Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
Miscellaneous - 940 JOHNSON STREET 4/30/2018 (2)
f C r N 0 O H N r O Y m CO 0m¢c C Q UUii� d) x... N m O O O D H H H r 0 J m m E E O U —I a Q 00 O rr O O F- CL LL N_ N_ c o cO U ao a O �c U iF= 2 3 M 0-0 �m ooX�V J co F' O W Q Z 2Q WQ K = w ca ca O Ir. CD m a) a) m O O O r o Q U 0 Z U � U N N a J� UL O a) U Q cc L — a) J W N c N a) C O to O a) Q M o d c2wUS O C r N 0 O H N r O Y m CO 0m¢c C Q UUii� d) x... N m O O O D H H H r 0 J m m E E O U —I a Q y O N } F- CL LL c W ao a O �c U iF= 2 3 M 0-0 �m J co O O W Q Z 2Q WQ K = Z O Ir. CD J W 00 F"' W J N> O O O r o Q U 0 Z U � maU a J� UL L Q OH ..O= Ch U Q 0,-i O a) J W N c U CD r a) Q M o d �o LL d =o i til; :0 Date .... 414?//S,;,, TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ....... P`......!` -'P7 ....................................................................................... m has permission to perfor.A.1./?l..P�.,....1'e....�,�,,,,.2C.. plumbin in the buildings of..,.,,-�?^ �:.. ..................................................... at .... .............yv�,,......v.r?^ �5�^�....... ............... North Andover, Mass. Fee5..b ................ Lic. No. kW .................................................................................... PLUMBING INSPECTOR Check #1b(Po Z -C\- ulr� POWNER TYPE OR PRINT CLEARLY MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY I NORTH ANDOVER I MA DATE 10-22-2015 PERMIT # - JOBSITE ADDRESS 940 JOHNSON ROAD OWNER'S NAMEJ STEVE DIAMOND ADDRESS I SAME I TELI 864-650-1484 FAX OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL NEW: 0 RENOVATION: 0 REPLACEMENT: 0 PLANS SUBMITTED: YES D NDE] FIXTURES -1 FLOOR— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE 1 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 LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER 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 CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY R OTHER TYPE OF INDEMNITYF-1 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 F-71 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 o y knowledge and that all plumbing work and installations performed under the permit issued for this application will b i ompliance ' h P inert p ion of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME 1. KENNETH J ROBERTS LICENSE # 11934 SIGNATURE MPED JP Q CORPORATION#,3304 PARTNERSHIPQ#OLLCE1#0 COMPANY NAME I ABSOLUTE PRECISION ADDRESS P.O. BOX 1260 CITY MIDDLETON STATE FMA___j ZIP 101949 TEL 978-766-1475 FAX 978-777-5371 1 CELL978-7661475 EMAIL KEN@ABSOLUTEPRECISIONPLUMBING.COM Date../ k�1%s........... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION Thir b L`'N"�-& 2C /J s certifies that....................................................../........................................................ has permission for gas installation ......................... /4— ................................................... in the budin s of m `. U h`� Ste^' , North Andover, Mass. Fe�.............. Lic. No. 3/............................................................................ GASINSPECTOR Check #' w -- IJ IL' 2 �� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK GOWNER TYPE OR PRINT CLEARLY CITY NORTH ANDOVER I MA DATE 10-22-2015 ]PERMIT #— JOBSITE ADDRESSI 940 JOHNSON ROAD OWNER'S NAME STEVE DIAMOND ADDRESS I SAME I TE 864-650-1484 FAX _ OCCUPANCY TYPE COMMERCIALE] EDUCATIONAL E] RESIDENTIALO NEW:O RENOVATION: 0 REPLACEMENT: El PLANS SUBMITTED: YESE] NDE] APPLIANCES I FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER / 1 BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT ! OVEN POOL HEATER ROOM /SPACE HEATER l ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITY 0 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 F71 AGENT ED 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 all P eat provis' of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUM BER-GASF ITTER NAME I KENNETH J ROBERTS I LICENSE # 11934 SIGNA E MP [D MGF Q JP F—] JGF Q LPGI ® CORPORATION Q# 3304 PARTNERSHIP 0# LLC [:]# COMPANY NAME: ABSOLUTE PRECISION ADDRESS 1, P.O. BOX 1260 CITY I MIDDLETON STATE MA ZIP 101949 ::]TEL 978-766-1475 _ FAX 978-777-5371 1 CELL 978-766-1475 EMAIL KEN@ABSOLUTEPRECISIONPLUMBING.COM 1 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: General Businesses Applicant Information Please Print Legibly Business/Organization Name: 445a/(.t-e Pflterszo-1 P/V /trhr, iff!tT?he- keo0/l'rle, -th Address: �• c) 8()X �'2G City/State/Zip: M 1-1) p/L--T 6 -, n119 0 // Phone #: g1 % J" ' 7 7 —,f+ 3S Are you an employer? Check the appropriate box: l I am a employer with employees (full and/ or part-time).