The URL can be used to link to this page

Home My WebLink AboutMiscellaneous - 80 BOSTON STREET 4/30/2018 (2)c N_ O O v W O O O O O O ?CA46p("v J &t- qtj� i MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY I NORTH ANDOVER MA DATE JUNE 19, 2014 PERMIT# 11/33 JOBSITE ADDRESS 80 BOSTON ST. OWNER'S NAME EDWARD MCALOON GOWNER ADDRESS EDWARD MCALOON TE 9786823098j FAX TYPE OR OCCUPANCY TYPE COMMERCIAL® EDUCATIONAL RESIDENTIALED PRINT CLEARLY NEW: E] RENOVATION: ® REPLACEMENT: ® PLANS SUBMITTED: YES® NO® APPLIANCES Z FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE _ DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOFTOP UNIT TEST _ UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER I INSTALL AN UNDERGROUND 1 GAS LINE AND CONNECT TO A PLUMBERS INSPEC ED GAS LINE AND TO A GENERATOR INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES E] NO E] I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [D 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 El SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are tru d accurate the st of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in '.ml om ianc with all rtine rovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME I JOHN LIPINSKI LICENSE #' ' ?Z S TURE MP ® MGF ® JP [:1 JGF FI LPGI E] CORPORATION Ej# PARTNERSHIPO# LLC ®#� COMPANY NAME: EASTERN PROPANE GAS ADDRESS 1131 WATER ST. CITY i DANVERS STATE MA ZIP 01923 TEL 1-800-322-6628 FAXI CELL EMAIL The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations W t I Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly *Any applicant that checks box #t must also fill out the section below showing their workers' compensation policy information. ' Homeowners who submit this affidavit indicating they are doing all wor!: and then hire outside contractors must submit a new affidavit indicating such. +Contractor 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 ant an employer that is providing workers' compensation insurance far my employees. Below is the policy and job site information. Insurance Company Name: Safehold Special Risk, Inc — EWGCD000080614 Expiration Date: 03 / 15 12015 Policy # or Self -ins. Lic. #: Job Site Address: To Bos S� City/State/Zip: nQrInn S & JXAe•;, J r - Attach a copy of the workers' compensation policy declaration page (shoving the policy number and expiration date). 01[ r46 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 S 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 paa� d penalties of perjury that e information provided above is true and correct. Phone #: 978750bbUU Eastern Propane Gas, Inc Name (Business/Organization/Individual): Address: 131 Water St City/State/Zip: Danvers, MA 01923 Phone #: 978-750-6500 Are you an employer? Check the appropriate box: Type of project (required): 1.0 I am a employer with 45 4. ❑ I am a general contractor and 1 have hired the sub -contractors 6 ❑ New construction employees (full and/or part-time).* listed on the attached sheet. 7. ❑ Remodeling 2. ❑ I am a sole proprietor or partner- These sub -contractors have g. ❑ Demolition ship and have no employees working for me in any capacity. employees and have workers' comp. insurance.11 9 ❑ Building addition [Nlo workers' comp. insurance 5. ❑ We are a corporation and its ME] Electrical repairs or additions required.] 3. ❑ I am a homeowner doing all work officers have exercised their 11,E] Plumbing repairs or additions myself. [No workers' comp. t right of exemption per MGL c. 152, have no l2.❑ Roof repairs 13.I Other Gas Fitting & Fuel Supply insurance required.] or kers' employees. [No workers' employees. [ coma. insurance required.] *Any applicant that checks box #t must also fill out the section below showing their workers' compensation policy information. ' Homeowners who submit this affidavit indicating they are doing all wor!: and then hire outside contractors must submit a new affidavit indicating such. +Contractor 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 ant an employer that is providing workers' compensation insurance far my employees. Below is the policy and job site information. Insurance Company Name: Safehold Special Risk, Inc — EWGCD000080614 Expiration Date: 03 / 15 12015 Policy # or Self -ins. Lic. #: Job Site Address: To Bos S� City/State/Zip: nQrInn S & JXAe•;, J r - Attach a copy of the workers' compensation policy declaration page (shoving the policy number and expiration date). 01[ r46 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 S 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 paa� d penalties of perjury that e information provided above is true and correct. Phone #: 978750bbUU NH477156 A�rte® L/ CERTIFICATE OF LIABILITY INSURANCE DATE (MMYY) 3/13/20142014 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 Commercial Lines - 800-990-7465 (CA DOI # OG13561)PHONE Safehold Special Risk, Inc. CONTACT Donna Desharnais NAME: 603-559-1361 FAx 855-529-7684 A/C No Ell: AIC No ADDRESS: donna.desharnais@safehold.com 230 Commerce Way, Suite 230 INSURER(S) AFFORDING COVERAGE NAIC # Portsmouth, NH 03801 INSURERA: HDI -Gerling America Insurance Company 41343 INSURED Eastern Propane Gas, Inc. INSURER B INSURER C P.O. Box 1800 INSURER D INSURER