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HomeMy WebLinkAboutMiscellaneous - 87 ADAMS AVENUE 4/30/2018am N° 9664 Date I I n I. &. )' TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING AC04US� This certifies that ....�.. 14 has permission to perform S 1 L.(,..".....` "l.:.`% 1 `�,n ? '-J. !' ., . plumbing ,i/ny the buildings of ...Mi. it\t, . - ........... . a,*,�.. �(��!A MS� .. r14. .... ........ , North A dover, M s. Fee .. `� lO... Lic. No.. NOI. r .... . �.. 3 ^ PLUMBING INSPEC Check # � 11�� WHITE: Applicant CANARY: Building Dept. PINK: Treasurer 9 11\ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK POWNER TYPE OR PRINT CLEARLY CITY North Andover MA DATE Nov 13, 2012 PERMIT# JOBSITE ADDRESS Adams Ave OWNER'S NAME Belford Construction ADDRESS 130 Marbleridge Rd, North Andover MA TEL 508-509-9430 FAX OCCUPANCY TYPE COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL X❑ NEW:® RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES ❑ NO ❑ FIXTURES Z FLOOR— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB 1 CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR /AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK 1 LAVATORY 1 3 ROOF DRAIN SHOWER STALL 1 SERVICE / MOP SINK TOILET 1 2 URINAL WASHING MACHINE CONNECTION 1 WATER HEATER ALL TYPES 1 WATER PIPING 1 OTHER Sillcock 2 INSURANCE COVERAGE: I have a current IiabilltY insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YESE] No ❑ IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ® OTHER TYPE OF INDEMNITY ❑ BOND ❑ L OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are a and ra to the bef of my knowledge and that all plumbing work and installations performed under the permit issued for this application will b ian h Perlin p vision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME Robert J. Frazier LICENSE # 13425 IGNATU MP ® JP ❑ CORPORATION ❑ # PARTNERSHIP ❑ # LLC ❑ # COMPANY NAME Bomar Plumbing & Heating ADDRESS PO Box 694 CITY Derry STATE NH ZIP 03038 TEL 603-325-8958 FAX CELL EMAIL Bob@BomarPH.com 11\ n r r n ,7-1 V: 6i �. • si W W rl 0 N co 0 1. U W= 00 I. -.J O M U) LL� M to W z o LL C7 rj) W _ O O� o w Z o Qm F -A • Qw N o WQ J)LL �' w ' -m W � 7,. 'Z tt1 0 Intl? g =1Z ~ x M O �V m .rte Lu Cr q L- '---- - Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ 33210'00.00 m $ - $ 3,984.00 Plumbing Fee $ 498.00 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 498.00 Total fees collected $ 5,080.00 87 Adams AVENUE 231-13 ON 9/11/12 New SF This certifies th---�.�.. �' * S �'�)'�. k.1 , ............. . has permission to perform .. V Q ............ . . . wiring in the building of .. l�.Cf .. � *�< . . at .......... ../4.�1 rt'I �' ... North Andover, Mass. Fee. V... Lic. No.. CPk.5 PI'..... .. .. ELECTRICAL INSPECT Check # a� 11244 l . ", t 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 PRINTWINK OR TYPEALL MFORW TIOA9 City or Town of. NORTH ANDOVER By this application the undersigned gives notice of his or her int( Location (Street & Number) t� % /¢QA^5 Owner or Tenant Owner's Address Date: To the Inspector o, f Wires: perform the electrical work described below. L A! Telephone No.'PSos -j o 9 ' )t D6-2 12q,?0 Is this permit in conjunction with a building ermit? Yes 9 No [I(Check Appropriate Box) Purpose of Building 5 r N(s 0- !/-/ DW 6LGo-0 Utility Authorization No. ,' 7 Existing Service Amps / Volts New Service c� 00 Amps 1AQ / d U Volts Number of Feeders and Ampacity Overhead ❑dgrd ❑ No. of Meters OverheadVuun,,dgrd El No. of Meters Location and Nature of Proposed Electrical Work: :::T kiT4-u W, A A,6 � Alcw ✓� fi Completion of the following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Cell: Susp. (Paddle) Fans Total Trsformers KVA Trans No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- ❑ rnd. rnd. o. o melts Lighting Batter Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges g No. of Air Cond. Total Tons No. of Alerting Devices g No. of Waste Disposers p HeatPump Totals: Number Tons ......................., KW ..............._._... No. of Self -Contained Detection/Alerting Devices No. of Dishwashers S ace/Area Heating KW p g Local ❑ Municipal El Other Connection No. of Dryers Heating Appliances Kyr Security Systems:* No. of Devices or Equivalent No. of Water ION Heaters No. of No. of Signs Ballasts Data Wiring: No. of Devices or Eg uivalent 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 Flues. 