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HomeMy WebLinkAboutMiscellaneous - 85 OGUNQUIT ROAD 4/30/201802 APPLICATION FOR CERTIFICATE OF OCCUPANCY/INSPECTION (� BUILDING PERMIT# ADDRESS/LOCATION OF PROPERTY Map Parcel Lot Number SUBDIVISION: v b-00 DATE REQUESTED FILED/READY FOR INSPECTION: CLOSING DATE ON PROPERTY: FIVE (5) DAYS NOTICE PRIOR TO CLOSING DATE IS REQUIRED ALL WORK AND SIGN -OFFS MUST BE COMPLETED WITHIN THIS TIME FRAME. A REINSPECTION FEE OF TWENTY DOLLARS ($20.00) WILL BE CHARGED IF THE STRUCTURE DOES NOT MEET ALL APPLICABLE CODES. Permit Issued to: APPLICANT SIGNATURE A )1�0 ROUTING TOWN ENGINEER, SITE PLAN — DRIVE -WAY REVIEW'V CONSERVATION PLANNING DPW -WATER METER SEWER CONNECTION `1 �lla�b/I DPW MUST INDICATE THAT THE WATER METER HAS BEEN INSTALLED PRIOR TO SUBMITTAL OF THE OCCUPANCY/INSPECTION REQUEST DPW SIGNA File: Application for OC form revised Jan 2007/2011 .,a m c C '�C V • � C N EE ��o m 3 c �0 �m..cm c N _O m m o m 3N cm CD m �= Mo A .= N m . �o mo O.V L ® N m m c N Q ..d CD F. R r i I�� 2 O W O C■ L 0 c CD CL O y ® C C CO3 O -0 C— y O O ca CD CD C .00 O coLft O OL C: _O O Os ME rm< H C 4— C CIO v c CD CL V y c C C � C O CO3 � i� c Z 0�O� C1 y C3. .Z .- VI: C3 CL a m mz3 =4— o F- W .y C w ym m.0 c O •+ •N v c c y Q. 401- O 'O my E .c .*- a� m ..d CD F. R r i I�� 2 O W O C■ L 0 c CD CL O y ® C C CO3 O -0 C— y O O ca CD CD C .00 O coLft O OL C: _O O Os ME rm< H C 4— C CIO v c CD CL V y c C C � C O CO3 � i� P 69 Date.....�.V� TOWN OF NORTH ANDOVER PERMIT FOR WIRING � This certifies that ........... ,............... ....... .................. .. ............................. has permission to perform .............: �a.r ....11......... wiring in the building of ............. )/ at ... -5 ....�......... �.:�................. orth Andover, Mass. Fee ... d Lic. No. J ffY.. /� �� 7 x ELECTRICAL INSPECTOR Check Jib- (/ lJ '10401 _ 2012 Massachusetts EIectrical Code Amendments 527 CMR12.00 § Rule 8: in accordance with the provisions of MG.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 bn 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 rm or corporation stated on the permit application. Such entity shall be responsible for the electrical permit shall he issued to the person, fr notification of completion of the work as required in M.G.L. e. 143, § 3L. c Permits shall_be limited as to the time of ongoing construction.activity, and maybe.deemed_by_the,Insp.ector_of_W.ires abandoned.and_invalidafhe—. or she has determined that the authorized work has not commeked or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be peraritted 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 173 of Chapter 240 of the Acts of 2010 and extended by Sections.74 and 75 of Chapter 23 8 of the Acts of 2012. The purpose of this act 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. I male 8 — Permit(Date Closed: l� �/y ��/T/ mote: Reapply for new f ❑ Permit Extension Act —Permit/Date Closed: Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] leave blank 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 INFORMATION) Date: 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) ?S C:,-,- v,V C:X J RMA Owner or Tenantet Owner's Address Is this permit in conjunction with a R-1 permit? Yes ❑ No U (Check Appropriate Box) Purpose of Building l<1$icatAjCQ Utility Authorization No. Telephone No. ?77- i 9S r33,5 7 Existing Service Amps / Volts 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: 4 Camnletinn n(tha (nllnwino inhln r. .., ho .., :---I 3.