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Miscellaneous - 89 OLD VILLAGE LANE 4/30/2018
6/15/2016 20591 This is an e -permit. To learn more, scan this barcode or visit northandoverma.viewpointcloud.com/#/records/20591 OF p10 R T/I 4ti o m }. 10 -.-9 e ��SSACHUS�� TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that George Salsman has permission to perform PLUMBING DRAINS AND WATER PIPES plumbing in the buildings of DAVID L. PHILLIPS LIVING TRUST at 89 OLD VILLAGE LANE, North Andover, Mass. Lic. No. 31636 Date: June 15, 2016 ❑ ❑ ❑ a P� 6/15/2016 20592 This is an e -permit. To learn more, scan this barcode or visit northandoverma.viewpointcloud.com/#/records/20592 OF ptORTH 4ti S�= OCG O ..p 5 LSS'CHUs�fi TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that George Salsman has permission for gas installation GAS PIPE DRYER in the buildings of DAVID L. PHILLIPS LIVING TRUST at 89 OLD VILLAGE LANE,, North Andover, Mass. Lic. No. 31636 Date: June 15, 2016 a o C L h �s:/r'nortliarldov�ma vlewpoinlzioud com%Y,,rec xdi/"-.L591 R 7 u o i:i Povs pHevawt Town of North Andover.. MA 4 20591 -Plumbing Permit - In Conjunction with a Building Permit (Commercial or Residential) i TIMELINE Submissign received jun 14, 2016 ac 9:1 Eam mPlumbing Permit Review In Progress ® pe—ir r^r yre PEn-litItSUa— Your request is in progress We'll let you know of any updates via email. Feel free to check the status at any time by coming brkm this page. 17 x p RcMe Sad to \\axaylWMOE'/_flfCOH '� ESC .S�Pllcar, i Lusa=;,n GEORGE SALSMAN 189 OLD VILLAGE LANE, NORTH AN DOVER, MA DAVID L PHILLIPS LIVING TRUST Attachments V-0TYPY.61Doi F Tuejun i4 20l s_13:27:.PDF .. Primary Contractor Search for your contractor using the search bar below. Either the Firm's Name or licensee 8 is required. Fircn's ('sllsinessi Hame c!um6^r s Na-=1L�cersee)'- 12- - 2-o i CD 4 1 e- -4 Tuesday, Jun 14, 2016 09:27 AM V ®A +� H V W tb du. 6i11n016a _d f -? C' Uh!:os:/,rrlorthandovErma.Newp...... oud.comjirfrcca��,�u..9� :::AGO% pNeWart 1w Town of North Andover, MA Q--------------------- - 20592 'Gas Permit - In conjunction with a Building Permit (Commercial or Residential) TIMELINE 0 Submisslon received Your request is in progress Jun 14, 2015 arv:zeam we'll le: you know of any updates via email. Feel free m check the status at arty time by coming back to this page. 0 Gas Permit Review in Progress , , 0 P . ryeCn„ r{; �—. 4 iq PPYmiC is Sn3li:"e d9 A^pilcan: GEORGE SALSMAN : 89 OLD VILLAGE LANE, NORTH ANDOVER, MA DAVID L PHILLIPS WING TRUST Attachments �,roa� Hn :_............... . -OTL-D41001F TueJun 14--701 G_13:30:.PDF Primary Contractor Search for your contractor using the search bar belmv. Either the Fiom-s Name or licensee 3 is required. v'c 3 !amt F Fm _rt p j. 170 (D a "L Tuesday, Jun 14, 2016 09:30 AM Workers' Compensation Insurance Affidavit: Buffders/Contractors/Electricians/Plumbers. TO BE ]FILED WITH THE PERMITTING AUTHORITY. Name (Business/Organization&dividual): Address: City/State/ZipS(� c �� Q Lei 0 Phone #: Are yon an employer? Check the appropriate box: 1. ❑ I am a employer with .:.. ! employees (fall and/or part-time).* 2. �am a sole proprietor or partnership and have no employees working for me in any capacity. No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself [No workers' comp. insurance required.] t 4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5. ❑ lam a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. instuance.r 6. ❑ We are a corporation and ifs offlce.rs 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): 7. E] New construction 8. E4R-efnodelirig 9. ❑ Demolition 10 ❑ Building addition I L E] Electrical repairs or additions 12-.E] Plumbing repairs or additions 13.E] Roof repairs 14. EJ Other *Any applicant that checks b6x#1 must also fid 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 a new affidavit indicating such. (Contractors that check this box must•atiached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub-c6f&actors fiave employees, tliey must provide their workers' comp..policy number. Iain an employer that is providing worker's` compensation insurance for my employees.' .Below is the policy andyob site information. Insurance Company Name:(p-Q�c,) Policy # or Self -ins, Lic. #:��� ) C Q 6Q�-� Expiration Date: fob Site Address: '��- V City/State/Zip: 46 FJIOC Attach a