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 in -ante including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such cov 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 erjury, that the information on this application is true anti complete. FIRM NAME:. o �� LIC. NO.: L.11 Licensee:QTOQ J(M p,) Signature LIC. NO.: ? U� (If applicable, enter "exempt" in the licens��jjnumber line.) Bus. Tel. No.: Address: L A 10LLd ;2 �A-n AJJ Alt. Tel. No. • �r7 1- *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 agent. Owner/Agent PERMIT FEE: $ Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the a 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, § K. 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 0 Failed ❑' Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass Failed Re- Inspection Required ($.) ❑ . Inspectors Comments:44 7 Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass 0 Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROU !J INSPECTION: Pass • Failed M Re- Inspection Required ($.) ❑ Inspectors Comments: Intpectors Signature: Date: FINAL INSPECTION: Pass Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: I Date: DEB WEINHOLD ...TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com t The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations 600 Washington Street Boston, MA 02111 Ut. www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Address: Y W C)t; L, J�� 2 (1 vd i City/State/Zip: VV Dau&J . � Phone #: S 'J5U7 Are you employer? Check the appropriate box: m a employer with 1. ❑V%mpla 4. El am a general contractor and I oyees (full and/or part-time).* have hired the sub -contractors 2. sole proprietor or partner- listed on the attached sheet. # ship and have no employees These sub -contractors have 4�orking for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] i employees. [No workers' comp. insurance required,] Type ofA!rroject (required): 6.New construction 7. Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other Sny applicant that checks box #I must also fill out the section below showing their workers' compensation policy information. Homeowners who submit this affidavit indicating they are 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. am an employer that isproviding workers' compensation insurance for my employees. Below is thepolicy and job site :formation. isurance Company N olicy # or Relf--ins. Lic. #: Expiration Date: )b Site Address: City/State/Zip: ttach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ne 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 up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Lvestigations of the DIA for insurance coverage verification. do hereby cert fy u ler the pain,>rf,4nd peg9*iej of perjury that the information provided above is true gnd correct. a.�it .� Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit[License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone 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, 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 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 -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, 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 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 permitilicense 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: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. 4 617-7274900 ext 406 or 1-877-MASSAFE evised 5-26-05 Fax 4 617-7277749 www.mass.gov/dia 173 Date.- 4!?.:. /,�- ..... . NpR*M TOWN OF NORTH ANDOVER pF ,.to ,c1ti0 pp PERMIT FOR MECHANICAL INSTALLATION ��SSACMUSE� This certifies that ............. . has permission for mechanical installation in the buildings of . �!L !� . � Q . . . . . . . . . .4. . . . . . . . . at .. A W4l?4.. ?Y { -r ......... North Andover,, Mass. Fee./pl-61.-:�' Lic. No... �' . .................... GASINSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer Commonwealth of 'Massachusetts Sheet Metal Permit Date: / f3 / 2, �', �—Permit 4 � SFJ Estimated job Cost. e Perm;t Fee: $ Pians Submitted: YES NO Plans Reviewer;: YES v0 Business License ;i �.pclicant License r Business Information: CiPS:toreeert:n Oxner ,` Job Lcc�ts ur. ncrmatton: Name: n'4,—/GQl_ Name: Agrl'� R.Qe Streei: IG LC/a� �j!;cwr: l�C'%���/t �� /Ll GI CityiTown. /1',1}/lC-1-0(1 C' Teiephore: !? 70- Y 33 SG i/ Tc�epr.ane: Yak soct O(iw Photoi.D. required r Copy oCPho:o LE. attazhed: YEa l/ NO Staff initial J-� �' -.:nresiricted lice J-2 l M -2 -restricted to ciwcilings 3-stcries or :css and cornme"cial up to 10,o07 sc. ! 2-stc74e3 er less Residential: t-? f=,.Iiy _X- Muiti-fa„ nily Condo ! To'xnhouses Other Commercial: Office Rctaii — Indus tial Ejucatienal InsdInitioral Cthcr Square Footage: ur.dc: 10,000 ;c. ft. LI -1- a,er 10.900 sq. It. Number of $torics: Shtet metal work to be completed: Nlcw'd crk: HVAC Metal Watershed Roofing K:tcl;en Exhaust 5vsiem Metal Chi: -nor !Veit: _ Air Balancing -rovide detailed description of :vert to to done: i INSURANCE COVERAGE: I 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 type of coverage by checdng the appropriate box below. IL-Q LiabilitV Insurance Policy ❑ Othertype 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 Genera Laws, and that my signature on this permit application waives this requirement �ZL"l Signature of Owner or Owners 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 sheet metal work and installation performed under this 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. Duct inspection required prior to insulation installation: Yes No Progress Inspections — Date Comments Date By: _ Title: Permit # Fee S: _ Inspector Signature of Permit Approval Final Inspection Comments Type of License Master ❑ Master -Restricted ❑ Journevoerson ❑ Joume erson -restricted 4 Signature of Licensee License #: SHEET METAL PERMIT (14.19.11 '°` "CERTIFICATE -OF LIABILITY INSURANCE 0AT(MMIODI CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, 03// 26/201212 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 POUCIES 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(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terns and conditions of the policy, certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: NORTH ANDOVER INSURANCE AGENCY, INC. M.J. FOSTER INSURANCE SERVICES 163 MAIN STREET AICD,NE%. ); (978) 686-2266 iac, No): (978) 686-6410 DRESS: c£ernandez@na£ins.com PRODUCER CUSTOM_E_R ID wrpp• A Mechanical, Inc. ' NORTH ANDOVER MA 0184.5-2508 INSURER(S)AFFORDING COVERAGEINSURE A GENERAL UABIUTY Y R.A .A Mechanical, Inc. — - IaE INSURER A :PEERSS INSURANCE CO ---- - — INSURER 8 :GUARD INSURANCE 16 Lomar Park Suite 1 INSURER C + PREMISES (Ea accuyence) _ S INSURER 0 INSURER E Pepperell MA 01463— INSURER F �UVCT Uca GYKIIFIL01!- NIImmI w- 01 11/ lnu ul IRAn CO. 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. ILTR TYPE OF INSURANCE INSR V"O POLICY NUMBER POLICT EFF(POCK? EJCP IMMIOOM(YY) i (MMIOOIYYYY) LIMITS A GENERAL UABIUTY Y CBP5337500 01/01/2012 01/01/2013 EACH OCCURRENCE S 1,000,000 X ; COMMERCIAL GENERAL LIABILITY - OAMM E O RENTED PREMISES (Ea accuyence) _ S 100,000 • CLAIMS -MADE X OCCUR MED EXP (Any one person) S 15,000 PERSONAL d ADV INJURY_ : S 1,000,000 GENERAL AGGREGATE S 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: -I / / / / PRODUCTS - COMP/OP AGG - S 2,000,000 X POLICY JECI PRO- LOC / / / / EBL1A--..