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HomeMy WebLinkAboutMiscellaneous - 91 MAIN STREET 4/30/2018 (3)6im R., �� C:::Zz� I�ig �q Vn Date. ..... . ................................... \, TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ......... & A' ........ .......... ............................................................................... has permission to perform4f � . . . ........ ................ ..... f � ,:I, ... ............ ............... ...... ........ .... ..... .... ...... .... ........ .. wiring in the building of ..... a., ..... .... Lk ................. at ... �.\.IJZ North Andover, Mass. ... ................................................ . V3'b'I Fee.... ...............- ......... Lic. No. 077;u ... .................................................................................... ELECTRICAL INSPECTOR Check # ion 2 L"' 0 S1 Commonwealth of Massachusetts t' Department of Fire Services A BOARD OF FIRE PREVENTION REGULATIONS OfficialUse Only Permit No. 10(_0 `' Date Issued: APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: November 11, 2015 City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) 91 V2 Main Street Map: Lot: Owner or Tenant Andover Credit Union Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ® No ❑ (Check Appropriate Box) Purpose of Building Restaurant Utility Authorization No. Existing Service Amps Volts Overhead ❑ Undgrd ❑ New Service Amps Volts Overhead ❑ Undgrd ❑ Dumber of Feeders and Ampacity No. of Meters No. of Meters Location and Nature of Proposed Electrical Work: Make safe and install temporary lighting and circuit for heating Completion o the followin2 table mav be waived hv the In ector nf Wires No. of Recessed Fixtures No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Lighting Outlets No. of Hot Tubs Generators KVA No. of Lighting Fixtures Swimming Pool Above ❑ In- ❑ o. o mergency Lighting rnd. grnd. Battery 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 No. of Air Cond. Total Tons No, of Alerting Devices No. of Waste Disposers Heat Pump J.Number ..................................................... I.Tons KW No. of Self -Contained Totals: 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 No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or E uivalent OTHER: I Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work $650.00 (When required by municipal policy.) N,; Work to Start: 11/14/15 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 licen- see 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 N BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on FIRM NAME: Inc is true and complete LIC. NO.: 14302 Licensee: Robert J. Branca Signature / LIC. NO.: *Per M.G.L. c. 147, s. 57-61, security work requires Department -6 ub afety "S" License: LIC.NO.: S: (If applicable, enter "exempt" in the license number line) Bus. Tel. No.: 978-475499 Address: 19 Dale St, Andover, MA Ziv: 01810 Alt. Tel. No.: 978423-8350 OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required bylaw. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Phone: Permit Fee: $150.00 cWM o!Fu CERTIFICATE OF LIABILITY INSURANCE aA,F �� 04/29/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE O D R. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the pollcy(les) 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 andorsement(s). PRODUCER Phone: (978) 474-0810 Fax: (978) 474-0890 =A' Samel Insurance Agency, Inc. JONATHAN M SAMEL CIC LIAPHONE 978.474-0810 F"'1 978-074-0890 SAMEL INSURANCE AGENCY, INC. 15 CENTRAL STREET ANDOVER MA 01810 EMAIL Info@samel-ins.com PRODUCER 1254 INSURER(S) AFFORDING COVERAGE INSURED ANDOVER ELECTRIC SERVICES INC PO BOX 829 ANDOVER MA 01810 INSURERA : Sentinel Insurance Co, LTD 11000 INSURERS : Citation Insurance Company 40274 INSURER : Sentinel insurance Co, LTD 