) Alt. Tel. No.: 2 S7 ' `y *Per M.G.L c. 147, s. 57-61, security work requires Dep tment 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 Owner/Agent PERMIT FEE: $ Signature Telephone No. r� The Commonwealth of Massachusetts 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 Lellibly Name (Business/Organization/Individual): ���/j,Q �tQ J C ( Q Address: City/State/Zip: Phone #: —]?� Are y an employer? Check the appropriate box: 1. I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ 1 am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.0 Roof repairs 13.❑ Other *Any applicant that checks box 41 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 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. Insurance Company Name: n Policy # or Self -ins. Lie. #: '� �� w ��� -- ( C. — �o �('7 � Expiration Date: D Job Site Address: -7 7 % re r,j 9d City/State/Zip: A),y4x-, 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 under the pains and penalties of perjury that the information provided above is true and correct. Signature: �/_.!`!� � Date: 7 / (,( (( n —QC) ( "D� 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 #: