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Miscellaneous - 858 JOHNSON STREET 4/30/2018
I '-V O a? o D z o N z o Cf) o C:) m o M 11 '* L --.,.tet- — Date ...... ( ...... —A—Y ........ TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ......... has permission to perform................... !�Uaeaz&z wiring in the Wilding of ........... at.......Z5 ........... ....... ,., North Andover, Mass. . - Fee .... .. . . .... Lic. No. tLECTRICAL INSPECTOR Check # 2 Commonwealth of Massachusetts Department of Fire Services t s` BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. 1 S O Occupancy and Fee Checked [Rev. 1/071 (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (Iv Q, 527 CMR 12.00 (PLEASE PRINT ININK OR TYPE ALL INFORMATIOA9 Date: City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice ofbis or her intention to perform the electrical work described below. Location (Street & Number) YO g011kfS °3W 'S7— Owner or Tenant lwgc3 Owner's Address "aSir J0/W'f(5®A% !S -T Is this permit in conjunction with a building permit? Yes hone No. No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. - Existing Service 'Row, New Service Amps / Volts Amps / Volts Overhead ❑ Undgrd ❑ Overhead ❑ Undgrd ❑ No. of Meters No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: /pi,`jd /r �j C, 1,C> ' 0� gaiC�—rVf— Completion of the following table may be waived by the Inspector of Wires. No. of Recessed,Luminaires Q% 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. grnd. No. of Emergency Lighting Batter Units No. of Receptacle Outlets /0 No. of Oil Burners FIRE ALARMS I 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 g 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 f` KW' Security Systems:* No. of Devices or Equivalent No. of Water KW Heaters No. of No. of Signs Ballasts Data Wiring: 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 le /f6 ical Work: (When required by municipal policy.) Work to Start: Ills -12 0/<& Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE RAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless tie 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. HECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify.) I certify, tinder the ains andpenallies ofperjury, that the information on this application is true and complete. FIRM NAME:. ,(;t�T.I�llr�2 SOS • LIC. NO.: %�U�- Licensee: AN - _ Signature LTC. NO.: �a20h�8 (Ifapplicable, ent "exempt" ' the license num a line.) Bus. Tel. No.: Address: D - y q t AJ -Al d - Alt. Tel. No.: AD.3_ 0 *Per M.G.L c. 147, s. 57-61, security work requ' s 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 agent. Owner/Agent Signature Telephone No. PERMIT FEE. $ i ❑ 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 �! 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 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 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. ❑ Rule 8 — Permit/Date Closed: *** Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection Pass M Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass M Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass F?1 Failed IN Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass Failed Re- Inspection Required ($.) ❑ Inspectors Co ents j Inspectors Signature: Date: ' FINAL INSPECTION: Pass M Y Failed M Re- Inspection Required ($.) ❑ Inspectors Comm a,% _ T .� Inspectors Signature: J Date: DEB WEINHOLD ...TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com The Commonwealth of Massachusetts Department oflndustrigl Accidents Office of Investigations 600 Washington Street Boston, MA. 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/Organi-zation/lndividual):� < Address: City/State/Zip: �`�/� `� Phone ,03 — VO ©2 X `X80 Are you an employer? Check the appropriate box: - Type of project (required): L ❑ I am a employer with 4. El I am a general contractor and 1 6. ElNew construction employees (full and/or part-time).* have hired the sub -contractors 7• [l Remodeling 2. [K I am a sole proprietor or partner- on the attached sheet. ship and'have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance, g, [� Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions required.] 3. [] 1 am a homeowner doing all work officers have exercised their right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp., c. 152, §1(4), and wehave no 12,0 Roofxepairs insurance required.] q � employees. [No workers' 13.[❑ other . comp. insurance required.] .: '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 ire doing all work and then hire outside contractors must submit anew 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 Policy 0 or Self -ins. Lia. Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A ofMGL o.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. X do hereby certiopuder tl paint cl pejzqt , f penury aat the information provided above is true and correct. - �?X 0 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. EIectrical Inspector 5. Plumbing Inspector 6. Other - - Pnnfnrf'PPrenn! � Phone ❑ 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 r 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 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 maybe 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 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 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. ❑ Rule 8 — Permit/Date Closed: *** Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection Pass M Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: . Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass n Failed Re- Inspection Required. ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPECTION: Pass R Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com The Commonwealth ofHassachusetts / , / Office of Invesfigailons /,Washington •� w 1 / / 02111 Name (Business/Organizaiion&dividual): .Address: City/SiateMi Phone #: Are you an employer? Check the appropriate box: Type of project (required): 1 • ❑ I am a employer with 4. ❑ I am a general contractor and I 6. D New construction employees (M and/or part-time).* have Hired the sub -contractors 2. ❑ I am a sole proprietor or partner- 'listed on the attached sheet. 7• ❑Remodeling ship and' lave, no employees These sub -contractors have 8. ❑ Demolition working forme in any capacity. workers' comp. insurance, g• Building addition [No workers' comp. insurance S. ❑ We are a corporation and its 10.❑ Electrical repairs or additions required.] officers have exercised.their 3.E1 X am a homeowner doing all work right of exemption per MGL 11. [] Plumbing. repairs or additions myself [Noworkers' comp. c.152, §1(4), and wehave no 12.❑ Roofrepairs insurancere ed. ► employees. [No workers' ] � 13.❑ Oilier . comp. insurance required.] '•`Any applicantthat checks box#1 must also fill out the section bel6w showingtheir wbrkers' compensationpolicy information. i Homeowners who submitthis affidavit indicating they a4e doing ailworlc and then hire outside contractors must submit anew affidavit indicating such. TContractors that checkthis.box must affached. an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. lam an employer that is providing workers' compensation insurance for my employees Bellow is the policy and job site information. Insurance Company Name% Policy ## or Self -ins. Lie,; #: Expiration Date: Job Site Address:-Pity/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy:aumber and expiration date). Failure to secure ooverage as requiredunder Section 25A. ofMGL c.152 can lead to the imposition of criminal penalties of a fine up to $1,50 0.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORTS ORDER. and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the AIA for insurance coverage verification. X do Hereby cert& under file pains and penalties of perjury that the information provided above is true and correct. Simature• Date: Phone #: 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. C41TCown Clerk 4. Electrical Inspector 5. Numbing Inspector 6. Other - - Contact Person: Phone 1 Information and Ins4ructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an ert ployee is defined as "..,everyperson tri the service of another under any contract of'hire,• express or implied, oral or written." An employei is dof med as "an individual, partnership, association, corporation or other legal entity, or anytwo ormore of the foregoing engaged in a joint enterprise, and including the legalrepresentatives of a:deceased employer or tare redelver or iriistee of aft 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 stub: 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 fox any applicant who has not produced -acceptable evidence of compliance with the insurance coverage required ' Additionally, MaL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance ofpubiic work until acceptable evidence of compliance with the insurance requirements of this chapter have beenpresented 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 -contractors) name(s), address(es) and phonenumber(s) along with their certificates) of insurance. Limited Liability Comp anies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are notrequired to cavy workers' compensation insurance. Tian LLC or LLP does have employees, a policy is required. Be advised that ibis affidavit maybe submitted to the Department of Industrial Accidents for coninmation 