1100 INSURERD: Hartford Fire Insurance Company 19682 INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: 42147 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, INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP POLICY NUMBER LIMITS A GENERAL LABILITY OBSBAIL4326 03/23/15 03/23/16 EACH OCCURRENCE $ 2,000,000 X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE 17X OCCUR DAMAGE $ 1,000,000 MED. EXP (Any one person) $ 10,000 PERSONAL & ADV INJURY $ 2,000,000 GENERAL AGGREGATE $ 4,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 4,000,000 POLICY PRO IECT X LOC $ B AUTOMOBILE LIABRM ANY AUTO KW7918 03/23/15 03/23/16 COMBINED SINGLE LIMIT $ 11000,000 (Ea accident) BODILY INJURY (Per person) $ ALL OWNED AUTOS BODILY INJURY (Per accident) $ X X SCHEDULED AUTOS HIRED AUTOS PROPERTY DAMAGE Per accident $ X NON -OWNED AUTOS $ $ C X UMBRELLA LAB X OCCUR 08SBAIL4326 03/23/15 03/23/16 EACH OCCURRENCE 2,000,000 AGGREGATE 2,000,000 ExtEea LIAs CLAIMS -MADE DEDUCTIBLE X RETENTION $ 10,000 $ D WORIOERS COMPENSATION AND EMPLOYERS' LABLLrrY YIN ANY PROPRIETORIPARTNERlEXECUTNE OFFICERIYEMBER EXCLUDED? a N I A 08WECCM5940 04128/15 04128/16 X I gyTLAZgOZ$ E.L. EACH ACCIDENT500,000 E.L. DISEASE -EA EMPLOYEE 500,000 (Margie Y In NH) K yea, deaW be under DESCRIPTION OF OPERATIONS below -T� E.L. DISEASE -POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If mora space Is required) Operations typical to commercial and residential electrical contractor. Town of North Andover SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 120 Main Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN North Andover, MA 01845 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Attention:— �Jonathan ".:f- �� .Samel .ORD 25 (2009109) 01988.2009 ACORD CORPORATION. All rights reservet The ACORD name and logo are reaistered marks of ACORD Location C...% r % No. �� r LDate 7 t � TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee. / tri $ _ � •� TOTAL $ // f Check # / kl ii tf ' / . =' Building Inspector OJ ER **� rro, S� �O TI- N Z��� o r O O cn cn E n. Lb; C L a) 4 O C O � O� (U O U Z Q- o CL co 3 N o o O co E L •— o c N O ..c cB o=3 c E a) 0 C: O.—D) U (n 4 Qo L- N (n od U�C;)cn a 4 1-+ W ^`N W O �c�> Ncu m L -C J cn > •"= m O Q U) t +' o 0 U c _ a) U 4- a) N U o ry (0 x c O .� (Y) � L •- N o Q -cm L W � Q d+ E o �oa)a _ Q.V O N O c� '> UO • tr 0 w I— m 2 O w a w T 0 Lw r z M J J J J z W H z U) rn 4- 0 L- U) U) TI- N Q r O N V% w N4.1 ti O LL C C U U I— N v 0 a H N N C L a) 4 O C O � O� (U O U Z Q- o CL co 3 N o o O co E L •— o c N O ..c cB o=3 c E a) 0 C: O.—D) U (n 4 Qo L- N (n od U�C;)cn a 4 1-+ W ^`N W O �c�> Ncu m L -C J cn > •"= m O Q U) t +' o 0 U c _ a) U 4- a) N U o ry (0 x c O .� (Y) � L •- N o Q -cm L W � Q d+ E o �oa)a _ Q.V O N O c� '> UO • tr 0 w I— m 2 O w a w T 0 Lw r z M J J J J z W H z U) rn 4- 0 L- U) U) Z-- I a� p o a a A ril v 1) R. A U a .bo N bp N �E d* N �0 N A 'ate N bd aa�UrnA8 O Id H 0 R H pq 1 0a 0 9 z UP w PC, A North Andover MIMAP August 29, 2016 © MVPC Bo Zoning Overlay Zoning 0 Municipal Boundary 13 Adult Entertainment Disinc Busine s 1 District O Machine Shop Village Ove 13 Busine s 2 District — Rail Line 0 Watershed Protection Dist O Businei s 3 District Interstates 0 Historic Mill Area ■ Busine s 4 District AORTR — 1 0 Medical Marijuana ■ Genera Business District t q — SR B Downtown Overlay District Q Plannei Commercial Dev r • •�� 0 Historic District .. Corido Development Dist 3�O<<t�•D • Roads t-, Easements V Osgood Smart Growth (40 Hydrographic Features O Corido Development Dist 13 Corrido Development Dist O _ ❑ ParcelsIndustri Streams I 1 District t ' : Industri 12 District 49 '-; Wetlands 0 Industri1 3 District °• �'~ :; Exempt Lands C Industri I S District Reside ce 1 District o �-•<�w �1 Reside ce 2 District ,S SACMU52 .; Reside ce 3 District