copy of the workers' compensatio olicy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of Investigations of the DTA for insurance coverage verification. I do hereby certify7wder tlycRains and penalties of peiyury that the information provided above is true and correct. -/Y�--10 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 #: The Commonwealth of Massgehusetts Department of IndustrialAccUenis 1 Congress Street, Suite 100 F Boston, MAOZX24 2017 www rnass.gov/dia Workers' Compensation Insurance Affidavit: Buffders/Contractors/Electricians/Plumbers. TO BE ]FILED WITH THE PERMITTING AUTHORITY. Name (Business/Organization&dividual): Address: City/State/ZipS(� c �� Q Lei 0 Phone #: Are yon an employer? Check the appropriate box: 1. ❑ I am a employer with .:.. ! employees (fall and/or part-time).* 2. �am a sole proprietor or partnership and have no employees working for me in any capacity. No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself [No workers' comp. insurance required.] t 4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5. ❑ lam a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. instuance.r 6. ❑ We are a corporation and ifs offlce.rs 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): 7. E] New construction 8. E4R-efnodelirig 9. ❑ Demolition 10 ❑ Building addition I L E] Electrical repairs or additions 12-.E] Plumbing repairs or additions 13.E] Roof repairs 14. EJ Other *Any applicant that checks b6x#1 must also fid 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 a new affidavit indicating such. (Contractors that check this box must•atiached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub-c6f&actors fiave employees, tliey must provide their workers' comp..policy number. Iain an employer that is providing worker's` compensation insurance for my employees.' .Below is the policy andyob site information. Insurance Company Name:(p-Q�c,) Policy # or Self -ins, Lic. #:��� ) C Q 6Q�-� Expiration Date: fob Site Address: '��- V City/State/Zip: 46 FJIOC Attach a copy of the workers' compensatio olicy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of Investigations of the DTA for insurance coverage verification. I do hereby certify7wder tlycRains and penalties of peiyury that the information provided above is true and correct. -/Y�--10 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 #: ;,.: �r �� �� •� �:e� �,in .0 � ;, � q f �� � ��� of Massachusetts General Laws ci x 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 contrdat of lure, 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 enferprise, 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 lias 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 checking1heboxes that apply to your situation and, if necessary, supply sub =contractoi(s) name(s), address(es) and -phone numbers) along with their certificates) 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 Depattment 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 yo'u'are required to obtain a workers' compensatioA. olicy, please call the Department at the number listed below. Self-iirsured companies sliould'entertheir self-insurance 1'oer'se 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 (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 proofthat 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 Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 021.14-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-7277749 Revised 02-23-15 www.mass.gov/dia I '10123 Date ....3 .. . ... 4/ .. . ... ... ...... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ..... e. 4� . .......... C. e— .... .. ............ ..... .............. has permission to perform ..... I ....................... ( ............. wiring in the building / of ..... ......... R/`/-.,.//, .............................. at ......... North Andover, ass./ Fee .....3.S......... Li— ....... ..... xli�� ��CT;R�IcA�L�INSPECT Check # Official Use Only Commonwealth of Massachusetts ERIN Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS ev.1/07] leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (M1E ), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: a -?hy /( City or Town of: NORTH ANDOVER To theIn pector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) 4(E 2 Q//) I", L ( A Ze C -,� C Owner or Tenant VAi h -c ce PA, t' W Telephone No.;�:/-. 7 ec,' ZcI3c� Owner's Address 4` Is this permit in conjuncttiir with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building /< ES , G?.e-t-e- E' Utility Authorization No. Existing Service 2au Amps Mia I Volts New Service Amps / Volts Number of Feeders and Ampacity v Location and Nature of Proposed Electrical Work: Overhead'— Undgrd ❑ No. of Meters Overhead ❑ Undgrd ❑ No. of Meters 2-e> c.> i�T/�}-•� �.-truce Completion of the following table may be waived by the Inspector of Wires. No. of Recessed Luminaires 5 No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators K -VA No. of Luminaires Swimming Pool Above ❑In- Elo. rnd. rnd. o Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of SwitchesNo. 3 of Gas Burners No. of Detection and Initiating Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: Number Tons KW No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ElMunicipal El Other Connection No. of Dryers Heating Appliances 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 ifdesn or as required by the Inspector of Wires. Estimated Value of Electrical� Work: t25 (When required by municipal policy.) Work to Start: 2-e-11 Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify, under the aims and penalties of perjury, that the information on this application is true and complete. FIRM NAME: 14"dve" LIC. NO.:Z15-0 777 Licensee: i1 �� /� r�C ✓Signatur LIC. No.,-,-Yo777 (If applicabl , enter "e gm t" in the lice a umb r lin �y Bus. Tel. No.• %%/- .) Address: J 7 J/'zy« � Ufa �` Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No, ,e'SZ}%7 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. $ 3 i U/ i 6,- -// f)t 4 WOR AND INSURANCE POLICY Ncci Code: 39071 1. Insured: Andrew C. Campagna Jr Technology Insurance Company A Stock Insurance Company 20 Trafalgar Square, Suite 459 Nashua, NH 03063 37 Spruce Road North Reading MA 01864 Other workplaces not shown above: See Extension of Information Page Producer: AmTrust North America, Inc. c/o Cowan Insurance Agency, Inc. 359 Main Street Haverhill MA 01830 Policy Number: WC 99 00 01 B 1 of 4 INFORMATION PAGE TWC3248830 X Individual Partnership _ Corporation or Federal Tax ID: 028547554 Risk Id: Renewal of: New 2. The policy period is from 7/10/2010 to 7/10/2011 12:01 a.m. at the insured's mailing address. 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: Massachusetts B. Employers Liability Insurance: Part Two of the policy applies to work in each stated listed in item 3.A. The limits of our liability under Part Two are: - State Bodily Injury by Accident Bodily Injury by Disease Bodily Injury by Disease MA $ 100,000 each accident $ 500,000 policy limit $ 100,000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: All states except ND, OH, WA, WY and State(s) Designated in Item 3A. D. This policy includes these endorsements and schedules: WC 00 00 00 A, WC 99 00 01 B, WC 00 01 13A, WC 00 0414, WC 20 0101, WC 20 03 01, WC 20 03 02, WC 20 03 03C, WC 20 04 01, WC 20 04 03, WC 20,04 05, WC 20 06 01A, WC 20 06 04 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. See Extension of Information Page TOTAL ESTIMATED ANNUAL PREMIUM STATE ASSESSMENT TOTAL ESTIMATED COST Minimum Premium Deposit Premium Issue Date: 7/12/2010 n / r.. Countersigned by: thorized Representative 1,707 98 1,805 449 245 S17 . 2� 0 I-rz- 4-11� iEn Companies CASUALTY COMPANY Gj1p N E R A L L I A B I L I T Y D E C L A R A T I O N S *- ----------------- ------* POLICY !,ER�OD: FROM 04/14/11 TO 04/14/12 * POLICY NUMBER * 4 D 5- 2 1- 9 8---12 *------------------------* N A M E D I N S U R E D: P R O D U C E R: - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - ANDREW C. CAMPAGNA JR. COWAN INSURANCE AGENCY, INC. 37 SPRUCE RD 359 MAIN ST NORTH READING MA 01864-1730 HAVERHILL MA -01830-4028 AGENT: AG 6807 DIRECT BILL AGENT PHONE: 978-372-1451 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - INSURED IS: INDIVIDUAL - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - LIMITSS OF INS U R A N C E EACH OCCURRENCE LIMIT $ 1,000,000 DAMAGE TO PREMISES RENTED TO YOU LIMIT $ 100,000 ANY ONE PREMISES MEDICAL EXPENSE LIMIT $ 5,000 ANY ONE PERSON PERSONAL AND ADVERTISING INJURY LIMIT $ 1,000,000 ANY ONE PERSON OR ORGANIZATION GENERAL AGGREGATE LIMIT $ 2,000,000 PRODUCTS/COMPLETED OPERATIONS AGGREGATE LIMIT $ 2,000,000 ------------------------------------------------------------------------------ C O V E R A G E S P R O V I D E D P R E M I U M ---------------------------------- ------------- OTHER THAN PRODUCTS/COMPLETED OPERATIONS $ 701.00 -------------------------------------------------- TOTAL ESTIMATED POLICY PREMIUM $ 701.00 -------------------------------------------------- ------------------------------------------------------------------------------ SEE ATTACHED SCHEDULE FOR LOCATION OF ALL PREMISES OWNED, RENTED OR OCCUPIED. --------------------------------.