---- A AUTOMOBILE UABIUTY BA8832363 01/01/2012 01/01/2013 COMBINED SINGLE LIMIT S 1,000,000 ANY AUTO (Ea acCldeml_- BODILY INJURY (Per person) S I ALL OWNED AUTOS / / / / — --- X BOOILYINJURY (Peracudenry S SCHEDULED AUTOS --- X / / / / PROPERTY DAMAGE S HIRED AUTOS (Per acadenl) X . NON -OWNED AUTOS--------g-------- A X UMBRELLA LIAB X OCCUR .— CUSS25678 01/01/2012 01/01/2013 EACH OCCURRENCE S 1,000,000 EXCESS Lue ! ----CLAIMS-MADE; -- / / / / AGGREGATE S 1,000,000 . 'DEDUCTIBLE / / / / `--- g--- RETENTION S / / / / S 13 WORNERs COMPENSATION RAWC231923 01/01/2012 01/01/2013 WC STATU- OTH- AND EMPLOYERS' UABIUTY YIN TQ RYLIMIT$__E$_____-_.__ ANY PROPRIETOR/PARTNERIEXECUTIVE / / / / E.L. EACH ACCIDENT S 5()0,00 0 OFFICERIMEMBER EXCLUDED? NIA i (Mandatory In NHI / / / / — E.L. DISEASE - EA EMPLOYEE S - 500 000 Ifyes, describe under / / / / - - DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT S 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES (Amon ACORO tat, Add Uional R—ka Sche 16. N mon sp— is mquir i) r "r -M1111731 -Air- MULLJr-K GANU1:LLA I IUN SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. R.A. MECHANCLAL, INC. 16 LOMAR PARK AUTHORUID REPRESENTATIVE SUITE 1 .•" PEPPERELL MA 01463- ACORD 25 (2009109) © 1988-2009 ACORD CORPORATION. All rights reserved INS025 (2ooeos) The ACORD name and logo are registered marks of ACORD SS=ACHUSETT'S' IDRIVER'S a = 1 — LICENSE s. OF to _ . - 9a 916 --'4E 1NIIIBEk -IT soc TTE. 4 e 657 MAMMOTH RIO - a DRACU7, MA 01826.1349 '+•"— — Spp 09.03•2o10 Rev 0T•1SM09 I !i c vv4✓� �.�j� COMMONWEALTH OF MASSACHUSETTS >= A AS A MASTER -UNRESTRICTED ISSUES THE ABOVE LICENSE TO: DONALD i 31JELLETTE �c 657 MAMMOTH RD �N DRACUT MA 01826-4349 4688 07!28/14 223139 v 0 ._ . 7 S f r -S a O 7'— ol The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Ann icant Information /, Please Print Legibly Name (Business/Organi=iofAndividual):' �R A. M ee_ha n l o&& T6c,- _ Address:„ kotne2 I�acl< Ci Phone #: Are you an employer? Check the appropriate box: 4. I am a general contractor and I 1. F I am a employer with ❑ 2. ❑ 3. ❑ employees (full and/or part-time).* have hired the sub -contractors I ilisted on the attached sheet. am a so a propnetor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] I am a homeowner doing all work myself. [No workers' comp. insurance required.] t These sub -contractors have employees and have workers' comp. insurance.* 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, §1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. 7_New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other Any applicant that checks box #I must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: 6on-ci _X7/) Policy # or Self -ins. Lic. #:1n /)C ,3 �'/6a4 % Expiration Date: Job Site Address: �? 7 �.�vL 61� City/State/Zip: e)?, aA� r Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certiJ fy_un er the paigs �nd penr#Ities o.tperjury that the information provided above is true and coned 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. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: LAWRENCE H. OGDEN, P.E. 198 EAST MAIN STREET GE.ORGFT W. N., MA 01.833 978-352-8318 fax 978 352-2858 cell: 978-502-5921 November 12, 2012 Mr..Mark. Rae Belford Construction 130 Marbleridge Rd.. North Andover, Ma 01845 RF-: Lotsl &24Adams°Ave. North Andover, Ma. 01845 Dear Mr.Rae As you requested I visited the site 11/12/12 to review the installation of the Engineered Materials consisting of LVLs utilized in the framing of the above project. T.hese.are sho-wn.on.plans slated 9/5/12 with 1heSraming sheetscertified.by.s -me 9/5/.1.2. Based on the above site visit and based on what I could visibly see. I can certify that to the best of my knowledge the LVLs members utilized in the framing as shown on the drawings are installed properly and meet the loading conditions of the 8th Edition of the. Massachusetts State Building Code for 1 &2 Family Residences, provided the following work is completed 1.0 Insure that the 3-16d nails (gun nails) from the plate to rim between the studs at the braced walls as shown on sheet 7 are installed. 