- A No. of Recessed Luminaires f1/ No, of Ceil: Susp. (Paddle) Fans o. of ota Transformers A KVA No. of Luminaire Outlets No. of Hot Tubs %f- Generators /1//A KVA No. of LuminairesSwimming Pool Above E]In- rnd. rnd. ❑ o. o Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners 1111A FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners IV% No. of Detection and 14/141- No. of Ranges / TotaInitiatingDevices No. of Air Cond. Tons l No. of Alerting Devices /y11) - No. of Waste Disposers Heat Pump Totals: Number Tons KW No. of Self -Contained Detection/Alerting Devices 4-I No. of Dishwashers Space/Area Heating KW off Local ❑ Municipal ❑ Other Connection No. of Dryers I&V 1.4 Heating Appliances � A, KW Security Systems:* No. of Devices or Equivalent No. of Water Kms, Heaters l'jj o. of o. of Signs Ballasts Data Wiring: No. of Devices or Equivalent 1?i No. Hydromassage Bathtubs No. of Motors Vlll_ Total HP Telecommunications Wiringg: No. of Devices or E uivalent/L OTHER: j Attach additional detail if desired, or as required by the Inspector of Wires. jj Estimated Value of Electrical Work:',SiJ 0 (When required by municipal policy.) Work to Start: r() -- j8•- /t 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 cove ge is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE [ BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: Flll 71,dcA LIC. NO.: C i �% 1 Licensee: jyl q RK V eJ1,evX Signature � _;X�'Xq LIC. NO.: .�7h (!f applicable, enter "exempt" in the license number line.) Bus. Tel. No. `17W— toy ?— 4.771' Address: Alt. Tel. No.: -Vl/,r *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. SS-Cy -- 0C)ly9 % OWNER'S INSURANCE WAIVER: 1 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 Signature Telephone No. PERMIT FEE: $ 90 b 11 Date. .%.'? ?.- t 1 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING S& S 'Iusl This certifies that .. sem!` F r .. \ . `�'�`?� ., ............. . has permission to perform ..1' He �-?. l lutv�- .................. plumbing in the buildings of`�"'',5 Cc>>–t,►�l��� �c.� , at. 5 A Q4 .............. North Andover, Mass. , Fee .76P -w.. Lie. No.. -'D ............................. . PLUMBING INSPECTOR Check # "M6`5UZ MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Location 85 Ogunquit Rd (Lot 6) Owners Name Tim & Travis Construction Inc. Type of Occupancy Res. Date 07/26/2011 Permit # Amount New 0 Renovation 0 Replacement [:] Plans Submitted Yes 1:1 No FIXTURES (Print or type) Installing Company Name Bomar Plumbing & Heating Address PO Box 694 Deny, NH 03038 Business Telephone 603-325-8958 Check one: Certificate Corp. Partner. Firm/Co. Name of Licensed Plumber: Robert Frazier Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy El Other type of indemnity a Bond Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature IOwner El Agent El I hereby certify that all of the details and information I have submitte (or entered) in above app�eation are true and accurate to the best of my knowledge and that all plumbing work and install ' s p orm der ermit Issued for this application will be in compliance with all pertinent provisions of the Massac g p r, of the General Laws. igna e Of kens r Type of Plumbin cense Title ROVED (OFFICE USE ONLY 13425 City/Town Icense um er Master El Journeyman ❑ PRO 15 r -- CONTROL # H a 8 n 2 1 c - v J J If this license is to IMPORTANT Division of P lost or destroyed Suite 710, 13 fessional License notify Your Bo at ton, AMA 02118-6100,' 1000 Washington the: If Your nam gton St. Of correct name address show Renewal ess to insure changed,notify your This license ation. Always insure ropr board nse is subject to then refer to your li 'ng of next or as amended, It is a provisions nse number, it Aersonlor ed to any other al privilege, and must General not Laws posted as required by IawKeep this licensbe el On yned HQg9216-- TOOL 1 1 CON RTANT INFO our Board at the: i destroyed, notify Your St., i is lost or 1000 If this license 8100. Division of Profess,MA 02118 sur ur board Suite 710, Boston, notify Y' of next shown is changed'er mailing e or address to insure proper license number. i If your nam e or address 1 ot Always refer to y of the General Laws R correct name rovisions est not be loaned Renewal Application' to the p e and m Keep this license on your This license i it is a personal privileg as amend, - any other person, or assig toa as required by law. person or posted _ 7 b % Date .... 2,-1 :` ......... NORTH ,e1ti0 o? TOWN OF NORTH ANDOVER h VIEW: PERMIT FOR GAS INSTALLATION t This certifies that ...�!MG r...�.u:�- .............. has permission for gas installation .......... in the buildings of ....... `i 12c�Q at 5-. . ��-lr?�, �.,.�.. .. ........ , North Andover, Mass. Fee/!' -?:w.. Lic. No.! 3`P57... GAS INSPECTOR Check #SSU Z MASSACHUSETTS UNIFORM APPUCATONFORPERN UI'TODOGASFITTING (Type or print) Date 07/26/2011 NORTH ANDOVER, MASSACHUSETTS Building Locations 85 Ogunquit Rd (Lot 6) Permit # Amount $ Owner's Name Tim & Travis Construction Inc. New El Renovation 1:1 Replacement 11 Plans Submitted (Print or type) Check one: Certificate Installing Company Name Bomar Plumbing & Heating Corp. Address PO Box 694 Partner. Deny, NH 03038 Business Telephone 603-325-8958 Firm/Co. Name of Licensed Plumber or Gas Fitter Robert Frazier INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes XD No ❑ If you have checked yes, please indicate the type coverage by checking the appropriate box. 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 Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner [] Agent .._.... .....—.Y uluk a., u. W, .,vu,,,b dJ1u in1UHI uun nave Suoumtea Tor enterea) m above application are true and accurate to the best of my knowledge and that all plumbing work and installations peffo d under,�ZIssued for tt� ation will be in compliance with all pertinent provisions of the Massachuse to e a t 42 of the General L ws. (OFFICE USE ONLY) Signature of Lic O Plumber Or Gas Fitter ® Plumber 13425 Gas Fitter License Number © Master Journeyman � a w v' w a a U o F a d F x �a o w d x Z o o z w w wdW x w m 0 a > �d C7 F z zd x w G7 > r& WV aO1 U WF SUB-BASEM ENT B A S E M ENT 1 1 1ST. FLOOR 1 2ND. FLOOR 3RD. FLOOR 1 4TH. FLOOR 5TH. FLOOR 6TH. FLOOR 7TH. FLOOR 8TH. FLOOR (Print or type) Check one: Certificate Installing Company Name Bomar Plumbing & Heating Corp. Address PO Box 694 Partner. Deny, NH 03038 Business Telephone 603-325-8958 Firm/Co. Name of Licensed Plumber or Gas Fitter Robert Frazier INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes XD No ❑ If you have checked yes, please indicate the type coverage by checking the appropriate box. 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 Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner [] Agent .._.... .....—.Y uluk a., u. W, .,vu,,,b dJ1u in1UHI uun nave Suoumtea Tor enterea) m above application are true and accurate to the best of my knowledge and that all plumbing work and installations peffo d under,�ZIssued for tt� ation will be in compliance with all pertinent provisions of the Massachuse to e a t 42 of the General L ws. (OFFICE USE ONLY) Signature of Lic O Plumber Or Gas Fitter ® Plumber 13425 Gas Fitter License Number © Master Journeyman Date .,�a........ p` „a. ... ry0L 0 TOWN OF NORTH ANDOVER • PERMIT FOR GAS INSTALLATION This certifies that has permission for gas installation . �f�.s.�.. . (// � %iirl /, uc�iwt........ . m the buildings of . %....S. � .......�r�►. ?--�� ...... . at ti. r! P/ . !� / ......... , North Andover, Mass. Fee...?4. ! .. Lic. No. �IP A4 . GAS INSPECTOR Check# zgv6o�lz 1 IZIYTI DCC N W Of z W MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING City/Town;yy /fady-ey- MA. Date: 16-5e-l� Permit# Building Location: 1 CiUt T ,Q Owners Name��; �� �GiTSIrtiG!`i� rn Type of Occ pancy: Commercial El Educational ❑ Industrial ❑ Institutional ❑ Residential New: L� Alteration: ❑ Renovation: ❑ Replacement: ❑ Plans Submitted: Yes ❑ No ❑ IZIYTI DCC N W Of z W rn m m 2 O W CO) Q V N co x O Q' F- x co W W O Z z N 0 W -- 1-- W rY O O H Q I— W W gmo > mz� III W�CnoWW I-- WWO WWoxLL 111 z W } Z O-1 F— O M m� a m w H w O m> Z J (7 O z u_ 0 FN- x In ~> W W z� W W x v o o u_ 0 0 x x5 O Oa � W W>>>� O SUB BSMT. BASEMENT c 1 FLOOR 2 FLOOR --i'FLOOR r 4 FLOOR 5 FLOOR 6 TH FLOOR 7 FLOOR -i 'FLOOR F–T—, L 11 I Installing Company Name: t"y' � � `f Check One Only Certificate # n � Address _ r i I (CmCi ( q -A City/Town: w." OC State: Corporation Business Tel: /2 r -6e3 -2%7 (Fax: ❑ Partnership Name of Licensed Plumber/Gas Fitter: /Grs�/� s ��nr��.C.o�c ) ❑Firm/Company INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes �No ❑ If you have checked )s, please Indic a the type of coverage by checking the appropriate box below. A liability insurance policy Other type of indemnity demnity ❑ 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 ❑ 