E: PERSONAL & ADV INJURY $ 2000000 Rochester, NH 03866 INSURER F: COVERAGES CERTIFICATE NUMBER: 7441964 REVISION NUMBER: See below 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 LTR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFFPOLICY MMIDD/YYYY EXP MMIDD/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE a OCCUR EGGCD000080614 3/15/2014 3/15/2015 EACH OCCURRENCE $ 2000000 DAMAGE TO RENTED 250000 PREMISES Ea occurrence $ GEN'L MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 2000000 AGGREGATE LIMIT APPLIES PER: POLICY1:1 PO - JET 7 LOC OTHER: GENERAL AGGREGATE $ 2000000 PRODUCTS - COM P/OPAGG $ 2000000 $ A AUTOMOBILE X1AUTOS LIABILITY ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS HIRED AUTOS NON -OWNED EAGCD000092214 3/15/2014 3/15/2015 COEa aMBccINED SINGLE LIMITident $ 2,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ Per accident UMBRELLA LIAB EXCESS LIAB HOCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION $ S A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? F (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N / A EWGCD000080614 03/15/2014 03/15/2015 X STATUTE OERH E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE - POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Evidence of coverage CERTIFICATE HOLDER CANCFLLATION Any city/town in Massachusetts SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN MA ACCORDANCE WITH THE POLICY PROVISIONS. MA • AUTHORIZED REPRESENTATIVE The ACORD name and logo are registered marks of ACORD ACORD 25 (2014/01) (This cerlificate replaces wOifiwte# 7441310 i—ed w 3113/2014) @ 1988-2014 ACORD CORPORATION. All rights reserved. Ln L -i Ln LLJ .Cc; LLI - US: . . ..... Ln Lf) W-= Ln LLJ U 0 -j CL O"N C3 -j z o i,er U- z LLJ Lij =--m LLI - US: . . ..... Lf) LLJ Location No. Z4/ Z/ //—/ Check # �G Date O �r TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $` Foundation Permit Fee $ Other Permit Fee $ TOTAL $ r. Buildings s ctor A N2 2. Date Z - � �—... i-/ °.<��`°.;� "�0 TOWN OF NORTH ANDOVER PERMIT FOR WIRING y This certifies that A has permission to perform .. .-.:-'?- '� 2-� . J........................................ ........ wiring in the building of . ....:::. � ..........:....................................................... at ....... � .......... r.... - c`e '"............. :...'.. ,North Andover, Mass. Fee..?...Lic. ............................................................... ELECTRICAL INSPECTOR . 10/27/98 09:00 15,00 PAID WHITE: Applicant CANARY: Building Dept. PINK: Treasurer The Commonwealth of Massachusetts ,. Department of Public Sofety BOARD OF FIRE PREVENTION REGULATIONS SU CMR 1200 3/90 orrtes roe met► hn/t Xe. oeewre4y.6 Fee *4dwa /l5 d (teaw ►taeU APPLICATION FOR PERMIT TO PERFORM ELEGTRICAL WORK All work to be pulormed In accordance whh the Massachusetts Markat Code. $17 CMR 12.00 (PLF,ASE PRINT XN MOR TYPE ALL INFORN=ON) Date l/Q'22' City or Towfi of b?o' , ; K & To the Inspector of hires: the undersigned applies for at permit *to perform the electrical work described below. -#-G Location (Street & Number) 5 U &s4 Owner or Tenant al a �L� ✓3 /C.� Owner's Address 42q Is this permit in conjunction with a building permits Yes ❑ 'no (Check Appropriate Box) Purpose of Building 'la2k as -KA' Utility Authorization NO. Existing Service _ Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / volts Overhead ❑ Undgra ❑ No. of Meters N=ber of Feeders and Ampacity Location and Nature of Proposed Electrical Work NdT t,3a•Lc'(_ ZOAO/L No. of Lighting Outlets Eh g No. o! Not Tubs Tots No. of Transformers 1CVA No. of Lighting Fixtures Swimming Pool Above In. d. ❑grnd. ❑ Generatorsta XVA No. of Reccgttaele Outlets No. o! Oil Burners NO EUnifss fight g tto. of Switch �butlets - - No. of Gas Burners FIRS AT.ARMS_. No. of Zones No. of Detection and Initiating Devices go. of Souading Devices No. of Sell Contained Deteetion Sounding Devices Local ❑ Municipal Other No. of Ranges No. of Air Coad. Total- tons No. of Disposals No. of eat' Total Totalons KV No. of Dish hers Space/Area Heating XW tb. of Dryers Heating Devices 1KW No. o! Water He#ters 1Qi NOof No. of S ' Ballasts Lou WiringVoltage No. Hydro Massage Tubs No. of Motors Total HP OnMR: INSURANCE COVERAGES Pursuant to the requirements of Massachusetts Ceneral Lava I have a current Liabili Insurance Policy including Completed Operations Coverage or its substantial '1 equivalent.• YESNO U I have submitted valid proof of same to this of/ice. YES ❑ No ❑ If you have checked YES, please indicate the type of coverage by checking tho appropriate. box. INSURANCE ❑ tW1iD ❑ 01M ❑ (Please Speeify) p rat on ate Estimated Value of Electrical Work $ Work to Start Inspection Date Requestedo Rough Final Signed a`.Aer the penalties of perjurss FM NAME10 (g � D t (. LIC. NO. Licensee /{�.� �._}M�� Signature 1�"` Q. _ _ LIC. N0, DST—� AddressBus. Tei. No. WI -6111 Alts. Tel. No. OWW 5 INSURANCE WAIVERS I as aware that the Licensee does not haw the insutshce coverage or its.su - suntial equivalent as required by Massachusetts Central Laws, an tat my sip►ature on this permit application valves this requirement. owner- Agent (Please cheek one) c� i Telephone No. pmat FSS Signature o er or Assn- 37