* 2. ❑ I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required) 3. ❑ We are a corporation and its officers have exercised their right of exemption per c. 152, §1(4), and we have no employees. [No workers' comp. insurance required]* 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. [No. workers' comp. insurance reg.) Business Type (required): 5. ❑ Retail 6. ❑ RestaurantBar/Eating Establishment 7. ❑ Office and/or Sales (incl. teal estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10.0 Manufacturing 11.❑ Health Care 12)ZfOther COn S7#'yC-7-W 1 *Any applicant that checks box # I must also fill out the section below showing their workers' compensation policy information. **If the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an organization should check box #I. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: 2 U R7 C 14 -R 04 f R X C,9 rl 1h S 1� A h,)c Insurer's Address: 6-G{a1 P3 T -SU/ U I-.rO -7 .I 1 1301' f;'►L fi*, w p r rut',44 a G3 City/State/Zip: QU R ��1Ir G �� 7 /1'1 i9 1 bo 3 — Y's / Policy # or -Self -ins. Lic. # WC 'Y/ -299 S -0 Expiration Date: 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. do hereby certify, under the pains and#enylties ofpyjury 191 the information provided above is true and correct. mob---7- Official use only. Do not write in this area, to be completed by city or town offrciaL City or Town: Permit/License # U - 2;? --?.UIS Issuing Authority (circle one): , , I. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board S. Selectmen's Office 6. Other Contact Person: www.mass.gov/dia Phone Date.... A / A0.�........ TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ....................................................................... ................................................. . l has permission to perform ........ ... 4.. ..:::?t' :......... .... .`zA7—............ wiring in buildin&of............................................... ..................................................... at ........ / % vD'cJ�................................... . North Andover, Mass. Fee. - ............. Lic. No.A&Z-33................................................................................. % ELECTRICAL INSPECTOR Check # `�� ,�4e Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. /C) - Occupancy and Fee Checked [Rev. 1/071 (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (NEC), 527 CMR 12.00 (PLEASE PRINT ININK OR TYPE ALL INFORMATION) Date: / 2 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) &!Por Tenant �G ✓,ii, Owner's Address RAI r< Telephone No. Is this permit in conjunction with a building permit? Yes ®�No ❑ (Check Appropriate Box) Purpose of Building c./ ,< ,„ 1 #..^ Utility Atthorization No. 2Q 7 q %l2Z Existing Service &I Amps 0 / Zc(6741ts Overhead V grd ❑ No. of Meters __�___ New Service Zoo Amps JIZO / 2-UVolts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Overhead Undg rd ❑ No. of Meters 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- ❑No--.OTEmergency rnd. grnd. Lighting Battery Units No. of Receptacle Outlets S 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 p Heat Pump Totals: Number Tons ........... � KW .......... No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW 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 Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: G O (When required by municipal policy.) Work to Start: �j' - / Z • Zj� Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCECOVERAGE: Unless waived the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability ins nce including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such covera s in force, and has exhibited proof of same to the permit issuing office. UR CHECK ONE: INSANCE OND ❑ OTHER ❑ (Specify:) Icertify, under thepains andpenalties ofperjury, that the information on this application is true and complete. FIRM NAME: , o vn. `% '�. •'0% ti LIC. NO.: Licensee: 4200.7 Signature L. _ LTC. NO.: (If applicable, enter "exempt" in the licensnzt ber ine.) /� l Bus. Tel. No.- Address: 7 1) V/4,net f'► { -W-11" � 1.1 C . 1�1 X.11 Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S""License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. Owner/Agent Signature _ Telephone No. I am the (check one) ❑ owner ❑ owner's agent. PERMIT FEE: ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed k 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 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass IN Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: . Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH IN PECTION: Pass 0 Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: G G Inspectors Signature: G� - Date: I r f > 7 FINAL INSPE ION: Pass 0 Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature Date: DEB WEINHOLD ...TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. i Homeowners who submit this affidavit indicating they 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. tithe sub-coniraciors 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: �(y ✓ t O C Policy # or Self -ins. Lie. #: Expiration Date: 1-2— Job 2 ---Job Site Address:_ y 0 �l G co r1 (, /� / City/State/Zip: ,( %p",.4 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 $250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. l? Ido hereby certify u0er417eporns and penalties ofggr jury that the information provided above is true and correct. Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # 2" — 1, Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Phone #• The Commonwealth of Massachusetts Department of IndustrialAceidents << d 1 Congress Street, Suite 100 = Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Eleciricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Le ibl Name (Business/Organization/Individual): `t G JC / .e < le n J Address: ����/� .,� ✓`✓A / Phone #: % City/State/Zip:^ ,4n.4a Are you an emplo . Check the appropriate box: Type of project (required): LED] I am ployer with employees (full and/or part-time).* 7. ❑ New construction 2. a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling any capacity. [No workers' comp. insurance required.] 9. ❑ Demolition 3. F1 I am a homeowner doing all work myselt [No workers' comp. insurance required.] t 10E] Building addition 4. F1I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole 11. ❑ Electrical repairs or additions proprietors with no employees. 12. ❑ Plumbing repairs or additions 5. I am a general contractor and I have hired the sub -contractors listed on the attached sheet. ❑ - 13. FJ Roof repairs These sub -contractors have employees and have workers' comp. insurance.$ 6. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 1. 14. ❑Other 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. i Homeowners who submit this affidavit indicating they 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. tithe sub-coniraciors 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: �(y ✓ t O C Policy # or Self -ins. Lie. #: Expiration Date: 1-2— Job 2 ---Job Site Address:_ y 0 �l G co r1 (, /� / City/State/Zip: ,( %p",.4 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. l? Ido hereby certify u0er417eporns and penalties ofggr jury that the information provided above is true and correct. Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # 2" — 1, Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact 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 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 to - ` — IASSACHUSETTS'"�CONINIONW ALTH OF IV ON / ELECTRICIANS THE L\CENSE AS |5SU[� THE FOLLOWER EL[CTR\�| REGISTERED nx"^ � NIS DANIEL [ ROONEY ,tn ~`~ 3 DUANE DK \� , ' Ol86�-l�0 \ READING n^ ' 66 � / / / / / ' / / ' � / 114 U -17 Date .0.�OV-5 .......... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING N BggC► Us�'5 . This certifies that .... ........P.:".....`..'...`.............................................................................. has permission to perform ...... .............................. .!!' �..: }........ plumbingin the buildings of.....:...1................................................................ at .......... t ...�.l..V 7.. o ........................................... North Andover, Mass. Feel*',. ... Lic. No. ..)1.