d dece 4 District 1" = 53 ft .d }.de ce 5 District Y de 6 District ce cge esidential District Horizontal Datum: MA Stateplane Coordinate System, Datum NAD83, Meters Data Sources: The data for this map was produced by Merrimack Valley Planning Commission (MVPC) using data provided by the Town of North Andover. Additional data provided by the Executive Office of Environmental AffairslMassGIS. The information depicted on this map is for planning purposes only. It may not be adequate for legal boundary definition or regulatory interpretation. THE TOWN OF NORTH ANDOVER MAKES NO WARRANTIES, EXPRESSED OR IMPLIED, CONCERNING THE ACCURACY, COMPLETENESS, RELIABILITY, OR SUITABILITY OF THESE DATA. THE TOWN OF NORTH ANDOVER DOES NOT ASSUME ANY LIABILITY ASSOCIATED WITH THE USE OR MISUSE OF THIS INFORMATION The Commonwealth of Massachusetts / Department of Industrial Accidents a Office of Investigations ' d 1 Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Hanle (Business/Organization/Individual): Andover Electric Services, Inc. Address: 19 Dales Street ip: Andover, MA 01810 Phone #: 978-475-4995 Are you an employer? Check the appropriate box: 1. ❑■ I am a employer with 5 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.$ required.] 5. ❑ ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 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. ❑ 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 41 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: The Hartford Policy # or Self -ins. Lic. #: 08 WEC CM5940 Expiration Date: 4/28/16 Job Site Address: 91 1/2 Main Street City/State/Zip: North Andover, MA 01845 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 violato Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insura�eerage verification. I do hereby certify under th ains nd penalties ofperjury that the information provided above is true and correct. 11/11/15 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 Plumbin Inc ector 6. Other Contact Person: Phone #: DIVISION OF PROFESSIONAL LICENSU GE OF' -,,P u : Date..L...�.................. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that �� 06',r.-- + ...................................... ( .. . ..... A . .... I,- . I..V . 1......., . T..........� has permission to perform AT -- wiring in the building, of..... .................................................................................... at .... ................................................. . North Andover, Mass. ic. No. .. .. ... . ............................................................................. Fee........... .... . ELECTRICAL INSPECTOR Check # J U vo �4 4 Commonwealth of Massachusetts = Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official ((Use ��Only Permit No. Date Issued: APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: February 8, 2016 City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) 91 % Main Street Map: Lot: Owner or Tenant Andover Credit Union Telephone No. Owner's Address same Is this permit in conjunction with a building permit? Yes ® No ❑ (Check Appropriate Box) Purpose of Building Credit Union Utility Authorization No. Existing Service Amps Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Wiring of new Andover Credit Union Com letion o the following table may be waived by the Inspector of Wires. No. of Recessed Fixtures 20 No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Lighting Outlets No. of Hot Tubs Generators KVA No. of Lighting Fixtures 8 Swimming Pool rnd. Above ❑ In- rnd. E] No. o Emergency Lighting Batter Units 4 No. of Receptacle Outlets 12 No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches 8 No. of Gas Burners No. of Detection and 71 6 in:4:..