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 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 luvestigations has to contact you regarding the applicant. Please be -sure to fill in the permit/license number which will be used as a reference number. Tn addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current PORGY information (ifneeessary) and under "Job Site Address" the applicant should write "all locations in (city or town) °' A' copy of the affidavit that has been officially stamp ed or marked by the city or town may be provided to the applicant as proof that a valid affidavit. is on file fox future p enmits or licenses. A new affidavit must be tilled 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 orpermit to burn leaves eta) 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 anyquestions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The CommonwalthofM'assachvsPits Dopartmt (XTudustial Accidents Qfte QfI'umaga lou 6.Q Vlasgf ai? Suet Basto�. M�, 4�X X 1 TQ1, # 617-7-2,' -4900 at 406 ox 1-877�MMSAM Revised 5-26-05 Fax 0 617-727-7749 www ma�s,govj& � ) » z� ` . ® ' % % > W y > .. / 2 � :r m.rp / ®z ® r m �� » 6 ( � �c�� ■. 0, & » I : o C-) d ew�� . . ��«�¥■� .. Q, . z k. . ) P Date ....... .................. TOWN OF NORTH ANDOVER PERMIT -FOR WIRING A L .......................... 0.. 9; ... This certifies that \-AJ ................... U ..........X/ ................................. has permission to perform ........ Nq!� ................................................ ,wiring in the building of ............ . 6 ................................................... at .... �'6 ................................................................ North Andover, Mass. Fe Lic. No . ................. Fee..... .... ... ................... E ELEC-MCALUS477 .1 Check #, 1:1844 Commonwealth of Massachusetts Official Use Only Department ®f Fire Services Permit NoOccupanc . • BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/0 ,yandFee Checked (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code W ), 5 7 CMR 12.00 (PLEASE PRINT INMK OR TYPE ALL INFORMATION) Date: WL0113 City or Town of. NORTH ANDOVER To the Inspector of Fire—s.- By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) 5-o1'?d150✓I fj-ft:e,p� Owner or Tenant 5-f ea 7—�Vlc 1 069 Telephone No. Owner's Address is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building 1Mp Utility Authorization No. ts(05-6115,01 ` Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service 16 Amps 90 /r2ild Volts Overhead ❑ Undgrd 0"", No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: ') fp ne 1 ) knd eJr) ) e C , AC- No. of Recessed Luminaires —2- - —.J.;kVry4,ts No. of Cell.-Susp. (Paddle) Fans cuuae icily ue waived by the ins ector of nares. No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- ❑ rnd. grnd. o, o mergency �g ting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches; �- c, - ^;� No. of Gas Buniers JAD. of Detection and Initiatin Devices No. of Ranges No. of Air Cond. Tonsl No. of Alerting Devices No. of Waste Disposers Heat Pum Totals ..... ............ Number Tons........ K!dDetection/Alerting No. of Self -Contained Devices No. of Dishwashers Space/Area Heating KW ILocalD Municipal ❑ Other Connection No. of Dryers No. of WaterNo. Heaters KW Heating Appliances KW No. Baasts Signs Ballasts Si Security Systems:* of Devices or Equivalent Data Wiring: No, of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Amin additional detail 1 desired or as required by the Inspector of fires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. 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. CBECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) t certify, itnder Chep in nd penalties of erjury, that the information on this application is true and complete. p FIRM NAME: 1. LIC. NO.: Licensee: �. ( b Signature LTC. NO.: afapplicable, enter "exert" in we e umb lin 7to1 Address: O 3 Bus. Tel. No.: *Per M.G.L c. 147, s. 57-6 , security wor requires Departme"Pfiblicfety "S" L cense: Alt. Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurancecoverage 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. $ ❑ 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, art electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the 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 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 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. ❑ Rule 8 — Permit/Date Closed: *** Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench In5pettion Pass Failed M Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: 1,46. tis e < l Date: Z 3 /� SERVICE IN PECTION: Pass Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: 1,2, ` /r_ I Date: = 23 -13 PARTIAL ROUGH INSPEC ION: Pass F?1 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INS CTION: Pass Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: i%� S `� l r Date: i- z 3 FINAL INSPECTION: Pass ® Failed Re- Inspection Required ($.) El Inspectors Co ents, Inspectors Signature: Date: M DEB WEINHOLD ... TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com The Commonwealth of Massachusetts Department ofkdustriglAccidents Office of Investigations 600 Washington Street Boston, MA. 02111 www.mass gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Eleetricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): City/State/Zip:��k-5 V<_ N 4 030( % Phone #: LOS 3_3 6_ 1t gU Are yopan employer? Check the appropriate box: - Type of project (required): 1. I am a employer with 3 4• ❑ I am a general contractor and 1 6. ❑ New construction employees (full and/or part-time).* 2. El am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. '!• E] Remodeling ship and'have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance.9. ❑Building addition [No workers' comp. insurance 5. El We are a corporation and its 10.❑ Electrical repairs or additions required.] 3. ❑ 1 am a homeowner doing all work officers have exercised their right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, § 1(4), and we have no 12,❑Roofrepairs insurance required.] employees. [No workers' 1311 Other comp. insurance required.] 'Any applicant that checks box#1 must also fill out the section below showing their workers' compensation policy information. I Homeowners who submit this affidavit indicating they aie 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 sub -contractors and their workers' comp. policy information. lam an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. Policy # or Self -ins. Lic. Job Site Expiration Date: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A ofMGL 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. X do hereby cert fy yc#tl ,4iie pains A4an 1 ies ofperjury that the information provided apove if true and correct. Of use only. Do not write in this area, to he completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. CitylTown Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - Contact Person: Phone #: Information and Instruction's 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 ofhire, - express or implied, oral or. written." An employeAs 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 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 ofits political subdivisions shall enter into any contract for the performance ofpublic 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 -contractors) 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 notrequired to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit maybe 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 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 permit/license 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 (ff 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 o 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 4pestions, please do not hesitate to give us a call. The Department's address, telephone acid fax number: N . • _ , Tho GoMonwoaltb ofMassocaysPits Depaztix it ofIndusWal .A.ccidonts . Qf�ee o1�In��estigatlo.� 600 Wasbingtorl Street Boston} MA 02111 Tel, # 617-727-4900 at 406 or 1:-877, M'.ASSA E Revised 5-26-05 Fay # 617-727;7749 I_J M Ad :. G.J. •: LICENSE NUMBER. EXPIRATLON DATE S_E.RIAL NUMBER Date......................... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ...... JAw-) ...... ......... .. .... . ......... as -i ............. -- has permission for g nstallation ....... 64k.-� ......... V* .............................. Y-7 6 in the buildings of ........................... .................................................................... at .................................................................. ........ ..................... . North Andover, Mass. Fee.Al: ....... Lic. No. .......... ...................................................... GAS INSPECTOR Check # U 8855 '-� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY I� MA DATE PERMIT # --- JOBSITE ADDRESS `� In I OWNER'S NAM-E G FAX OWNER ADDRESSW. _ _. N. - -- _. TE`1 - ------05:1 TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL'. CLEARLY NEW: RENOVATION: REPLACEMENT: [11 PLANS SUBMITTED: YES _[._I NO APPLIANCES -1 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 1 12 13 14 BOILER- t.J.. _ ... BOOSTER .__. CONVERSION BURNER _. f 1 _.J _ COOK STOVE —1 ra �.. _ I� i� J DIRECT VENT HEATER DRYER --- ---- - FIREPLACE.-_ FIREPLACE. FRYOLATOR- FURNACE - _ -:Tui L I GENERATOR l i.