�� 't .................................................................................. PLUMBING INSPECTOR Check # U M MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK POWNER TYPE OR PRINT CLEARLY CITY NORTH ANDOVER MA DATE 11-10-2015 PERMIT # 11461 JOBSITE ADDRESS 940 JOHNSON STREET OWNER'S NAMEJ STEVE DIAMOND ADDRESS SAME TEL 8646501484 IFAX OCCUPANCY TYPE COMMERCIAL ® EDUCATIONAL Q RESIDENTIAL NEW: RENOVATION:E:1 REPLACEMENT: 0 PLANS SUBMITTED: YES Q N0[D 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/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 LAVATORY 1 ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER . I } INSURANCE COVERAGE: I have a current liabili insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES NO E] IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Q OTHER TYPE OF INDEMNITY F-1 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 Q 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 compPance with P i Oht prov' n of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME I, KENNETH J ROBERTS LICENSE # 11934 SIGNATURE MPE3 JPQ CORPORATION# 3304 PARTNERSHIP#O LLC Q# COMPANY NAME I ABSOLUTE PRECISION ADDRESS I P.O. BOX 1260 CITY MIDDLETON STATE MA ZIP 01949 TEL 978-766-1475 FAX 978-777-5371 CELL 978-766-1475 EMAIL KEN ABSOLUTEPRECISIONPLUMBING.COM M Date... W..)9JI ..................... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION Thiscertifies that................t`.N............................................................................... . has permission for gas installation ....... 66 ................................................ in the buildings of ....... Df't VY1l t.......................................................................... at ........ �NQ......-3.6�.'.�.': )O^..'.... ..., North Andover, Mass. Fee I; t Lic. No..�.��.� ...... GASINSPECTOR Check # U �o \k V MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK FS CITY I NORTH ANDOVER MA DATE 11-10 2015 PERMIT # Dy ` JOBSITE ADDRESSI 940 JOHNSON STREET OWNER'S NAME FTEVEDIIAMPND .- G OWNER ADDRESS I SAME TE 8646501484 JFAX TYPE OR OCCUPANCY TYPE COMMERCIAL[] EDUCATIONAL ❑ RESIDENTIALD PRINT CLEARLY NEW: F71 RENOVATION: ❑ REPLACEMENT: ED PLANS SUBMITTED: YES❑ NOE] 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 1 FIREPLACE FRYOLATOR _ FURNACE GENERATOR _.. GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT — TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER - INSURANCE COVERAGE �I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES NO ❑ ql IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Q 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 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 cop lance withal e ' e rovisi of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. /�. !! PLUM BER-GASFITTER NAME I KENNETH J ROBERTS I LICENSE # 11934 SIGNATURE MP ❑ MGF ❑ JP ❑ JGFF-1 LPGI CORPORATION Q# 3304 PARTNERSHIPF-1# LLC ❑# COMPANY NAME:j ABSOLUTE PRECISION ADDRESS 1, P.O. BOX 1260 CITY I MIDDLETON STATE =ZIPI 01949 TEL 978-766-1475 FAX 978-777-5371 CELL 978 766-1475 EMAIL KEN@ABSOLUTEPRECISIONPLUMBING.COM1 11 11 0 \k V The Commonwealth of Massachusetts Department of Industrial Accidents �Uv Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name: iA6 sok, f -c PA crsre -t P/u * R Ih & /ff lT.T'qe, 1- C oa l rrl e, -th Address: F. d Rem- / Z,/-, a City/State/Zip: /yILl�O/LTo-t msgo/J Phone#: 77J-'77Y-jc+3S Are you an employer? Check the appropriate box: t I am a employer with — employees (full and/ or part-time).* 2. ❑ 1 am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required] 3. ❑ We are a corporation and its officers have exercised their right of exemption per c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required]* 4. ❑ We are a non-profit organization, staffed by volunteers, with no employees. (No workers' comp. insurance req.} Business Type (required): 5. ❑Retail 6. ❑ RestaurantBar/Eating Establishment T. ❑ Office and/or Sales (incl. real estate, auto, etc.) 8. ❑ Non-profit 9. ❑ Entertainment 10.0 Manufacturing 11. C3 Health Care 12ZOther C0't371'UL7-W" 'Any applicant that checks box N I must also fill out the section below showing their workers' compensation policy information. '• If the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an organization should check box #I. 1 am an employer that is providing workers' compensation insurance for my employees. Below is the policy information. Insurance Company Name: 2 U R? C 14 — t4 A, •F R X Cq 7 1/15 y A t9 7 C Insurer's Address: G{vi 03j'T .Sol v A --To -t jr 1 Rut 1;'-47''', wo.