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 accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be In compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. By Type of License: ❑ Plumber Title ❑ Gas Fitter �i�ganature of Licensed Plumber/Gas Fitter ElMaster�Q� City/Town ❑.l neyman License Number: 4 6 APPROVED (OFFICE USE ONLY LP Installer _ d AS. Mid G. ISSUES TO .6 . LANCELOT k I�.E;S -1JH 0 SA07c� 1022 0:t U.I/12 7�f'`•r 1 1 The Commonwealth of Massachusetts Department of lndustrial Accidents Office of Investigations 600 Washington Street s Boston, MA. 02111 www.mass govldia Workers' Compensation Insurance davit: Builders/ContractorsAElectricians/Plumbers Micant Informnfinn Name (Business/Organization&dividual): S CJS i 4A1 D�� y Phone #: 7 _�d•�. X77/. A560H an employer? Check the appropriate box: 1.rJ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* 2. ❑ I am a sole proprietor or have hired the sub -contractors listed partner- on the attached sheget. t ship and have no employees These sub -contractors have working for me in any capacity. [No workers' comp. insurance workers' comp. insurance. 5. ❑ We are a corporation and its required.] 3. ❑ I am a homeowner doing all ,officers have exercised their 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 re; , -A • Type of project (required): 6. El New construction 7. El Remodeling 8. El Demolition 9. El Building addition X0.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 11" lle ] 13.❑ Other L/ C- Gys %lip I Any applicant that checks box #1 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. tcontractors that check this box must attached an additional sheet showing the name of the tsidsub_e contractors ntractors and their workers' comp. policy information. information. an employer that is providing workers' compensation insurance for my employees Below is the policy and fob site information. Insurance Company Policy # or Self -ins. Lie. #: _ Expiration Date: Job Site Address:_ L City/State/Zip:j2- Attach acopy of the worker com ensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required Wider 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. ado hereby ce �' under fliepain andpenalties ofperfury tliat the information provided above is true and correct. Official use only. Do not write in tlais area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, orad. 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 j oint 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 employer." 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 for any applicant who has not produced acceptable evidence of compliance 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 of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers', compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-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, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the 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 r 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 printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permithicense number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) 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 may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new 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 questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: Tlxe Go-run-kormealtia of Massachusetts Depad ment of industrial Accidents Office of investigations 600 Washington Street Boston; MA. 02111 Tot. R 61.7-727-4900 ext 4406 ox 1.-877-MA.SSAF13 Revised 5-26-05 Fax #X61.7^727.7749 10244 Date ....... tF-2--2.' % / TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that elzi...s �vi tJ G .... 01- ................. ..... .. ..� has permission to perform......A' UjDl, ..................................................................... wiring in the building of T��. Oj6%v.Q.V.. r.. %.......l..`..;1 .... , North Andove ass. Cie Fee..%6o........ Lic. No.. f cP 7..............................,.