�ji..- I L=nj GRILLE INFRARED HEATER LABORATORY COCKS -:► ._ _ T = I �� -� I (_-�__- -. ,�_ys� 1... :,, 1-- _- f. MAKEUP AIR UNIT- _. OVEN - r,. l �- - _ �(—'� _ _ I_- _ . _J L _:_-- ._ (__� _-.- - POOL HEATER ! ,_..._ r (_- _ J= __ ,I_ , - _- . _ .: _ f _�( I __1 ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER jj I _I -_, -- INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES NOE] 1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY tA OTHER TYPE INDEMNITY Ej BOND I__I OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER (� AGENT ._�__i( SIGNATURE OF OWNER OR AGENT 1 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 ' h all Perone rovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME_Z SIGNAT LICENSE # _ ... _.--_ _._ . l MPII MGF JP JGF LPGI CO ORATION I # PARTNERSHIPD# COMPANY NAME. DDRESS C _! CITY t2 STATE ZIP ��.._,_.. _._ TEL yr FAXCELL EMAIL = \\V \` ��aca Y r 10144 r'i1 r Date.. ......... p1ORT/� rx TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING Cd 4 This certifies that ......... has permission to perform .. !�.�...°.`.. ..................... plumbing in the buildings of .f�A! 'q) oi/+ ........ ... . at... ... ` . 1 `�.QGt . , North Andover, Mass. Vb .. '' .................... . PLUMBING INSPECTOR Check MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY �� rMA; DATE `— PERMIT # 1 JOBSITE ADDRESS, .� OWNER'S NAME 0 �i P OWNER ADDRESS TEL TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL D RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: 0f PLANS SUBMITTED: YES NO FIXTURES Z FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM - DEDICATED GAS/OILISAND SYSTEM �I _._ f _ I( DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN _-------- _! __.73 FOOD DISPOSER FLOOR/ AREA DRAIN_ INTERCEPTOR (INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN I ------ SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION !NATER HEATER ALL TYPES __j t # WATER PIPINGs f ( ) OTHER I f INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES NO Ell IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY -M OTHER TYPE OF INDEMNITY D BOND Q d 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 a AGENT i ; SIGNATURE OF OWNER OR AGENT 6 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 P ' nt provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAMEi YV�ILICENSE # SIGNATURE MPV JPQ CORPORATION F1#=PARTNERSHIPM#LLC I COMPANY NAME f ADDRESS (. CITY 011. _...__ .........................._I TATE ZIP �Q�—`� TEL FAX CELL EMAIL H Z O H w j or z y❑ w � w w O 7 0- w u u _ '= 3 ® a W a U)LU c a 0 z ?� a � w a as � a a a = w f- Li- w H 0 O E� U M cri z e,a C7 z as w o a The Commonwealth of.NTassachusetts - Department of IndustriglAccidents Office of Investigations qu 600 Washington Street Boston, ,NTA 02111 www.rnass90v1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/Organizationgndividual): Are you an employer? Check the appropriate box: 1. [� I am a employer with 7— 4. ❑ I am a general contractor and I Type of project (required): f employees (full and/or part-time.).* have Hired the sub -contractors 6. ❑ New construction 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. x 7. ❑ Remodeling ship and'have no employees These sub -contractors have 8. ❑ Demolition working for mein any capacity. workers' comp. insurance. 9. E] Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its ME] Electrical repairs or additions required.] officers have exercised their 3. ❑' I am a homeowner doing all work right of exemption per MGL 11.Plumbing repairs or additions myself. [No workers' comp. c.152, § 1(4), and we have no 12.�Roof repairs insurance required.] i employees. [No workers' 13.❑ Other comp. insurance required:] ,any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. . Homeowners who submit this affidavit indicating they s're 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 sub -contractors and their workers' comp. policy information. I am an employer that ispro viding workers' compensation insurance for my employees. -Below is thepolicy and job site information. y� Insurance Company Name:. - / (( Policy # or S elf -ins, Lie. #: Expiration Date: Job Site Address: City/State/Zip: Attach a. copy of the workers' compensation -policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder 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. Ido hereby cerci nder thep dpenalties ofperjury ilzat the informationprovided above is true and correct. iii 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): , I. Board of Health 2. Building Department 3. C41Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone Information and Instructions Massachusetts General Laws chapter 152 requires allemployers 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, 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 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 ofits 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 -contractors) 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, apolicy is required. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents fox 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 affidavitis-complete -andprinted legibly: The Department"has provided a space at the bofiom 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 permit/license 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 bum 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: Tho Commonwealth of Mbssachwotts Department ofJadustxial Accidents office ce dIuvestigatiom 6. Q � Vi�ashilagtaxt Street Boston, UA, 0211.1 Tel, # 61.7-727-4900 at 406 or 1.-$77'� UA.SS F1, Revised 5-26-05 Fax # 617-727-7749 307 Date .9 . A . � .j .... . TOWN OF NORTH ANDOVER PERMIT FOR MECHANICAL INSTALLATION q � ' This certifies that r%.' .....n . has permission for mechanical installa�t :C. A.� .. (' .. 14—:: in the bu' dings of P. i. at f� .-� :.. -4f - n .. -S ` , North Andover, Mass. FeerQ9�- .. Lic. No... X . ..... ........ GASINSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer Commonwealth of Massachusetts Sheet Metal Permit Date: C- O- d 3 Permit # So Estimated Job Cost: $ , r0 Permit Fee: $ Plans Submitted: YES NO V Business License # 0171 Business Information: l Name: Q "Street: 91 eA mno., City/Town: Nc iil Ayy An t y Telephone: -79„ Photo I.D. required / Copy of Photo I.D. attached: J-1 /unrestricted license Plans Reviewed: YES NO Applicant License # Id qdy Property Owner / Job Location Information: Name: FrdYXC bSg - Bldrs . Street: City/Town: // �yo �u✓�� Telephone: YES k, -'NO Staff Initial J-2 / M -2 -restricted to dwellings 3 -stories or less and commercial up to 10,000 sq. ft. / 2 -stories or less Residential: 1-2 family Multi -family Commercial: Office Retail Institutional Condo / Townhouses Other Industrial Educational Other Square Footage: under 10,000 sq. ft. over 10,000 sq. ft. Number of Stories: Sheet metal work to be completed: New HVAC ��Metal Watershed Roofing Metal Chimney / Vents Provide detailed description of work to be done: Work: Renovation: Kitchen Exhaust System Air Balancing 4� q(r 'r _ f'yncrr v INSURANCE COVERAGE: 1 have a current liability,insurance policy or its equivalent which meets the requirements of M.G.L. Ch. 112 Yes No ❑ If you have checked Yes, indicate the ty �e 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 112 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 Owner's 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 sheet metal work and installations performed under the permit issued for this application will be in compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws. Date Date By Title City/Town Permit # Fee $ Duct inspection required prior to insulation installation: YES NO Inspector Signature of Permit Approval Progress Inspections Comments Final Inspection Comments Type of License: ❑ Master ❑ Master -Restricted ❑,lourneyperson Signature of Licensee ❑Journeyperson-Restricted / a License Number: l7 ❑ Check at www.mass.aov/dpl '�` °aW�� CERTIFICATE OF LIABILITY INSURANCE �--� DATE (MMIf012 10/16/2012 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERT7IRCATE 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 endonminengs). PRODUCER NORTH ANDOVER INSURANCE AGENCY INC. yE,: M.J. FOSTER`'INSURANCE SERVICES 163 MAIN. STREET CONTACT NAMPHONE E (978) 686-2266 FAX No): (578) 686-6010 Ecfernandez@nafins.com ADDRESS: PRODUCERCallahan Air Conditioning fi Eeatin CUSTOMER ID $, g g INSURERS AFFORDING COVERAGE NAIC # NORTH ANDOVER I�Lk 01845-2508 INSURED INSURER A :PEERLESS INS CO Callahan Air Conditioning & Heating, Inc. INSURER B GUARD INSURANCE Callahan Air Conditioning Services, Inc. 91 Belmont Street WSURER C INSURER D INSURER E North Andover MA 01845- WSURER F I.UVr_KAUt=z GLKIIF1GAlt NUMBER: RF1nSIrl1+1 WiIMRFR- 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. INS_LTR I TYPE OF WSURANCE L INSR WVD 111 I POLICY NUMBER POLICY EFF (MM/OD/YY)'Y) POUCY EXP (MMlDDMlYI� LIMITS A GENERAL LIABILITY y y P4016154 9/25/2012 9/25/2013 EACH OCCURRENCE S 1,000,000 X COMMERCIAL GENERAL LIABILITY / / / I DAMA ER NTE) IS .occurrence' s 300,000 CLAIMS 7 / / / / -MADE OCCUR MED EXP (Any one person) s 5,000 X C CTaAL ~ / / / 1 PERSONAL &ADV INJURY s 1 -000,000 X X.C.U. COVERAGE, GENERAL AGGREGATE S 2,000,000 / / / / GEN 'LAGGREGATELIMIT APPLIES PER : PRODUCTS - COMP/OP AGG E 2,000,000 / / / / POLICY x. JECTPRO- LOC / / / / NOWND Is A AUTOMOBILE LIABILITYy Y `4544035 9/25/2012 9/25/2013 COMBINED SINGLE LIMIT s 1,000,000 (Ea —derd) ANY AUTO / / / / BODILY INJURY (Per person) S ALL OWNED AUTOS / / / BODILY INJURY (Per accident) s X SCHEDULED AUTOS / / / / PROPERTY DAMAGE s X / / / / HIRED AUTOS (Per accident) X NON -OWNED AUTOS k COMP.