------------------------------------------- --- FORMS APPLICABLE: CG0001(12/07)*, CG0068(05/09)*, CG0300(01/96)*, CG2147(12/07)*, CG2151(09/89)*, CG2167(12/04)*, CG2170(01/08)*, CG2176(01/08)*, CG7001A(04/10)*, CG7003(10/08)*, CG7191(01/06)*, CG7584(10/08)*, IL0021(09/08)*, IL7028(10/05)*, IL7131A(04/01)*, IL7609(01/99)*, IL8383.2(01/08)*, IL8384A(01/08)*, IL8576(09/09)* AUDIT PERIOD: ANNUAL DATE OF ISSUE: 04/22/11 BPP FORM CG7000A ED. 08-99 BPP 04/22/11 040 PB 4D52198 1201 Date ..71f / TOWN OF NORTH ANDOVER PERMIT FOR WIRING 1119x-e.6.^j 1, SThis certifies that ... ......................�i. � 'J ........................................................................................ has permission to perform (���c-� ,,.(` Vl ..... `#.....��. " W ° j� wiring in the building of ......... ....+!..5 at .�...d.......... ........ ......... y. .......... /e a. ..................... . N h Andover Mass. ... ...... ...�,�-........ ... U Fee... 6 - Lic. No. 1377 ELECTRICAL INSPECTOR Check # J V N Commonwealth of Massachusetts Official Use Only Permit No. l m Department of Fire Services Occupancy and Fee Checked a BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071(leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code C , 527 CMR 12.00 (PLEASE PRINT IN) K OR TYPE ALL INFORMATION) Date: l y City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of leis or her intention to perform the electrical work described below. Location (Street & Number) Owner or Tenant Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. - Existing Service IP -A Amps I / Z LIP Volts Overhead ❑ Undgrd �y No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: GS] Completion ofthe following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs - Generators KVA No. of Luminaires Swimming Pool Above ❑ In- Elo. rnd. rnd. o mergency Lighting Battery Units No. of Receptacle Outlets I No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiatin Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Totals: I Number Tons ............ J.KW.......... of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances 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:, j vZ Q- 9 Attach additional detail if desired, or as required by the Inspector of 'res. Estimated Value of le trical Work: 10-2NAttach required by municipal policy.) Work to Start: 1 - 1 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 su coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSLTRANCE,X BOND ❑ OTHER ❑ (Specify:) I certify, cinder the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAE. • LIC. NO.: Licensee: /per C S Signature LTC. NO.: '&'� 6 (If applicable, enter "exempt"int a license mber,line.) Bus. Tel. No.: Address: ev►d tlq,vy\ fJ d 30 Alt. Tel. No.:`13a ZZ i 3 *Per M.G.L c.' 147, 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: $ o —� 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 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 N Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass Failed Re- Inspection Required ($.) ❑ Inspectors Com nts: Z_ --f Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass IN Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: PassXN Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comm IT N ^/ 6 Inspectors Signature: Date: FINAL INSPECTION: Pass Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: UAl 1.1 JA v V Inspectors Signature:&ij --�� —14)Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com Fes. The Commonwealth of Massachusetts Department of IndustrlqlAccidints Office of Investigations 600 Washington Street Boston, MA 02111 qV www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leyjbly Name (Business/Organization/Individual): Af 33r, S�&Ov� i 3 Address:ttI -73 City/State/Zip: ► J �`c 03an Phone #: �j0` "` 30 ^ Z& Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 4. F1 am a general contractor and I 6. New construction ` ❑ employees (fall and/or part-time). * 2.1514am a sole proprietor or partner- have ]tired the sub -contractors listed on the attached sheet. T 7• ❑Remodeling ship and'have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity, workers' comp. insurance. 