2.0 Add additional nailing of sheathing to the studs and header at the garage doors as shown on sheet 6.. All other framing requirements of the drawings and code, including but not limited to materials, nailing schedules, blocking, connections, manufacturers installation requirements and other details are the responsibility of the licensed construction supervisor responsible for the project. Should you have any questions please do not hesitate to call. Yours truly, Lawrence �Hogden P.E. Structural 27765 OF M,�,'r9 cy oz LAWRENCE c � our H 11�1�1�1 .p I� 65 �0 �lk- FSS�ONAL iN 14 LAWRENCE H. OGDEN, F.E. 198 EAST MAIN STREET .GEO.R.GETOWN, MA X833 978-352-8318 fax 978 -352-2858 cell: 978-502-5921 November i2, 2012 Mr..Mark Rae Belford Construction 130 Marbleridge Rd.. North Andover, Ma 01845 RE: Lots 2 & 24 Adams Ave. North Andover, Ma. 01845 Dear Mr.Rae As you requested I visited the site 11/12/12 to review the installation of the Engineered Materials consisting of LVLs utilized in the framing of the above project. These -are shown-on.plans dated 9151.-12 with the.framing sheets.certified.by.rne 915/1-2. Based on the above site visit and based on what I could visibly see. I can certify that to the best of my knowledge the LVLs members utilized in the framing as shown on the drawings are installed properly and meet the loading conditions of the 8th Edition of the Massachusetts .State Building Code for 1 &2 Family Residences, provided .the following work is completed 1.0 Insure that the 3-16d nails (gun nails) from the plate to rim between the studs at the braced walls as shown on sheet 7 are installed. 2.0 Add additional nailing of sheathing to the studs and header at the garage doors as shown on sheet 6.. All other framing requirements of the drawings and code, including but not limited to materials, nailing schedules, blocking, connections, manufacturers installation requirements and other details are the responsibility of the licensed construction supervisor responsible for the project. Should you have any questions please do not hesitate to call. Yours truly, d+�."-- wrenceH. Ogden P.E. Structural 27765 Of Sqc� � y aJA OtD y vG ?Ii�l STEL ���• �FSSlOnlAl EAG .s LAWRENCE H. OGDEN, P.E. 198 EAST MAIN STREET .GEORGETOWN,1 .(11.833 978-352-8318 fax 978 —352-2858 cell: 978-502-5921 November 12, 2012 M.r..Mark Rae Belford Construction 130 Marbleridge Rd.. North Andover, Ma 01845 RE: Lots 2 & 24 Adams Ave. North Andover, Ma. 01845 Dear Mr.Rae As you requested I visited the site 11/12/12 to review the installation of the Engineered Materials consisting of LVLs utilized in the framing of the above project. Th.ese.are shown.on.plans .dated 915/.12 with.the.framing sheets.certified.by,me 9!5/12. Based on the above site visit and based on what I could visibly see. I can certify that to the best of my knowledge the LVLs members utilized in the framing as shown on the drawings are installed properly and meet the loading conditions of the 8th Edition of the Massachusetts State Building Code for 1 &2 Family Residences, }provided the following work is completed 1.0 Insure that the 3-16d nails (gun nails) from the plate to rim between the studs at the braced walls as shown on sheet 7 are installed. 2.0 Add additional nailing of sheathing to the studs and header at the garage doors as shown on sheet 6.. All other framing requirements of the drawings and code, including but not limited to materials, nailing schedules, blocking, connections, manufacturers installation requirements and other details are the responsibility of the licensed construction supervisor responsible for the project. Should you have any questions please do not hesitate to call. Yours truly, (Vtnce H. Ogden P.E. Structural 27765 NA OF At � y �Kooto C> .� 6s �a DOFF ST�¢G`��. 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