$1000 DED COLL.$1000 DED / / / / $ A X UM13REUA UAB [3xF OCCUR Y Y =8809334 9/25/2012 9/25/2013 EACH OCCURRENCE s 5,000,000 EXCESS ,UAB CLAIMS -MADE / / / / AGGREGATE $ 5,000,000 DEDUCTIBLE s / / RETENTION S / / s B WORKERS COMPENSATION AND EMPLOYERS' y 358427 9/25/2012 9/25/2013 WC STATU- DTH- X T RY IMIT R LWBILITY YIN - E.L. EACH ACCIDENT s 500,000 wf PROPRIEiORIPARTNER(EXECLMVE OFFICER/MEMBER EXCLUDED? ❑ N/A (Mandatory fn NH) / / / / If m describe under E -L. DISEASE - EA EMPLOYE s 500,000 E -L. DISEASE -POLICY LIMIT s 500,000, DESCRIPTION OF OPERATIONS below / / A INLAND KkPaDTE P4016154 9/25/2012 9/25/2013 LIMIT 50,000 EQUIPMENT / / / / DEDUCTIBLE 1,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEFHCLES (AU..h ACORD 101, Additional Remarks Scheduie, if more :pace is requimd) CERTIFICATE HOLDER rA►drGl I ATInW 1(978) 688-9500 (978) 688-9542 TOWN OF NORTH ANDOVER 120 MAIN STREET NORTH ANDOVER MA 01845- ACORD 25 (2009/09) lk on ._ ��1�1 1 Ukt Nl.._V.tSL�r1A fT)P..�r7 fl SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE © 1988-2009 ACORD CORPORATION. All rights reserved. -- 40WMah%anN1*"— A/C & HEATING SERVICES 91 Belmont Street North Andover, MA 01845 www.callahanac.com TO: FRANCIOSA BUILDERS 8 Newell Farm Road West Newbury, MA 01985 PROPOSAL PROPOSAL #: 107355 DATE: 9/9/2013 JOB LOCATION: 852 JOHNSON STREET NORTH ANDOVER, MA REP: KJM DESCRIPTION Total INSTALLATION OF NEW HEATING AND AIR CONDITIONING SYSTEM (GAS PIPING AND ELECTRICAL NOT INCLUDED) CONSISTING OF THE FOLLOWING:(FIRST FLOOR) A_GOODMAN MODEL #GMH95904CX GAS FIRED 95% HOT AIR FURNACE 90,000 BTU B_GOODMAN MODEL #GSX13361 13 SEER 36,000 BTU CONDENSER (R410A) C_GOODMAN MODEL #CAPF3642C 36000 BTU COIL D_FREON LINE SET E_ELECTRICAL BY OTHERS F_GAS PIPING BY OTHERS G_PVC FLUE AND COMBUSTION AIR PIPING THROUGH SILL PLATE TO OUTSIDE H_30 x 30 CONDENSER PAD [PRECAST] I_CONDENSATE PUMP AND PIPING J_INSULATED DUCTWORK WITH FLEXIBLE BRANCH LINES TO REGISTER K_CENTRAL RETURN REGISTER FOR FIRST FLOOR L_APRIL AIR HEATING AND COOLING MODEL # 8463 DIGITAL THERMOSTAT M_SUPPLY REGISTER FOR EACH ROOM INSTALLATION OF NEW HEATING AND AIR CONDITIONING SYSTEM CONSISTING OF THE FOLLOWING:(SECOND FLOOR) A_GOODMAN MODEL #GMH95904CX GAS FIRED 95% HOT AIR FURNACE 90,000 BTU B_GOODMAN MODEL #GSX13361 13 SEER 36,000 BTU CONDENSER (R410A) C_GOODMAN MODEL #CHPF3636B 36,000 BTU COIL D_INSULATED DUCTWORK WITH FLEXIBLE TAKEOFFS E_ELECTRICAL BY OTHERS INCLUDING LOW VOLTAGE WIRING PAYMENT TERMS SEE PAYMENT SCHEDULE —T—Total All material is guaranteed to be as specified. All work to be completed in a workmanlike manner according to standard practices. Any alteration or deviation from above specifications involving extra costs will be executed only upon written orders, and will become an extra charge over and above the estimate. All covered by Workman's Compensation Insurance's. Equipment warranty by manufacturer. Contractors labor warranty for one year. AUTHORIZED SIGNATURE: DATE: CUSTOMER ACCEPTANCE: DATE: ** A signed copy of this proposal and deposit must be received for us to schedule this installation. (This proposal may be withdrawn by us if not accepted within 30 days.) —�� Authorized 111air'e' Partner in Comfort Page 1 Callahan A/C & HEATING SERVICES 91 Belmont Street North Andover, MA 01845 www.callahanac.com TO: FRANCIOSA BUILDERS 8 Newell Farm Road West Newbury, MA 01985 PROPOSAL PROPOSAL #: 107355 DATE: 9/9/2013 JOB LOCATION: 852 JOHNSON STREET NORTH ANDOVER, MA REP: KJM DESCRIPTION'.Total F_NEW APRIL AIR DIGITAL HEAT/ COOL MODEL # 8463 THERMOSTAT G_SUPPLY REGISTER FOR EACH ROOM H_CENTRAL RETURN REGISTER I_B-VENT FLUE THROUGH ROOF J_GAS PIPING BY OTHERS K_PERMIT BY PLUMBING CONTRACTOR L_REQUIRED DRAIN 'k PAYMENT TERMS SEE PAYMENT SCHEDULE Total All material is guaranteed to be as specified. All work to be completed in a workmanlike manner according to standard practices. Any alteration or deviation from above specifications involving extra costs will be executed only upon written orders, and will become an extra charge over and above the estimate. All covered by Workman's Compensation Insurance's. Equipment warranty by manufacturer. Contractors labor warranty for one year. AUTHORIZED SIGNATURE: DATE: CUSTOMER ACCEPTANCE: DATE: ** A signed copy of this proposal and deposit must be received for us to schedule this installation. (This proposal may be withdrawn by us if not accepted within 30 days.) Authorized 111aN'C` Partner in