5. ❑ We are a corporation and its 9. ❑ Building addition [No workers' comp. insurance required.] officers have exercised their 10. ❑ Electrical repairs or additions 3. ❑ I am a homeowner doing all work right of exemption per MGL 11. El Plumbing repairs or additions myself. [No workers' comp. c. 152, § 1(4), and we have no 12. ❑ Roof repairs insurance required.] t 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 afire 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 is providing workers' compensation insurance for my employees. Below is the policy and job site information. 6)_W_C,4, Insurance Company Name:. PP&u s ce ,b Policy # or Self -ins. Lic. #: j Expiration Date: Job Site Address: old �%) ��1('� Pity/State/Zip:Vi 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. Ido hereby cert under thepains anIties ofperjury that the information provided above is true and correct. Phone#: �eQ 3 � 30 — 2S73 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 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 not required 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 conf rmation 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 (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. Anew 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: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Stxeet Boston, SIA, 02111 TO, # 617-727-4900 oyt 406 or 1-577,7MSSAFB Revised 5-26-05 Fax # 617-727-7749 wwtv.mass,gov1dia 40 106314'. Date ... A Al ........ TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifiesthat ...............�.............. has permission to perform ...r�rR rv- cC C) ek ........................................................... plumbing in the buildings of...... '.`.t!1.0......................................................... at ... .... {. ..... �........... -!...!.................... North Andover, Mass. Fee'...+...... Lic. No. bhp. .1M:!!. ............................................................ PLUMBING INSPECTOR Check # 3� P 4- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY N )-P/ �1 MA DATE 7 ^ l L ! ct (� RMI, # JOBSITE ADDRESS OWNER'S NAME POWNER ADDRESS TEL r—FAX_ TYPE OR OCCUPANCY TYPE COMMERCIAL ® EDUCATIONAL ® RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: ® REPLACEMENT: Q PLANS SUBMITTED: YESE] NO Ell FIXTURES -4 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 GASIOILISAND SYSTEM DEDICATED GREASE SYSTEM _..__ j _— [ _� ► (.._ ._..� ._._.._� f -__.__._.__[ € [ DEDICATED GRAY WATER SYSTEM I===== DEDICATED WATER RECYCLE SYSTEM ! j .-_._._._[ 4 � _..___.? [ ( DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREADRAININTERCEPTOR (INTERIOR) [ J _.�._f _--_. _-_ ( I _..... KITCHEN SINK —I [ _ J _-__l I----- _-j --._.._.[ --__I ----i ..__.__I ___-i LAVATORY ---[ -__J .- i ------ I 173 .--[ -- ROOF DRAIN SHOWER STALL SERVICE / MOP SINK I I [ _.._.__f __..— _____1 ___..1 ___.._.� __► i __� ..Tf .._. _ P _..____I [ TOILET URINAL _ I I WASHING MACHINE CONNECTION f I _. _--_f _ I ____._I VATER HEATER ALL TYPES I t I i t 1 WATER PIPING _ ( _t f t — (' ._ [ -�- .I _--_--__! _I _.f -- Ol'HER _____ __ ___ _ ______I ( _i 1 ._._...._.f _.__-- E —[ I __-.-_-[ _....__--_► ..._._____I INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YESBANO Ell It YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Lill," OTHER TYPE OF INDEMNITY © BOND Q 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 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 compli a with all P e provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME C _ LICENSE # SIGNATURE IIP �]I JP CORPORATION FJ#PARTNERSHIP 0# y_T_ ; LLC( COMPANY NAME S $h��/1y Mb�` i ADDRESS & fi (41ES CITY 1. Jf� -- - - I STATE _I ZIP I C� ��6 k3 �6 TEL FAX CELL EMAIL �� �-�J ----- __...--------------------__._ .._.._- ----- _...__._._.-..—...--------- _ - In N ❑ W w w The Commonwealth of Massachusetts - Department of IndustriglAccidents Office o fInvestigations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leeibly Name U \__11\J MSC City/State/Zip:"3M0b05 ONSWO Phone #: Are you an employer? Check the appropriate box: Type of project (required): L ❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑ Ne construction loyees (fall and/or part-time).* have ned the sub -contractors 7• glemodeding 2. 0 lam a sole proprietor or partner-' ship and'have no employees listed on the attached sheet. t These sub -contractors have 8. E]Demolition working for mein any capacity. workers' comp. insurance. g, ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 1011 Electrical repairs or additions required.] 3. ❑ I 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• ❑ 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 be18w 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 anew 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 is providing workers' compensation insurance for my employees. Below is the policy and job site information. A Insurance Company Name:i Policy # or Self -ins. Lic. M C) oC) t)3zo -` Expiration Date: Job Site Address:_ �3� J� `1 C� i V1 t- City/State/Zip: Q J- A f1 Oy ee- 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. X do hereby cert nder the pains a�penalties ofperjury that the information provided above is true and correct. oil Official use only. Do not write in this area, to be completed by city or town official. City or Town: PermitUcense 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 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 em,ployer 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 Iegal 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 commonwealthnor 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 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 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 (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. Anew affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or pemut 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 Co onw.0althofmassachnsetts Departmelit of ladustdal .Acoldents Office of1"Ostigatio1w 600 Washingtoa Street Boston, MA. 02111 Tel, # 617-72.7-4900 ()Kt 406 or 1-877,MASSAFE Revised 5-26-05 Fax # 617-727-7749 912 C 9003 Date . 6 7.13 .' I I . . TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that .. S.`A 5.6.c'''t ..Q.� Y . .......... ......... has permission to perform .. /`��.}�^• G.o!`�. nQy!%�: t-.. . plumbing in the buildings of ...4? �. .. �'.'� ............ . at. 1 fJ . V, �. Ems-. �' tib? ....... , North Andover, Mass. FeY.,577, 5C?.. Lic. No—alk,3(. ....... &-G* . . (� PLUMBING INSPECTOR Check # rtionMASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING : �/Q v �-`y Or Q _, MA. Date: Permit# F; q �,> t (� E 1 �.� Owners Name: h pancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential []� I I New: U Alteration: ❑ Renovation: 6Z"-- Replacement: ❑ Plans Submitted Yes ❑ No ❑ FIXTURES _ DEDICATED F z SYSTEMS z Y u O Z O Q- Ln Q u F w O 0 'na F _Z z W � Q W a z ' Ln S y Q W z F- _W Z la— yf N z N Q O_' Q W Q z C' Q y z to U d X Q F- N D: O x J Q W Q LL F C' W p W W z t% V ~ a W O Ln V O n Z z N 0 N F- F- Q Q J E.. O x Q Q Q Q Q H O W W Q LL x s 3 � F- 3 3 3 0B a FW - N 3 •SUBSMT. BASEMENT 1ST FLOOR 2ND FLOOR 3RD FLOOR 4T" FLOOR ST" FLOOR 6T" FLOOR 7T" FLOOR 8T" FLOOR p Installing Company Name: Check One Only Certificate # s� V 1 E S �� ❑ Corporation Address: D ' 1 City/Town: N G State: ❑ Partnership Business Tel: -�Zl gay a63? Fax: ❑Firm/Company / Name of Licensed Plumber: G T Q (C 6j S� (� S //% /� i�./ 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 Yes, please indicate the .type of coverage by checking the appropriate box below. A liability insurance policy Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I•am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only Signature of Owner or Owner's Agent Owner ❑ Agent ❑ 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 :ofLicense: Title Signa re of icensed Plumber :E]Journeyman City/Town APPROVED (OFFICE USE ONLY) License Number: CERTIFICATE OF LIABILITY INSURANCE OP ID BS FDATE(MM/DDIYYYY) v nai�ai,r, THIS CERTIFICATE IS ISSUED ASA MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS +v CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: the certificate holder Is an ADDITIONAL N R , the po Icy les must be endorsed. If SUBROGATIONIS WAIVEU,_SuVject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER NAME: PHONE F jAJC, No