-Ar p r nj't�t�1t'L oZ.03 City/State/Zip: ,CS U R /inV G ren /)I Policy # or -Self -ins. Lic. # "y/ S - Expiration Date: 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. 1 do hereby certify, under the pains undljenytties of perjury dyt the information provided above is true and correct. _7J -.-7% Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # //- /a -oZGI Y - Issuing Authority (circle one): . 1. Board of Nealth 2. Building Department 3. City/Town Clerk 4. Licensing Board S. Selectmen's Office 6. Other Contact Person: Phone M www.niass.gov/dia v COMMONWEALTH OF MASSACHUSETTS 5 #I AM• PLUMBE09M VASFITTERS ISSUES THE FOLLOWING LICENSE +� LICENSED AS A JOURNEYMAN PLUMBER , w QNNETK .! ROBERTS W PO BOX 1260 MIDDLETON MA 01949-326o 22552 05/01/16 223979 COMMONWEALTH OF MASSACHUSETTS ?LUMBERSgTE 5SF1TTERS iSSt3ES TRE FOLLOWING LICENSE � LICENSED AS A MASTER PLUMBER *; KENNETH J ROBERTS P.O. BOX 1260 U MIDDLETON MA 01949-3260 11934 05/01/16 223978 e COMMONWEALTH OF MASSACHUSETTS ['.r L�1►(S�r7 ilii-ol 2 W. -*l It1 a �iliw�i�l� kii!�_ BOARD OF PLUMBERS AND GASFITTERS ISSUES THE FOLLOWING LICENSE REGISTERED AS A PLUMBING CORP a z KENNETH J ROBERT ABSOLUTE PRECISION PLB. & HEATIN N 5 WILDWOOD RD A U J MID.DLETON MA 01949-2133 3304 05/01/16 2o4671 Date...dIJ ....................... r ....................... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION & . � � This certifies that .......�-olu...�.....&�.vvk).................................... has permission for gas installation .....7k. ..... !'--Q inthrenf�...e buildd�in s of................................................................................................................. at ...7..� 6)-C U..S ..... ., No �A. over, Mass. Fes .Dom..... Lic. No. f J.l`.. ..... ............r...... . . ............................... GA SPECT Check # a6o� iC�.1 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK - CITY I NORTH ANDOVER 1 MA DATE 11-11-2015 PERMIT # JOBSITE ADDRESS 1 940 JOHNSON STREET OWNER'S NAME I STEVE DIAMOND GOWNER ADDRESS SAME TE 4-650-1484 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL[] EDUCATIONAL Q RESIDENTIAL PRINT CLEARLY NEW: ©I RENOVATION: 0 REPLACEMENT: F-1 PLANS SUBMITTED: YESFI N0[] APPLIANCES 7 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 GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST 1 UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER INSURANCE COVERAGE I have a current liabilfty insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Q OTHER TYPE INDEMNITY F] 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 E3 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 be of my knowledge bee and that all plumbing work and installations performed under the permit issued for this application will be in compli�ith all rt' of e Massachusetts State Plumbing Code and Chapter 142 of the General Laws. o W4 PLUMBER-GASFITTER NAME I KENNETH J ROBERTS LICENSE #F1 1934 (GNAT MP El MGF F-1 JP[:] JGF F-1 LPGI Q CORPORATION [D# 3304 PARTNERSHIP FI# LLC Q# COMPANY NAME] ABSOLUTE PRECISION ADDRESS I P.O. BOX 1260 CITY I MIDDLETON STATE MA ZIP 01949 TEL FAX 978-777-5371 CELL 978-766-1475 EMAIL KEN@ ABSOLUTEPRECISIONPLUMBING.COM The Commonwealth of Massachusetts 02 Department of Industrial Accidents Office of Investigations �Uv 1500 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: General Businesses Applicant Information Please Print Legibly Business/Organization Name:^Wlot-c PREersTo-t lfE'7-T?he- r tooll•�G Address- �• C) Ro r 'Z G D City/State/Zip: /t XQ Q1 CTo'1 Mg o /VS Phone #: 17 J 7 7 Y- jr-J� 3S Are you an employer? Check the appropriate box: 1 I am a employer with — -- employees (full and/ or part-time) * 2.0 I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required] 3.0 We are a corporation and its officers have exercised their right of exemption per c. 152, §1(4), and we have no employees. [No workers' comp. insurance required)* 4.0 We are a non-profit organization, staffed by volunteers, with no employees. [No workers' comp. insurance reg.] BuMeRss Type (required): 5. etail 6. ❑ RestaurantBar/Eating Establishment 7. ❑ Office andlor Sales (incl. teal estate, auto, etc.) 8. 0 Non-profit 9. 