Comfort Page 2 i Callahan A/C & HEATING SERVICES 91 Belmont Street North Andover, MA 01845 www.callahanac.com TO: FRANCIOSA BUILDERS 8 Newell Farm Road West Newbury, MA 01985 PROPOSAL PROPOSAL #: 107355 DATE: 9/9/2013 JOB LOCATION: 852 JOHNSON STREET NORTH ANDOVER, MA REP: KJM DESCRIPTION, Total PAYMENT SCHEDULE: _ FIRST PAYMENT DUE UPON COMPLETION OF THE ROUGH 15,000.00 _ BALANCE DUE UPON COMPLETION 4,000.00 PAYMENT TERMS SEE PAYMENT SCHEDULE 7—Total $19,000.00 All material is guaranteed to be as specified. All work to be completed in a workmanlike manner according to standard practices. Any alteration or deviation from above specifications involving extra costs will be executed only upon written orders, and will become an extra charge over and above the estimate. All covered by Workman's Compensation Insurance's. Equipment warranty by manufacturer. Contractors labor warranty for one year. AUTHORIZED SIGNATURE: DATE: CUSTOMER ACCEPTANCE: DATE: ** A signed copy of this proposal and deposit must be received for us to schedule this installation. (This proposal may be withdrawn by us if not accepted within 30 days.) Authorized 111aire' Partner in Comfort ----- Page 3 Page 1 Residential Heat Loss and Heat Gain Calculation 9/9/2013 In accordance with ACCA Manual J Report Prepared By: Callahan A/C & Heating For: Franciosa Builders (First Floor) 852 Johnson Street North Andover, MA 01845 Design iConditions: Boston Indoor: Outdoor: Summer temperature: 70 Summer temperature: 88 Winter temperature: 70 Winter temperature: 9 Relative humidity: 50 Summer grains of moisture: 88 Daily temperature range:Medium Building Component Sensible Latent Total Total Gain Gain Heat Gain Heat Loss (BTUH) (BTUH) (BTUH) (BTUH) Infiltration Ceilings 4,033 4,571 8,604 19,789 Windows 6,777 0 6,777 10,435 Floors 10,774 0 10,774 9,341 Duct 1,921 0 1, 921 9, 012 Walls 0 0 0 5,761 Fireplaces 1,290 0 1,290 3,646 Glassdoors 0 0 0 3,478 Doors 1,562 0 1,562 1,560 Skylights 124 0 124 351 Misc 00 0 0 People 2,400 0 2,400 0 Whole House 1,500 1,150 2,650 0 30,381 5,721 36,102 63,373 (3tons ) HVAC -Calc Residential 4.0 by HVAC Computer Systems Ltd. Load calculations are estimates only, actual loads may vary due to weather and construction differences. 888 736-11 O1 Page 1 Residential Heat Loss and Heat Gain Calculation 9/9/2013 In accordance with ACCA Manual J Report Prepared By: Callahan A/C & Heating For: Franciosa Builders (2nd Floor) 852 Johnson Street North Andover, MA 01845 Design Conditions: Lawrence Indoor: Outdoor: Summer temperature: 70 Summer temperature: 87 Winter temperature: 70 Winter temperature: 0 Relative humidity: 50 Summer grains of moisture: 95 Daily temperature range:Medium Building Component Sensible Latent Total Total Gain Gain Heat Gain Heat Loss (BTUH) (BTUH) (BTUH) (BTUH) Infiltration 4,294 6,245 10,539 26,461 Windows 13,606 0 13,606 12,985 Walls 2,417 0 2,417 8,217 Ceilings 4,157 0 4,157 7,098 Duct 1,299 0 1,299 5,477 Skylights 0 0 0 0 Glassdoors 0 0 0 0 Doors 0 0 0 0 Misc 0 0 0 0 Fireplaces 0 0 0 0 People 1,500 1,150 2,650 0 Floors 0 0 0 0 Whole House 27,273 7,395 34,668 60,238 (3tons ) iVAU-Ualc Residential 4.0 by HVAC Computer Systems Ltd. 888 736-1101 Load calculations are estimates only, actual loads may vary due to weather and construction differences. Location-5f?�/�S S No. L/L -2:) Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Ot , rf-ermit Fee $ /4 SewerCanfnect-io6, Fee;• _ 4$ Water C6rm/ection Fee$ TOTAL n �c t'C F •• ,r e w / 1s ng Inspector Div. Public Works APPLICATION FOR PERMIT TO BUILD - NORTH ANDOVER, MASS. PAGE I MAP KVO. LOT NO. 2 RECORD OF OWNERSHIP IDATE BOOK 'PAGE ZONE SU DIV. LOT NO. LOCAT NFs PURPOSE OF BUILDING �/s ,�a� OWNKIPS NAME NO. OF STORIES SIZE OWNER'S ADDRESS r�Zr/ BASEMENT OR SLAB ARCHITECT'S NAME SIZE OF FLOOR TIMBERS IST 2ND 3RD BUILDER'S NAME SPAN DISTANCE TO NEAREST BUILDING DIMENSIONS OF SILLS DISTANCE FROM STREET POSTS DISTANCE FROM LOT LINES - SIDES REAR " GIRDERS AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW SIZE OF FOOTING X IS BUILDING ADDITION MATERIAL OF CHIMNEY IS BUILDING ALTERATION IS BUILDING ON SOLID OR FILLED LAND WILL BUILDING CONFORM TO REQUIREMENTS OF CODE IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION. IF ANY IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE • INSTRUCTIONS SfX BOTH SIDES PAGE 1 FILL OUT SECTIONS 1 - 3 PAGE 2 FILL OUT SECTIONS 1 - 12 ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED /jAND APPROVED BY BUILDING INSPECTOR DATE FILED Ld &i/ ATURE OF OWN OR A THgRIZED AGENT FEE !O► �14 - PERMIT GRANTED a?- 2-- 19 3 PROPERTY INFORMATION LAND COST EST. BLDG. COST add it EST. BLDG. COST PER SQ. FT. EST. BLDG. 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