Ext: (AIC, No): McLaughlin Insurance Agency ADDRESS: 828 Lynn Fells Parkway Melrose MA 02176 cuSTOMERID#: SALSM-1 Phone:781-665-2775 FaX:781-665-0295 INSURER(S) AFFORDING COVERAGE NAIC# INSURED INSURER A: Commerce Insurance Company 34754 George Salsman 6 St. James Rd INSURER B: INSURER C: Saugus MA 01906 INSURER D: PREMISES(E.occurrence) $ 100000 INSURER E: COMMERCIAL GENERAL LIABILITY CLAIMS -MADE F—I OCCUR INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 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. LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER (MWDD/YYYY) (MM/DD/YYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 500000 PREMISES(E.occurrence) $ 100000 A COMMERCIAL GENERAL LIABILITY CLAIMS -MADE F—I OCCUR BCMQLL 06/08/10 06/08/11 MED EXP (Any one person) $ 5000 PERSONAL& ADV INJURY $ 500000 X Business Owners GENERAL AGGREGATE $1000000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $1000000 POLICY PRO- LOC JECT $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY (Per person) $ ALL OWNED AUTOS BODILY INJURY (Per accident) $ SCHEDULED AUTOS HIRED AUTOS PROPERTY DAMAGE $ (Per accident) NON -OWNED AUTOS $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS -MADE AGGREGATE $ DEDUCTIBLE $ $ RETENTION $ WORKERS COMPENSATION - AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIV� OFFICER/MEMBER EXCLUDED? / %� TORY LIMITS ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ T7 PROPERTY 5000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, K more space is required) Plumber CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE INFO -01 I THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. For Information Only 0 ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD reserved. Date. ....... TOWN OF NORTH ANDD A" PERMIT FOR GAS I ELATION Irk. This certifies that. . . . . . . . . . . . . . . . . . . has permission for gas installation ... ................... in the buildings of .... ( ............................ at ... �y s) ......... North Andover, Mass. Fee. Lic. No. .q. 7 3.I ... Q'i GASINSPECTOR Check # 9 ) - -� 5823 G 1 F r `lC , MASSACHUSETTS UNIFORM APPLICATION FOR' PERMIT TO DO GASFITTING (Print or Type) ' I �2' AWA~. Mass. Data Q v p� 201 P mit Building Lctpatlon d24 ownersa iA,04ve f'il • 11 Type of Occupancy New Renovation ❑ Replacementp/ Plans Submitted: Yes ❑ No ❑ Installing Company Name INSURANCE COVERAGE: I have a currentli bility Insurance policy or Its substantial equivalent, which meets the requirements of MGL Ch, 142. Yes V No ❑ If you have checked yes, please indicate the type of coverage by checking the appropriate box. A liability Insurance pollcyw"'� Other type of indemnity ❑ Bond ❑ OWNER'S INSURNACE 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 Signature o Owner or Owners Agent Check one: Owner ❑ Agent ❑ I hereby certIfy that all of the details and Information I have submitted for entered) In above application are true and accurate to the beast of my knowledge and that all plumbing work and Installations performed under the perm) ed for this appl on will be in co pliance with all pertinent provisions of the Massachusetts s tate Gas Code and Chapter 142 of the C e L t j*h $ Type of License: By ❑ Plumber g re of L ce s lumber or Cas Fitter Tian ❑ Cas (atter City/Town LpX5ster License Number APPROVED (OFFICE USE ONLY) 0 Journeyman i • i • � Installing Company Name INSURANCE COVERAGE: I have a currentli bility Insurance policy or Its substantial equivalent, which meets the requirements of MGL Ch, 142. Yes V No ❑ If you have checked yes, please indicate the type of coverage by checking the appropriate box. A liability Insurance pollcyw"'� Other type of indemnity ❑ Bond ❑ OWNER'S INSURNACE 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 Signature o Owner or Owners Agent Check one: Owner ❑ Agent ❑ I hereby certIfy that all of the details and Information I have submitted for entered) In above application are true and accurate to the beast of my knowledge and that all plumbing work and Installations performed under the perm) ed for this appl on will be in co pliance with all pertinent provisions of the Massachusetts s tate Gas Code and Chapter 142 of the C e L t j*h $ Type of License: By ❑ Plumber g re of L ce s lumber or Cas Fitter Tian ❑ Cas (atter City/Town LpX5ster License Number APPROVED (OFFICE USE ONLY) 0 Journeyman