�............... ... r L J ELECTRICAL INSPE�-MR Check # DATE (MMIDDT(Y� ACORpm CERTIFICATE OF LIABILITY INSURANCE 10/05/2011 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 ENTS CERTIFICATE OF INSURANCE DoF-5 NOT OR PRODUCER, AND THE CERTIFICATE HOLDER. A CONTRACT QFTWEEN TME ISSUING IN6URER(S), AUTHORIZED REP IMP RTAN : If the cortlflcato holder s an A DITIONAL IN RED, t e policy(les) must be endorse . H SUBIR ON I WAIVED, subject to the terms and conditions of the policy, certain politics may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). p ane D ra PRODUCER Fur... 508. 797. 350 Braley & Wellington Insurance Agency Corp. =08-762-�111 A1C Ne44 Park Avenue : l- t r INSURER(S) AFFORDING COVERAGEMAIC i P.O. Box 15127 17978! Worcester, MA 01615-0127 INSURER A: ACa is Insurance INSURED INSURER B: Starr Indemity & Liability Co Haffner's Service Stations Inc. INSURERC: Liberty Mutual Insurance Co. Z International Way INSURER 0: Lawrence MA 01843 INSURER E : NUMBER: THIS IS TO CERTIFY THAT THE POLICIES Ur INbUKAE"VC Bio _� ^•� ----- INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOC CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HER EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. TYPE Or INSURANCE IN It PaLICY NU BER M DNYYY GENERAL LIABILITY CPA0151878-1 06/0112011 06101110 2 X COMMERCIAL GENERAL LIA®ILrEY CLAIMS -MADE a OCCUR A GEWL AGGREGATE LIMIT APPLIES PER: r j� X LOC WjILITY MAA0151879-1 06/01/2011 ALLOWNED UTO X tt AAUTO$ AUT" OS PXq NO"WLED NON.OW NED X UMBRELLA /.IAS 1C OC MB EXCESS LIAR DED I X I RETENTION S wORMRS COMPENSATION AND EMPLOYERS' LIABILITY Y I N ANY PROPRIETORIPARTNER/EXECUTIV � C OFFICEMEMBER EXCLUDED? I M I N I A R/ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 191, Additional Rairarks 6Ghaduli, N ogre 6Pac9 Is HOLDER Town of North Andover 1600 Osgood Street North Andover,_MA 01845 ACORD 25 (2010105) ,MED ABOVE FORT E POLICY PERIOD )MENT WITH RESPECT TO WHICH THIS :IN IS SUBJECT TO ALL THE TERMS, LIMITS EACH OCCURRENCE S 1, 000, OOO PREMISEra Eaoaeurronca $ 250 00 MED EXP (Any one peron) $ 5 .00 PERSONAL d ADV INJURY E 1,000,0001 GENERAL AGGREGATE S 2.000.00 PRODUCTS • COMPIOP A $ 2,000,00 S Ee acoidont $ 1 000.00 BODILY INJUIYY (Per Por=n) S nODILYINJURY(Poraccident) S Per accdent ii EACH OCCURRENCE $ 5.00 0 000 AGGREGATE S 5,000,00 S I X TO LIMITS ER- ' El, EACH ACCIDENT S 1, 000, ON E,L. DISEASE: • EA EMPLOYEd b 1,000,000 H.L. DISEASE -POLICY LIMIT i s 1,000,00 SHOULD ANY OF TNF ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. REPRESENTATIVE n 4, Di The ACORD name and logo are registered marks of ACORD ZO'd OS:OT TTOZ S 130 Z2T928982_6:xPJ 30IAd3S S�GN33HH Commonwealth of Massachusetts Official Use Only Permit No. Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 1/07] leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code MEC), 527 MR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: City or Town of: NORTH ANDOVER To the Ins ector ofWires: By this application the undersigne tice of his or her intention to perform the electrical work described below. Location (Street & Number) Tr d O CIV tdfC,� v t %r /4 • La -r C7 Owner or Tenant I %IV /9 V11 Owner's Address ') 70 8 C9 )( f -V /Of S 7` T/eleph/oneNoGj2e 4 V -227' 1AAQLrle- 'd ,L'S Is this permit in conjunction with a buildin ermit? •Yes No ❑ (Check Appropriate Box) Purpose of Building (/1 Q/ -e 0-4C�-0)_ Utility Authorization No. Overhead ❑ Overhead ❑ Existing Service Amps Volts New Service � Amps % / q OVolts Undgrd ❑ No. of Meters Undgrd ©� No. of Meters _L Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion of the ollowing table in be waived by the In ector o Wires. No. of Recessed LuminairesNo. 7 No. of Ceil.