+:.... ....:...... i No. of Dishwashers Space/Area Heating KW IOKW Local El Municipal ❑ Other No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices 6 No. of Waste Disposers Heat Pump Totals: J.Number Tons KW "' ""' No. of Self -Contained Detection/Alerting Devices i No. of Dishwashers Space/Area Heating KW IOKW Local El Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems: _ No. of Devices or Equivalent No. of Water KW No. of No. of Data Wiring: 6 M Heaters Signs Ballasts No. of Devices or Equivalent N No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: 8 No. of Devices or Equivalent OTHER: Remove and replace existin¢ nanel_ Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work $6,900.00 (When required by municipal policy.) Work to Start: 3/1/16 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 licen- see 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:) 1 certify, under the pains and penalties of perjury, that the information on this lation is true and complete. FIRM NAME: Andover Electric Services Inc LIC. NO.: 14302 Licensee: Robert J. Branca SignatureLIC. NO.: *Per M.G.L. c. 147, s. 57-61, security work requires Department Pu afety "S" License: LIC.NO.: S: (If applicable, enter "exempt" in the license number line.) Bus. Tel. No.: 978-475-4995 Address: 19 Dale St, Andover, MA zip: 01 10 Alt. Tel. No.: 978-423-835 OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required bylaw. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Phone: Permit Fee: 225.00 The Commonwealth of Massachusetts Department oflndustrialAccidents u Office of Investigations W ' I Congress Street, Suite 100 w Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: 19 Dales Street Citv/State/Zit): Andover, MA 01810 Andover Electric Services, Inc. Phone #: 978-475-4995 Are you an employer? Check the appropriate box: I.0 I am a employer with 5 4. ❑ I am a general contractor and I employees (full and/or part-time).* 2. ❑ I am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ 1 am a homeowner doing all work myself. [No workers' comp. insurance required.] t have hired the sub -contractors listed on the attached sheet. 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. ❑ 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 # 1 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 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: The Hartford Policy # or Self -ins. Lic. #: 08 WEC CM5940 Expiration Date: 4/28/16 Job Site Address: 91 1/2 Main Street City/State/Zip: North Andover, MA 01845 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance cwA<age verification. I do hereby certify under the 54995 penalties of perjury that the information provided above is true and correct. 2/29/2016 Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #• 11 DATE (MMOIDIYYYY) coRO• CERTIFICATE OF LIABILITY INSURANCE 04/29/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFIATE DOES NOT END OR ALTER THE BELOW. TH S CERTIFICATEOFAFFIRMATIVELY DOES NOT CONSTITUTE EA CONTRACT BETWEEN CTHE IISAFFORDED INSURER(S). AUTHORIZED REPRESENTATIVE OR PRODUCER AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the policy(les) must be endorsed. if SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endoreement(s). PRODUCER phone: (978)4740870 Fax: (973)474-0590 CONTACT Samel Insurance Agency, Inc. JONATHAN M SAMEL CIC LIA 978-474-0810 FAX 978.474-0890 PHONE SAMEL INSURANCE AGENCY, INC. =SS1 lnfo@samel-ins.com 15 CENTRAL STREET PRODUCER 1254 ANDOVER MA 01810 INSURER(S) AFFORDING COVERAGE INSURED ANDOVER ELECTRIC SERVICES INC PO BOX 629 ANDOVER MA 01810 _ INSURER A Sentinel insurance Co, LTD 11000 INSURER B : Citation Insurance Company 40274 INSURER : Sentinel insurance Co, LTD 1100 INSURER D: Hartford Fire Insurance Company 19682 INSURER E POLICY EXP 03/23/16 INSURER F efr.ncrnu u1 WDCD• 2,000,000 EACH OCCURRENCE$DAMAGETO COVERAGES CERTIFICATE OF INSURANCE ADDL THE SUBR NUMBLK: 4z14y LISTED BELOW HAVE BEEN TERM