0 Entertainment 10.0 Manufacturing 11.0 Health Care 12)?TOther CGn S7✓uGT� `' 'Any applicant that checks box 01 must also fill out the section below showing their workers' compensation policy information. •' If the corporate officers have exempted themselves, but the corporation has other employees, a workers' compensation policy is required and such an organization should check box tll. I am an employer that is providing workers' compensation insurance for my employees. Below is tine policy information. Insurance Company Name: Z U /QT C 14— R .47 'E R 169 ei .rh S u R o7,7 C Insurer's Address: 6-ey1 p T Saly%LrG'l.J 1 Pr �+ut' ft oZ G3 City/State/Zip:.. /S U R /i,Y G 7-G 7 /1'► �'Li�' 1 t�� , YSS !� / Policy # or -Self --ins. Lic. # i�/C 'y1 X 79S '0 Expiration Date: l —�-Q �b 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 51,500.00 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 certify, under the pains and noies of w)'Ury th t the information provided above is true and correct. j '7J-.77 Official uve 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. Licensing Board S. Selectmen's Office 6. Other Contact Person www.mass.gov/dia Phone COMMONWEALTH OF MASSACKUSETTS a s 1 IrelaMfolM- kw, PLUMB ERSBOIN WASFITTERS ISSUES THE FOLLOWING LICENSE LICENSED AS A JOURNEYMAN PLUMBER KENNETR s ROBERTSLu l.� PO BOX 1260 MIDDLETON MA 01949-3260 22552 05/01/16 223979 COMMONWEALTH OF MASSACHUSETTS a • Va QAmLw• '`�`` • ' PLUMBERSB�At BASF 1 TTERS ISSUES TKE FOLLWI.NG LICENSE LICENSED AS A MASTER PLUMBER KENNETH J ROBERTS _0� P.O. BOX 1260 J MIDDLETON MA 01949-3260 1�4 11934 05/01/16 223978 o COMMONWEALTH OF MASSACHUSETTS a ajqj au •s - • BOARD OF PLUMBERS AND GASFITTERS ISSUES THE FOLLOWING LICENSE REGISTERED AS A PLUMBING CORP a z KENNETH J ROBERT N ABSOLUTE PRECISION PLB. G HEATIN N 5 WILDWOOD RD' U J MIDDLETON MA 01949-2133 3304 05/01/16 204671 Ar^+Ot7 7 0 l� R CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 12/22/2014 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 HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Andrew Atsaves C/o Artex Risk Solutions, Inc. 8800 E. Chaparral Rd, Suite 230 Scottsdale, AZ 85250 CONTACT NAME: PHONE FAX o Ext): (480) 951.4177 _ (AIC, No): (480) 951-4266 E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # EACH OCCURRENCE DAMAGE TO RENTE PREMISES (Ea occur ence) INSURERA: Zurich -American Insurance Company 16535 INSURED INSURER B: Genesis HR Solutions, Inc. One Burlington Woods Dr. Suite 203 INSURER C Burlington, MA 01803-4552 INSURER D: INSURER E : i i INSURER F: GENERAL AGGREGATE PRODUCTS - COMP/OP AGG COVERAGES CERTIFICATE NUMBER: 15MA603806009 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. INSR .TYPE OF INSURANCE MD LTR SUBRT POLICY EFF V POLICY NUMBER - MMIDDIYYYY POLICY EXP MM/DDIYYYY LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS -MADE U OCCUR I EACH OCCURRENCE DAMAGE TO RENTE PREMISES (Ea occur ence) $ $ i ED EXP (Any one person) PERSONAL & ADV INJURY $ $ GEN'L AGGREGATE LIMIT APPLIES PER: POLICY F7, PRO L LOC `~ JECT i i GENERAL AGGREGATE PRODUCTS - COMP/OP AGG $ S OTHER: $ AUTOMOBILE LIABILITY j I COMBINED SINGLE LIMIT Ea accident $ BODILY INJURY (Per person) $ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS i BODILY INJURY (Per accident) $ NON-OWNEDI HIREDAUTOS AUTOS PROPERTY DAMAGE peraccdent $ $ UMBRELLA LIAB �--� OCCUR i EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADEi i AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATIONPER AND EMPLOYERS' LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE A (OFFICER/MEMBER EXCLUDED? ❑ NIA{ j ( WC 48-41-995-04 01/01/2015 01/01/2016 OTH- X STATUTE ER E.L. EACH ACCIDENT $ 1,000,000 E_L. DISEASE - EA EMPLOYEd $ 1,000,000 (Mandatoryin NH) If yes, describe under DESCRIPTION OF OPERATIONS below i E.L. DISEASE - POLICY LIMIT $ 1,000,000 I I Location Coverage Period: 01/01/2015 01/01/2016 Client# 1957 -MA DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Coverage is provided for Absolute Precision Plumbing & Heating, Inc. only those co -employees 5 Wildwood Road of, but not subcontractors Middleton, MA 01949 to: I.CK I (FILA 1 G MULUMM UANUI=LLA 1 IUN Absolute Precision Plumbing & Heating, Inc. 5 Wildwood Road Middleton, MA 01949 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE zzsd�oe �42�� ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD 10 AC40RV CERTIFICATE OF LIABILITY INSURANCE DDYYYY) 778/10/15 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 HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Circle