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HomeMy WebLinkAboutExplosive Permit - Permits - 285 HOLT ROAD 10/10/2019 North Andover i Application for Standard Permit FP-a4s .1(Rev.04112) Return completed application to: 1� Permit Number: �-�� DIG SAFE NUMBER city or Town: North Andover Date: 10-10-2019 Start Date: In accordance with the provisions of M.G.L. Chapter 148, as provided in Section b application is hereby made by NAES Northeast LLC (Full Name of Person,Firm or Corporation) (Phone Number) of 1240 Saratoga Rd. Ballston Spa NY 12020 (Address:Street or P.O.Box,City or Town,Zip Code) for permission to(state clearly purpose for which permit is requested) Use explosives to clean the interior surfaces fo power plant boiler located @ 285 Holt rd. North Andover, MA 01845 Name of Competent Operato (if plicable) Lee F. Kimble No. BL-4 26 Date Issued-rejected By / r� � 61 ( ignature p scant) Date of expiration Fee Amount Paid$ —A —_—._.........._.--._._-----------------------------------------------..............----- FP-006 (Rev.04112) PERMIT Cityor Town: AN�d•/b�� DIG SAFE NUMBER Date: b 1 Start Date: Permit Number(if applicable): In accordance with the provisions of M.G.L. Chapter 148, as provided in this permit is granted to rvg�5 l lf,457 LLC, (F it Name of Person,Firm or Corporation for V 51i' LL-td ,n (2,)yfL �vR 4 � �LL W' Restrictions:at �,✓oI.IL 1n ��' '! �� l4CCoLh�g(1R, dt� �,Mt� (Street and#or Describe Location for Adequate Identification) L �� Fee Paid$ Thi mit will expire on J _ ' �+ Signature of Official Granting Permit: Title This permit must be cons icuously posted upon the premises sg€ tEttdlili�i: �, �1°[;f�iil.i§:i4;liilll,l ¢€s -�.. w 0,/ 11to 6 6� '90aWm� ol (�Xxe �gelx,� Explosives User Certificate EUC-000321 This is to certify that in accordance with all Massachusetts laws and regulations a Explosives User Certificate is hereby issued to: Expiration Date.- 06/01/2020 Restrictions or Secondary License Type: NAES Northeast LLC 1240 Saratoga Road Ballston Spa NY 12020 State Fire Marshal Post in a conspicuous place. Verify the status of this Certificate at www.mass.gov/dfs minO3X3 To: Whom it may concern Here is a list of all my current MA blasters. I wanted to send you this; due to the nature of our industry we never know who might end up doing the work. If you have any questions or need any further information,please feel free to call me. My direct line is (518) 885-6422 ext. 109. Name Lic# expiration Perkins,Dana BL-6994 10-17-20 Pero, Rich BL-7111 12-16-19 Horinka, Gary BL-4169 09-26-20 Lambert, James BL-3123 02-08-20 Kimble, Lee BL-4226 06-16-20 Simok, George BL-7185 12-06-19 Sincerely Lee Kimble Compliance Officer NAES Northeast LLC DD1YY ACURV CERTIFICATE OF LIABILITY INSURANCE ORTE(MlN YY) D6/1 MIDDNY �- 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 have ADDITIONAL INSURED provisions or 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 LTC #0829370 1--205-581-3330 CONTACT Kelly Chapple NAME:Edgeweod Partners insurance Center (EPIC) PHONE FAX 205 581 3390 [Alabama Branch Branch ID 15491] -(A/c,-No,,(xi) .... (y� No �- 205-250-1173 E-MAIL y•cha le 2901 2nd Avenue South, Suite 200 _ADDRESS: kell pp @epicbrokers.com INSURER(9)AFFORDING COVERAGE NAIC# Birmingham, AL 35233 INSURERA:ASPEN SPECIALTY INS CO 10717 ... ............ ......... ---- INSUREO INSURERB: OLD REPUBLIC GEN INS CORD 24139 North American Industrial Services, Inc. INSURERC; ASPEN AMER CO......... ---�'43460 ._ ----- -..... --- --- — --.- ........ ......................... 1240 Saratoga Road INSURERD_ ALLIED WORLD ASSUR._CO US INC _... 19489 INSURERE: GEMINI INS CO i10833 Ballston Spa, NY 12020 INSURERF: p COVERAGES CERTIFICATE NUMBER: 56447260 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. ADDLSUBRi -_--- - - POLICY EFF _.POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER MMIDDNYYY MMIDDlYYYY LIMITS A 3 X COMMERCIAL GENERAL LIABILITY X X I EROOCV919 06/17/19 p 06/17/20 EACH EACHOCCURRENCE -. -� 1,000,000 DAAAG TO RENTED. GLAIl.1S•A1ADE I X OCCUR PREMISES Ea occurrence],. S 300,000 ... . X I Cont Pollution (OCC) ;MEP EXP(Any one person) is 25,000 11X E&O (Claims Made) I I PERSONAL&ADV INJURY Is 1,000,000 ....._.. ....