OR CONDITION OF ANY INSURANCE AFFORDED BY THE POLICY NUMBER ISSUED TO THE CONTRACT OR POLICIES INSURED OTHER DOCUMENT DESCRIBED NAMED ABOVE FOR THE POLICY PERIOD WITH RESPECT TO WHICH THIS HEREIN IS SUBJECT TO ALL THE TERMS, THIS INDICATED. CERTIFICATE IS TO CERTIFY THAT THE POLICIES NOTWITHSTANDING ANY REQUIREMENT, MAY BE ISSUED OR MAY PERTAIN, INSURANCE POLICY EFF 03/23115 POLICY EXP 03/23/16 LIMITS 2,000,000 EACH OCCURRENCE$DAMAGETO 7GENE-ML ENERAL LIIABILITY DE I 7� OCCUR OBSBAIL4326 RENTED $1,000,000 MED. EXP (Any one person) $ 10,000 PERSONAL & ADV INJURY $ 2,000,000 GENERAL AGGREGATE $ 4,000,000 PRODUCTS - COMP/OP AGG $ 4,000,000 GENL AGLIMIT APPLIES PER: POLICY X IFrT PRO- LOC $ COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) B AUTOMOBILE X X X LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS KW7918 03123/15 03123/16 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE $ Per accident $ C X UMBRELLA UAB EXCESS LIAB X OCCUR CLAIMS -MADE OBSBAIL4326 03123115 03123/16 EACH OCCURRENCE 2,000,000 AGGREGATE 2,000,000 X DEDUCTIBLE RETENTION $ 10,000 D WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN ANY PROPRIETORIPARTNERIEXECUTIVE OFFICERIMEMBER EXCLUDED? I1 (Mandatory In NH) if yes, describe under DESCRIPTION OF OPERATIONS below NIA OBWECCM5940 04128/15 04128/16 X CSTA 0TH $ E.L. EACH ACCIDENT 500,000 E.L. DISEASE -EA EMPLOYEE 500,000 E.L. DISEASE -POLICY LIMIT $ SDQ,p00 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, K more space Is required) Operations typical to commercial and residential electrical contractor. Town of North Andover SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 120 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. North Andover, MA 01845 AUTHORVED REPRESENTATIVE Attention: Jonathan M. Samel AGUKU A* tAUUUIUV) The ACORD name and logo are registered marks of ACORD This certifies that .......,6v .4a ..... ......................�............ ........ has permission to perform .... .. .............' 41 ....... � plumbing in the buildi sof . �. �1—y1.v .... Gl .............. . ort Andover, Mass. Fee,%1 t ic. No. l/f .y .... .............. �� �vt► i+�A'J L MBING I SPECTOR Check # Date l.1f-IL TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING A4- 0 Date ...... I ...... 1. //"u r ................... r, 1--// TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that . ............................................................. has permission for gas installation ..... !24: r .... n in the buildings of..�`- ........................................... at ... ...... North Andover, Mass. Fee'i.-Iu..rJ Lic. No. ...... ....... .. GAS INSPECTOR 40 - Check # "j, I� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ' CITY �' °`L /� _ �� MA DATE S ( PERMIT# h JOBSITE ADDRESS Q 1T i4 r✓ s7' i OWNER'S NAME L 7=<� C'A ad, t G POWNER ADDRESS TEL[JIFAX TYPE OR OCCUPANCY TYPE COMMERCIAL. EDUCATIONAL © RESIDENTIAL DI PRINT CLEARLY NEW: ! RENOVATION: 0 REPLACEMENT;, PLANS SUBMITTED: YES 0 NOD 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 (_._.._ . (._.__ f _.__.1 ._ ._..__ _I _ _ ___ ____._.J ....... DEDICATED GREASE SYSTEM Ji .___-J € E DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN __€ ...__-_€__-_-J ._-.-_-( ._-_._► ._...__I FOOD DISPOSER _ _€ _._ _.! .__.._._ _.€ ..-- -.__1 __ _ 1 € .. _ ..J .__ . ! ._._.._..._J .-- —� _... __I .--._.._ _1_.. ___! FLOOR/AREA DRAIN 1 _ __J _..._ _____ _._ _1 __.._.J INTERCEPTOR (INTERIOR) __ I _._.__1 ._.____.1 _–._J KITCHEN SINK LAVATORY ROOF DRAIN 1 _ __J .___._k _ `AHOWER STALL SERVICE / MOP SINK JILD T, ]LET URINAL WASHING MACHINE CONNECTION __ _1 _..._-.._i WATER HEATER ALL TYPES _€ f . _- .- 4 f I — € _.._ __ t __ _ _..J . __ _ J _ _1 WATER PIPING _ _ i '_j € OTHER INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES .--_€ NO _ IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY Q BOND 0 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 R 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 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 al;�P�= f the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME ?i �I LICENSE # I SIGNATURE MP N- JP Q CORPORATION R#� PARTNERSHIP 0# _ : LLC D j COMPANY NAME �. v .at P-+ }-(- ; ADDRESS z c' rt s S CITYSri c v✓` _ ]STATE A�.._I ZIP (� 3y_ _—kl TEL �— FAX� CELL �EMAIL o F] z LU w w w The Commonwealth ofMassachusetts Department of IndustrialAccidents I Congress Street, Suite 100 Boston, MA 02114-2017 •°` www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers- TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: 1-1 C i10 ' Citv/StateOD: 55�t tv(/ ►y' (`- Are you an employer? Check the appropriate box: 3 0 n Phone #: 61�, 0`�, 3 Z Z of 0 l 9 1.] I am a employer with employees (full and/or part-time).* 2.ZI am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3.0 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.❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.# 6.Q 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): 7. ❑ New construction 8. [1 Remodeling 9. ❑ Demolition 10 ❑ Building addition 11.❑ Electrical repairs or additions 12.0 Plumbing repairs or additions 13. E] Roof repairs 14. ❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. Homeowners who submit flus affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such tContractors that check this box must attached an additional sheet showing the name of the 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 N Policy # or Self -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 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 DIA. for insurance coverage verification. 7jo hereby cert! under tlae pain/s . d penalties of perjury Haat the informali0n�pro vided above istrue annature: ! : Z— _ Officialuse only. Do not write in this area, to be completed by city or town of 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 _ 11 Contact Person: Phone #: 11 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 ofhire, 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 bd 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 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 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 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY CN"�" �j w.n v� c"�- � MA DATE I t2 -. r - _s� I� PERMIT # - JOBSITE ADDRESS R Z VA tf T OWNER'S NAME r--d. e_ 0L "..uJ OWNER ADDRESS of .-e— I TE FAX TYPE OR PRINT OCCUPANCY TYPE COMMERCIA EDUCATIONAL F1 RESIDENTIAL CLEARLY NEW: RENOVATION: El REPLACEMENT:,®' 6*5 1-1 N 'e-, PLANS SUBMITTED: YES 0 NO F APPLIANCES Z FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE.!-a GENERATOR.�h_..-I GRILLE._... .... INFRARED HEATER LABORATORY COCKS (—� (� — MAKEUP AIR UNIT OVEN POOL HEATER _ J ROOM / SPACE HEATER T ROOF TOP UNIT �{ TEST UNIT HEATER UNVENTED ROOM HEATER I WATER HEATER�- OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL. Ch. 142 YES [I NO Ej 1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 21 OTHER TYPE INDEMNITY ® BOND OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT 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 with all Pertinen provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. /Z�Z PLUM BER-GASF ITTER NAME 'A 12,1e_E int_ LICENSE # 4`x_29 J SIGNATURE _— - MP 21 MGF EjI JP JGF LPGI 0 CORPORATION F]# I PARTNERSHIP ®#= LLC Ejl#= COMPANY NAME: 'ADDRESS yz e L CITY STATE =ZIP ra 30 `f TEL / d 3 z. t 41 v !I FAX CELL EMAIL H O z 0 H U W P-4 w o� z O yrl W � H W OF O a z w W 3: � a W 55 w a W O w L LU a w a oEn F, a a- < w x w LL. H z° 0 H U W �o � 4 Un `O O I -1, W4 co : 7 - 2 D■\� b� UJ'.®�� 2 6 � dW ��/ 7 CL ^ ir, 7k<< : 7, '1, A j ,n, cel Wt, -�-� e (� ► fi -7,ti 40-q �v