Business Ins. Agcy, IncPHONE 247 Newbury Street Danvers, MA 01923 CONTACT NAME: A. Cote FAX 978) 777_9898 978 777-5619 / No: ADDRESS: LCote@CircleInsurance.net INSURER(S) AFFORDING COVERAGE NAIC # INSURERA:Utica Mutual X COMMERCIAL GENERAL LIABILITY INSURED INSURERB:SafetV PropertV & Casualt INSURERC: Absolute Precision Plumbing & INSURER D: Heating, Inc. Po BOX 1260 INSURER E: Middleton, MA 01949 INSURER F: COVERAGES CERTIFICATE NUMBER: 2015-2016 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. INSR - ADDLSUER POUCY EFF POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER MM/DD/Y MMIDDVYYYY LIMITS A GENERAL LIABILITY AUTHORIZED REPRESENTATIVE 4541084 7/8/15 7/8/16 EACH OCCURRENCE $ 1,000,000 DAMAGETORENTED $ 50,000 X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE a OCCUR MED EXP (Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'LAGGREGATE LIMIT APPLIES PER PRODUCTS - OOMP/OPAGG $ 2,000,000 XPOLICY PRO LOC B AUTOMOBILE 6218367 7/8/15 7/8/16 CO MBINEDSINGLELIMIT ,accident $ 1 000 000 BODILY INJURY (Per person) $ ANY AUTO ALLOWNED X SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ NON -OWNED X HIREDAUTOS X AUTOS PROPERTY DAMAGE $ erac4den1t UMBRELLA LIAR OCCUR EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB CLAIMS -MADE DED RETENTION $ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? N / A 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 1 $ DESCRIPTION OF OPERATIONS / LOCATIONS /VEHICLES (Attach ACORD 101, Additional Renerks Schedule, if more space is required) CERTIFICATE HOLDER CANCELLATION © 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD Phone: Fax: E -Mail: jkconstruction@comcast.net SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN J. K. Construction ACCORDANCE WITH THE POLICY PROVISIONS. 24 Windsor Lane AUTHORIZED REPRESENTATIVE Topsfield, MA 01983 Lori A. Cote © 1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD Phone: Fax: E -Mail: jkconstruction@comcast.net Date ...... ... Z:r�.....�. Z-' TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that - J-c>0v 5�AIMv � .................................................. ............... ....................... has permission to perform ...........� ............. wiring in the building of ........... /....... '. t,......................._�_...�..................... at .........9 1`x.... T. d/1......5 r' .............. NIft' h Ann Mass. Fe ../7.< m.....-... Lic. No. �:141;i- .......... ... .... .................... .... .. ,............... LECTRicAL INSPE6MR Check ff '10746 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. Atter a permit application has been accepted by an Inspector of Wires appointed pursuant to M. GI c. 166, § 32, an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G L. c. 143, § 3L. Permits shall be limited as to the time of ongoing construction. activity, and maybe deemed_bythe,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 cm, k permit shall be terminated upon the written request of either•,the owner or the installing entity stated on the. permit application. n 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 -j& -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 dxtends, for four years beyond its otherwis a 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. Ule 8—Permit/Date Closed: Note Reapply for new per 541,2 ❑ Permit Extension. Act — Permit/DAte Closed: 1 (�ommonweatlh o�a39achu�g Official Use only Permit No. i © -7 q6 �epa� o�� �Seiwices - Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS m1/07) blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK Ali work to be performed in accordance with the Massachusem Electrical code (MEC), 527 CMR MOO (PLEASE PRINT'ININK OR 7TPEAUMLMATIOA9 Date: '� — 2 — 12 4 City or Town of: No CR y To the Inspector of Wires: By this applicartion the undersigned gives notice of his or herntion to perform the electrical work descxrbed below. Location (Street & Number) Q 4,0 hS" Owner or Tenant " F�, g -r., t D Owner's Address I Z 5o,, Telephone No. 603 3 Ir-- 3 gG c� Is ibis permit in conjunction with a building permit? Yes ❑ No �- (Check Appropriate Boa) Purpose of Building Utility Authorization No. Existing Service Amps 1 Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps 1 Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Com letion 4Ae oilow' table maybe waivedbydielkspectorof Wires. No. of Recessed Luminaires No. of Ceil,-Susp.