-I _-__ �. ...._............_---__— GENI AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE is 2,000,000 r� PRO- ........ ..... - POLIGY��L X_{{JECT LOC I I�ODUCTS-COMPlOP AGG $ 2,Q00,000 1 i� - ....... - -- I OTHER: " ' S B I AUTOM091LE LIABILITY06/17/20 X X A4CAA0006000 06/17/19 COMBINEDSINGLEHIAT _ 2,000,000 ` i g BODILY INJURY(Per person) S X 1 ANY AUTO E;E ............... 'HIREOWNED SCHEDULED i i BODILY INJURY(Per accident) $ .. _ .... ...... ...- +�__- AUTOS ONLY __. A�OS ONLY L(PROPERTY Cr id ntDAMAGE j S ---- -OWNED i X I AUTOS ONLY X �. 1 111 I A UMBRELLALIAB X E pCCUR X X �EXOOCVA19 06/17/19 : 06/17/2D ��, EACH OCCURRENCE S 5,000,000 + .. T 5,000,000 'i, X j EXCESS LlAB -.-_ l CLAIMSMADE I .AGGREGATE.- S DED RETENTIONS S ON ILITY ANYPROPR EOORIPARTNIERIEXECUTIVEYIN PER OTH- I X '1A4CWAD06000 06/17/19 06/17/20 ER !AND OF FCERI fIETO REXCTUD F � N!A E.L.EACH ACCIDENT S 1,000,000 B (Mandatory ) E.L.OIS AS ---- $ 1,000,000 Mandato in NH) I !E.L.DISEASE-EA EMiPLOYEE I I( es,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S C ;Leased 6 Rented Equip IIM00CVG19 06/17/19 06/17/20 Per Item 1,000,000 D Excess Liab - Layer 2 0311-8866 06/17/19 06/17/20 Per Occ/Agg 5,000,000 E Excess Auto GVE100228301 iO6/17/19 E06/17/20 Limit 1,000,000 DESCRIPTION OF OPERATIONS 1 LOCATIONS f VEHICLES(ACORD 101.Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Wheelabrator North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 285 Holt Road AUTHORIZED REPRESENTATIVE North Andover, MA 01845 USA ii 4-1.. ©1988-2015 ACORD CORPORATION, All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD KChapple 56447260 SUPPLEMENT TO CERTIFICATE OF INSURANCE DATEas/11/zols NAME OF INSURED: North American Industrial Services, Inc. Additional Description of Operations/Remarks fsom Pa g 11: Certificate holder is named as additional insured as respects to General Liability, Auto Liability, Pollution Liability and Excess Liability on a Primary and Non-Contributory basis as required by written contract; Waiver of Subrogation is issued in favor of Certificate holder as respects to General Liability, Auto Liability, Pollution Liability, Excess Liability and Workers Comp/EL as required by written contract; All policies contain a 30 day notice of cancellation (10 for nonpay) subject to policy terms and conditions; GL includes a per project aggregate; XCU, Contractual Liability, where required in a written "insured" contract, Broad Form Property Damage, includes separation of insureds, and independent contractors; WC includes alternate employer, Stop Gap for monopolistic states and USL&H; General, Pollution and Professional Liability policy include 1MM per occ/2MM agg with Aspen Specialty Insurance Company, then an excess 5MM with Aspen and an excess 5MM with Allied World Insurance Company; Auto Liability includes a 2MM limit with Old Republic General Ins Co, then a 1MM limit with Gemini Ins Cc then an excess 5MM with Aspen and an excess 5MM with Allied World Insurance Company; Employers Liability includes a 1MM/1MM/lMM with Old Republic General Ins Co, then an excess 5MM with Aspen and an excess 5MM with Allied World Insurance Company; Additional Information: SUPP(05104) Additional Named Insureds Evergreen North America, LLC(Delaware LLC) Evergreen Environmental Services, L.L.C. (Texas LLC) Evergreen GEM Holdings, LLC(Delaware LLC) GEM Mobile Treatment Services, Inc(California Corp.) Industrial Services Acquisition Parent, LLC(Delaware LLC) Evergreen North America Acquisitions, LLC(Delaware LLC) Industrial Services Holdings, LLC(Delaware LLC) Industrial Services Investments Holdings, L.P. (Delaware LP) Industrial Services Investments, LLC(Delaware LLC) Evergreen Industrial Services, Inc. Mussop, Inc. (Arkansas Corp) NAES Northeast, LLC(NY LLC) North American Field Services, LLC(NY LLC) North American Industrial Services, Inc. North American Pipeline Services,LLC(NY LLC) North American Services Group, LLC(Kentucky LLC) Targhee, Inc.(New York Corp.) Western Relief LLC(Wyoming LLC) Evergreen North America Industrial Services