-Susp. (Paddle) Fans of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- Elo. rnd. rnd. o mergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches 5- V No. of Gas Burners No. of Detection and f Initiatin Devices I No. of Ranges / No. of Air Cond. Total 3 Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: Number ­ Tons " "'"'.......... KW No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers < Heating Appliances KW stems:* Security No. of DeSyvices or Equivalent No. of Water KW Heaters No. of No. of Si ns Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of MotorsTotal 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 El ctrical Work: (When required by municipal policy.) Work to Start: ,i Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE CO ERA E: 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 forc , nd has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE&n BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of erjury,.tli`at—the infor4nation on this application is true and complete. �} FIRM NAME: (�✓, ice' {� f�L�C� ��' < LIC. NO.: j / - Licensee: ri c Signatur -LIC. NO.: (If applicable ent " empt the license n mber line.) j Bus. Tel. No. qd Address: r!`+� ?? %' f ri?�/� Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department 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 Signature Telephone No. PERMIT FEE: $ vpt,A ot/, e,2�b-1 / Iq Z--14 -0/ /�� %n -4 l < ( a i 1 i I Date.... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ....... ............ , , C. 11 has permission to perform ..........7` ......... 7`-�111 --I' ........... ........... wiring in the building of ... ........... ;.':. . . .......... at..e4 ... 7.4. ..... 6 ...... .......... ,gp/, North Andover, Mass. Fee .... �3 ......... Lic. No .............. ........ Check # !!T-f'V!f—Z •�Af w .�Y 1 N N Commonwealth of Pfassachusetts Official Use Only Department of Fire Services Pemut No. BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked _ APPLICATION �®� ®C®�' [Rev. 1/07] (leave blank PERMIT TO PERFORM ELECTRICAL cif®RK All work to be performed in accordance with the Massachusetts Electrical Code (ME ), 527 CMR 12.00 (PLEASE PRfffflVINK OR TYPE ALL INFORMATIO City or Town of: NORTH ANI3OVER Date: t'i f/ By this application the undersigned To .the Inspector of Wires: gn gives noti4111's or her intention to perfatm the electrical ork described below. Location (Street & Number) V T Owner or Tenant 1 /� A�t (' �-� ' V V Owner's Address CSC( (oat. Is this permg Permit. it in conjunction with a building V Purpose of Building yes ❑ No (Check Appropriate Box) Utility Authorization No, j/% 6 � G ;5;% Existing Service `fps —_Volts Overhead ❑ Undgrd ❑ No. of Meters Newer Ce f% G Ams C�c1 Amps _ /,�L4t U Volts Overhead ❑ nd rd Number of Feeders and.Ampacity g No. of Meters / Location and Nature of Proposed Electrical Work: No. of Recessed Luminaires No. of Luminaire Outlets No. of Luminaires No. of Receptacle on No. of Switches No, of Ranges No. of Waste Disposers No, of Dishwashers No. of Dryers Heaters KW Hydromassage Bathtubs c om letion of the No. of Ceil: Susp. (Paddle) Fans NO- of Hot Tubs bwunming Pool aod e ❑ No. of oil Burners of Gas Burners No. of Air Cond. 'Area Heating KW ig Appliances KW Ballasts. of Motors Total HP 0 table may be waived by the Generators KVA ALAR -MS INo. of Zones of Alerting Devices noruAierting Devices ❑Municipal Connecfinn 0 Other o. o. of Devices or ommunications o, of Devices or Wires. Estimated Value of lectri al Work: .Attach additional detail ifdesired, or as required by the Inspector of Wires Work to Start:_4p % t� (When required by municipal policy.) a' Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE VE GE: Unless waived by the owner, noPermit the licensee.provides proof of liability insurance including "complet "completed for ophe eration- coverage or its substantial a ce of electrical work may issue unless undersigned certifies that such covers is in force, and has exhibited proof of same to the permit issuing CHECK ONE: INS equivalent. The INSURANCE BOND ❑ OTHER g office. I certify, under t pains and en es of er u th (Specify.) FIRM NAME: � n'' i znformation'on this application is true and complete. Licensee: ft I W �C� �. l LIC. NO.: (If applicable, nter a Signatur Address: p :n the license number l LIC. NO.: *Per M.G.L c. 14 , s. 57-61, s curity work requires D `�f `'� r% Gl8�/ Bus. Tel. N� - &C) '7t 7 OWNER'S INSURANCE W Dep of Public Safe Alt Tel. No.: AMER: I am aware that the Licensee does not have License: liability Lic. No. required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑� owner coverage normally Owner/Agent Signature ❑ owner's agent. Telephone No. PERMIT ELECTRICAL PERMIT NO. INSPECTION REPORT: INSPECTOR - DOUG SMALL I. ROUGH INSPECTION: Passed — [ ] Failed — [ ] Inspectors' Re -inspection required ($50.00) j ] comments: (Inspectors' Signature - no initials) Date 2. FINAL INSPECTION: Passed — [ ] Failed — [ ] Inspectors' comments: Re- inspection required ($50.00) (Inspectors' Signature - no initials) Date 3. UNDER GROUND INSPECTION: Passed — [ ] Failed — [ j Inspectors' Re -inspection required ($50.00) comments: r (Inspectors' Signature - no initials) Date 4. INSPECTION— SERVICE: - DATE CALLER ATIONAL GRID: NAME: . Passed — [ Failed — [ ] Inspectors' comments: Re -inspection required ($50.00) - [ ] (Inspectors' Signature - no initials) 17 Date 5. INSPECTION - OTHER: Passed — [ ] Failed — [ ] Inspectors' comments: Re -inspection required ($50.00) (Inspectors' Signature - no initials) Date DOOR TAGS ARE TO BE FILLED OUT.A,ND LEFT ON SITE IF THE AREA TO BE INSPECTED IS NOT ACCESSIBLE AND A gE_]NSpECTION OF $50.00 IS TO BE CHARGED. J 1� Tcmp I C 3099 The Commonwealth of Massachusetts yid l+(ti . Department of Industrial Accidents Se<,,, 1/ rC•e Office offnveshgations 1 1 63 169 ..000 Washington Street up Boston, MA 02111 www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Piumbers Applicant Information Please Print rLe Name (Business/organization/Individual): ( G Address: lql- 4 A City/State/Zip�eAy&- r', 0( g `(q Phone#: q7$ "360" — 7 Are you an employer? Check the appropriate box: L a employer with 4. ❑ I am 'a general contractor oyees (full and/or part-time—).* Vlam and I have hired the sub -contractors 2.a sole proprietor or partner- listed on the attached sheet. t ship and have no employees These sub=contractors have working for me in any capacity. [No workers' comp. insurance workers' comp. insurance. 5. ❑ We are a corporation and its 3. ❑required.] I am a homeowner doing all officers have exercised their work myself. [No workers' comp, right of exemption per MGL c. 152, §1(4), and tare have insurance required.] f no employees. T iiorkers' [i\0 � comp. insurance required.) *Any aYucant that checks box #1 mist also f ll out the sectio, bele:=., s^e• �� f Homeowners who submit th' ffida ' n Wb _neo Ivor ecs' con^MS., • Type project (required): 6. New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12. ❑ Roof rcpa irs 13.❑ Other u a art inalcattached n a they are doing all work and then lure outside contractors must submit new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' come- nnl;,- A um un employerthat is providing workers' compensation i information. nsurance for my employees. Insurance Company Name: Z. UA IC Below is the policy and job site Policy # or Self -ins. Lic. #: 7= f l 3 ? V Q f p afion Date: Job Site Address:_ 46"r b 6 t&1 Q (/0 �7 ;01 Attach a copy of the Workers' compensation Policy declaration page (showing the Policy numbeand expiration 0�at �/- Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of crimial 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. Td- L..__L w� •tu e: ce�ujy unser the pains and nallies of perjury t at the information provided abov is true and correct Si ature: Phone F0fj11Ci1a7only. Do not write in this area, to be completed by city or town official n• Permit/License # ority (circle one): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical In 5. Plumbing Inspector 6. Other Contact Person: Phone #: •` s '60MMONWEALTH OF MASSACHUSETTS OF ELECTRICIANS REGISTERED MASTER ELECTRICIAN ISSUES THE ABOVE LICENSE TO: CHRISTOPHER C LAWRENCE 292 ,HAMRSHIRE RD METHUEN MA 01844.-1.119. , z 814937, CONTROL # H 0 0 5 7 2" IMPORTANT ed, notify your Board at the: If this license is lost or destroy Washington St., Division of BostonsMA021ional Licensure 6100. 1000 suite 710, notify your board Proper mailing Of next If your name or address shown is changed, license number. Of correct name or address o rIn rrto y Renewal Application. Alwaysrovisions Of the General Laws This license is subject to the p and must not be loaned as amended. It is a personal privilege, or assigned to any other person. Keep this license on your person or posted as required by law.