-(Paddle) Fans o. o Total Transformers KVA No. of Luminaire Outlets No. of Hot Tabs Generators KVA No. of Luminaires Swimming—Pool gmdAbove ❑ d. of Emergency LAgating Bane iTa No. of Receptacle Outlets No. of OR Burners FIRE ALARMS]No. No. of Zones No. of Switches No. of Gas Burners o. o electron aadIniflaffuz Devices No. of Ranges No. of Air Cond. Tons No. of Alerting Devices ` No. of Waste Disposers eat p Totals- ombet ons o. o ontam etection/61 Devices No. of Dishwashers Space/Area Heating KW Muni )a Local ❑ Couneditia ❑Other No. of Dryers Head APplianc�s KW Na of 'cam or FAuivalent No. of Water KW Heaters o. of No. of SignsBallasts Data Rr�� No. of Devices or fauldent. No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivilent Anach ad&fu mal detail ifdesir A or as required by the Inspector of Wires Estimated Value of Electrical World j rd (When required by municipal policy.) Work to Start Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation' Coverage or its substantial equivalent The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify-) 1 certify, under the pains andpenaldes ofperlury, that the infotrnadon on this application is true and complete FIRM NAME: LIC. NO: Sigaure NO: Zc�7�Licensee: Sir` A (If4pplicnblt7 e,+t�exempt.. inft a ) Bus. Tel. No.; 7 rz i 7 Address. -3Z i�r � Ali. Tel. No. - *Per M.G.L. c.147, s. -61, se4uity work requires Department of Public Safety "S" License. Lic. No. OWNER'S INSURANCE W R: I am aware that the Licensee sloes not have the liability insurance coverage normally required by law.- By my signatuffbelow, I hereby waive this requirement I am the (check one)E] ❑ owner's a ent Owner/Agent Signature Telephone No. PERMIT FEE: S _ Tke Cotnawawet Uh ofHkv=hhzse& - DepwftiHt afladaft 'Accitiifs Ofj"ice afB;vesfigRfiMs 600 WasFiit in Street Boston, MA 02LIf www.gayld%a Mfor%eW Compensationbmance Affidavit: Bm3bnfContracionAgcctricim"lnmbers A plfcant Information Please PrintI.etsihiy Address: f l 3 OI V M Q i Cztylstddzi t: �` o P G Zo J Phone#: 79-/ -01-1106 Are y an employer? Check the appropriate box: 1. am.a vn0q--rwM_& 4. Q I am agermaiconhador and employees (full vwdrpart imej * have 16redthe snit -ern trarlm 211 1 I am a soleproptiietororpar6ier- ship and'bave no emplapees v:,oltg fir me, in my capacity. [No workers' comp, insrtrame r�tt�ci.] 3.❑ 1 am ahomtovmer doing ailwork lrw&df [Nowcdxra' comp- iasumce=gaire i.] t listed on do affachedshset t These sub-contutm have warl=' mmp. ince. 5. D We are a omporation and its offs ers have excised their ofeKw4AianperMGL c. 15% §1(4), andwebaveno employees. Wo workers' Guam. iusarance nanbW Tope of project (required): 6. ❑ Mew canstractioa �. ❑ Rornodaling 8, Demolition -r 9. ❑ iuildmg addition 10.flE(Rect6cal repairs or addWons 11.0 Plumbing repah or additions 12.Q Roofrepaim 13.©Mar ?nvtrr-:atii�-tck�%?:;tl mnstatso;�i a�Sersev�.soabeFciwshoFn�igUreii c�slce�a'�onPcliayiafmmetiors t hflm�xnus sea strimitfhis rffrdar3 inriitsetitrgi6e� dsripgsll work smd Brea lobe auk cvws imwts4bmit a mew s$davifcg sect+ thaicnect $us M+xExust a*�ohe3 sn ei3rYiawzi dwdelmdugtba n me offt a sub-mniractoo weft dMir WO kiss comppolicy bromagoa IT am an ern7ft-0,29UprOvIdIng WOAMI cappawaffm i>1sma we fimray eWA9ya&L Below is fhepoliq andjob dfe informatzom Insvramce Company Policy It or self -in. Mo. F-: - ezow_l ExpiratieuDaft: I (} Tob Safe Address: l U 30 Y� S � �'�` _ CityMtaWZz K. . & � kC V eil— � Attach a copy of the workers' compensation-golley declaration page (showing the policy number and expiration date). Page to some coverage as requireduader Section 25A of MGD e.152 can. lead to the imposition of crimindmaltim of a flue up to $1,500.00 andlor one veer h4irLsonment; as weltas civ penalties i t the foot. of a STOP WORT{ ORDER and a fine of up to V-50.00 a day against the violator; Be advised fhata copy of this statement maybe forwardedto the Office of InvoWgatians of flte DIA for fi=anc e coverage vetificadaL X do hereby ceMp wMerffiepains and p&wftier of pe#uty Stat Me ihftrm rt on pmvftd ab?ve L- #ue and correct Pone #- [?ffWal use only. Do net write in fids area, to he covWkfed by CRY Oftrtty» offtCW City or fiowtr: PermitaAce3ase g issuing Authw ity (&Ile one}: 1. Board of Health Z. Budding Department 3. Cityi uwn Clerk. 4. Elec€rical Inspector 5. Plumbing Inspector 6. € ther - - ContactPerson: