HomeMy WebLinkAboutMiscellaneous - 150 Kingston Street i
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Datel.1 1
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TOWN OF NORTH ANDOVER,
03�
n PERMIT FOR WIRING
s,CMUS�
This certifies that ..........�4Y1. ......... t:a. ?.......................................................
4
has permission to perform ..�e,. ........ ? - ,
wiring in the building of.�`....!?e
1
at
...................... ? . .:... :........................>North Andover,Mass.
3
Fee....... a
.../.....--............Lic.No. ���..�"'....................................................................................
ELECTRICAL INSPECTOR
Check# 1-17�4
1Gr� Ur
� 3
C omm.or:aeAM OY M1,1:fac4ajei7± - --- Official CJs:Only -
'I ire
Permit No. I ----
r .Un.��arEmen�
BOARD OF FIRE PREVENTION REGULATIONS O,,, 1/0 ) and Fee Checked
�__--- (leave blar)[cj
All-CIrk to be perfon-ned in accordance with t;:c tv,a:.sac�- —z Tit'., ct,l Coci:-('✓BC
), 527 CivfR 12,00
(PLEASE'PRINT IN INK OR TYPE,4LL.It\1FORMATION) Date:
Town City oi- Toof: ---��L�--
� 1` _7•o rhe o i1%fires.
BYthis application the undersigned giveS notice of hIS or her111te11C10n CO pCr{OrIll L. 3;.^Cir
I ,,_r.. described be o-'v.
Location (Street&Number r
Owner or Tenant ) ^ .—.1 .�_ -
a-f -------�y-W- 03 ------- -- f'elep-hone No.
mmner's Acidl•ess r
Is'thisthis permit in conjunction ivItIll a briildrrlp permit? ;es i��o --- a' ---- ---
� ,,� ` Lel (Checl :,.pprapriate Bo )
Purpose of Building----� ��.g/� - _ -- Utility Authorization No.
Fxisdri-Service ®� A-mps —Volts Overhead s ------- -- �l
_ Undgrd � Nio. of Meters
New Service / --�
I.IL�e_ :Amps 4- VolO
ts verh 'ad -) CJndgrcl J No. of MIeters J
Number of Feeders and Ampacity
Location and Nature f Pro)osed Electrical Work0 J6— e — -- -- -
ri; - s � _
�:'- --arw-
i r.:'ir OW11 p taoie m.c (..e ti„awed b� rrle: !i'IPB.S.
[No.
, of Recfssed Lii:Tiinaires Fro. Of Ceti.-cusp. (Faddi ) Paris ; —
t I Transformers 1��A. ofLuminaire Outlers Noof Hot'Tubs �-FGeneritors. of Lu minaires T — —,----Abnve - In- ---- �oulLmeenung1swirnming roolrnd.— �rnd. I� IBat.tel�lnits of Receptacle Outletsof Oil BurnersFIIti? A.I_,:i,2NISiNo. of 7_,onesof switchesINo. of GPS Burners Na. of Detectionrnidatirl�_ Devices
of Rangestin. ofA.ir Conti,
Toris lio cf:kierting Devices
INo. of Waste Disposers
'- -IOiPis: I
rNn. r;tiSoT:;1';A-C.leortinai�ne.. ........... .... ............ iad—_
--- ----`�
Devices
INo. of Dishwashers Space,%Area Heating K«' - i ,1 1- "iurir. pa]- ----- \
- ------
Connection hL1
INo. of Dryers He itin'a Appliances-- K`V
1 N 0. of a t C'I' -- '----.__.----- ---- ---- --NO. a`v i r i'S or P.h,u I
Heaters K.
]N-0- o f �'o. o f -T_— --- ---=-------_ __.
Suns Ps:s
-----�--- ----- `0. �'' c 1 1 e ri t
No. Hydrom _saac Bathtubs ------- -- r;:rcc':nl;:unicahons '1;;ring;
--- .. --- -- INo. of Motors Tot ! r`IP
----- ----..— ------_-_.---
No. o f D e v i(:es Or- E cl u i Fal e n t
�� o;- s requi, y the irspeclw'n/1Tire..
Estimated Value ot'Clectrical 1�'orlc:
` cgLi: d by municipCl policy
ork to Start:- - 5F c, — r” )
Ir•snecti iS CO:ie rC(IileSieCr m cordance with i\fL-•
[N'SrrR4NCE COVERAGE: Cll:iess waived 'Y"
Ci!e 0' -..r, "n p- 111it For the pel-fo!?IlaneB (?i-c15CirICF!I �r�orh may 1SSlle
!!Gens _"C.'.0 proc'IOf11aC111?y i11sL':"aT1C' Tl^livii- `ni. '
atlon' ce era, or ltS Sul,siantial eq
._..__..'c;•;,._ �'rrit il�J' iiiat sl.ich ;:0\;.,?ae ... Livalc!i. ...:.
�� 'il I:)ril-' :iii: ,iiS eX_�i C' ;-. c� .
CKON;-'. -,�i Z TI'ANCE, (�i BOND i:. pe:; ;, is uin� ofllce.I ceri jl-, ur:Ger e-he pains and penalties of LIerjurn'; fs
c)'ue and con;p(ete.
FIRM NAME:
.e
-- "�+r'r-'�G
licen e n::c;b,.r line.1
4ddress: �—d'�Q�C�(3� Qe �y� ��� [ us. Tel.
Per tvi — — — - _ t. d
U.i_.. . i?:%. s. %-GJ,security wor:r - - �I - - --
Tel ��'o,:
� 'edulre :.�:_�.---lent of ublle
o VNT'I"S P\`SUP-kN'C1J 'NAIVLR., I ;ai e it: Licensee dogs nol h-'
':
I is N
instllance covera _
required by 1::':;. By my sib_:<:hirebelow, 1 r:_reb} v.; ', requirement. [ am r ( � _
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!8) l—) OY',�ner
5ianature Ni - _ - `
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09/03/2015 09:39 Ne i I & Ne i I I nsurance Agency (FAX)14137316629 P.001/001
,4 ! t CERTIFICATE OF LIABILITY INSURA►NCE' Dan(mMrDDmrrrl
09/0312016
15
.
THIS CERTIFICATE IS ISSUED AS A MA'K'ER 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($), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If tho cortHlcato holder Is an ADDITIONAL INSURED,tho POHGy(les)must,be 0 nab If SUBROQATION IS WAIVED,sub)act to
the terms and conditions of the policy,certain poIICleti may require an endorsement+ A statement on this certificate does not confer rights to the
cortlficate holdor In Ilau of such ondorsamant(s)•
FRoaucERDavld Jarry
Neill 8 Neill Insurance Agency Ino Me UT
692 Riverdale Street FNONE (413)732-+1137 C No (413)731.8829
West Springfield,MA 01089 aooRL a,
INSURERS AFFORDING COVERAGE NAIL N
INSURERAt State Auto Insurance Company STA
INsuREo Michael Farelli ElectrlGat 1NeUSE�s. Acadla Insurance Co. 31325
9 Applewood Lane
Methuen,MA 01644 INSURER O, i
INSURER O: '
' N8U E i
INSURER F
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS 16 TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INbICAT6b, NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE 1SSU90 OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
ILTR NSR TYPE Or INSURANCE M
POLICY Numlaek C EX i
A GENERAL LIABILITY BOP2748517 06/10/2015 06110/2016ELIMIT9
MACHOCCURRENCE a 1,000,000
COMMERCIAL GiNERAL LIABILITY P I ! 60,000
CLAIMS-MADE ®OCCUR MED'EXP cna anion S 5,000
PERSONAL GADV INJURY S 1,000,000
GENERALAGGREGATE 1 2,000,000
G8N'LAGGREOATELIMITAPPUESPER: PRObUGT$-COMPldPAL3G 3 2,000,OCu
p ►
POLICY LOC
AUTOMOBILE LIABILITY
ANY AUTO Roup INJURY(Per person) 3
LHIREDAUTOU
EP A�C�1TTODULEO BODILY INJURY(Pvr accident) 6
AUTOS EDPRQPERtle DAMAGEAUT08 ELLA L1A! OCCUREAQFi pt~CURRENQE9LIAa CLAIMS-MADE AGGREGATE 9
DED RETENTION t
WORKERS COMPENSATION WC-20-20.001481-05 03/20/2015 03/20/2016 I nj�TA`rUT• STH• s
AND EMPLOYERS'LIABILITY Y f N
LIMI
ANY PROPRISYO91PARTNEWEXECUtIy9
OFFICERIMEMSER EXCLUDED? NIA E,L,EACH ACCIDENT b 1 D0.00
liar
(MandatoryInand E.L.DISW8-PA EMPLOYEE 3 100,000
Ilyye3 tletrriheuntler � ,
DE$L�RIPTIDN OF OPERATION$below E.L.DISEASE+POLICY LIMIT S 500,000
1
DESCRIPTION OF OPERATIONS!LGCATIONE I YERICLES(Attach ACORD 101,Additional ROMA"50hedule,N More ApecN Is nqulrad)
Faxed to: 978.882-1480
• i
CERTIFICATE HOLDER CANCELLATION ! _
SHOULD ANY OP THE ABOVE DESCRIBED POLICIES BE CANCELLED 29FQR2 S
Town of Andover Building Department THE EXPIRATION DATE THCREOF; NOTICE WILL eE DEiLMRED IN
36 Bartlett Street ACCORbANCE TH THE POLICY PR6V161ON8,
Andover MA 01810
AUTHORI=9 RHP 9H AT1V8 A
O-k,*
®1988.2010 AGOR ' ORPORA IONJ All rights reserved.
ACORD 28(2010106) The ACORD name and logo are registered marks of ACORD
The Commonwealth of M. assachusetts
Department of-IndustrialA ceidents
I Congress,Street, Suite 100
Boston,MA 02114-20,17
www mass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Cmitractors[Electricians/Phrinbers.
Alicant Information TO BE FILED WITH THE PERMITTING AUTHORITY.
Please Print Le ibl
Nalne (Business/Organization/Individual):
Address:
City/State/Zip:_ *,'YJPhone a ' �,, l?a_.
[2.
e y an employer?Check the appropriate box:
F7E
of project(required):
am a employer with employees(full and/or part-time).❑I am a sole proprietor or partnership and have no employees working for me in New Construction
any capacity.[No workers'comp,insurance required.] Remodeling
3.❑I am a homeowner doaig all work myself.[No workers'comp.insurance required.]i Demolition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 0 Building addition
ensure that all contractors either have workers'compensation insurance or are sole
proprietors with no employees. 11.�Electr•ical repairs or additions
5.[J I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 12. I Plumbing repairs or additions
These sub-contractors have employees and have workers'comp.insurance.$ 13.❑Roof repairs
6.E]We are a corporation acrd its officers have exercised their right of'exemption per MGL c. 14.Q Other___
152,§1(4),and we have no.employees.[No workers'comp.iiisurance required.]
*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-contactors and state whether or not those entities have
employees. If the sub-eoniraclors have employees,they must provide their workers'comp.policy number.
fain an employer tliat ispioviding wof•kers'conzpensatiozz insurance fol•my employees. Below is thepolicy andjob site
information.
Insurance Company Name:
Policy#or Self ins.Lic.#:_ W C C,.- G .• oGr ) la .{ S Expiration Date:
p � c i
Job Site Address: �� _N A 64^ S�. ���.(�� � City/State/Zip: An d
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 WORI.�,'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.
I do hereby certify nder the pains and penalties ofpeijuly that the information provided above is true and correct.
Sign ure: l.A c ��
Date
Phone
F
icial use only. Do not write in this area,to be completed by city ortown official.y or Town: Permit/License#ing Authority(circle one):
1
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person:_ Phone#:
' 3
•4
011ICPA NMF ALT11 � _
32,•1 � �
A:, j�MlA�y,S,�� �rf m � f � ,•
itJ SSIUES tME FC�LLOW'I NC�W � � '` A
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to
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9 APPCEVkflf7N f+
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NORT:,� TOWN OF NORTH ANDOVER a
° p PERMIT FOR PLUMBING
;,SSACNUSE�
This certifies that . . . . . . .
has permission to perform . . . . . .. . `. .-:�?�?
plumbing in the buildings of . . . . . . . . . . . y
North Andover, Mass.
�. 6
Fee's . . . . . .Lic. oa�'. . . . . . . . . . . . . .
PLUP 9INSPECTOR
Check # v
i
i
8301 y
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
City/Town: MA.. Date: ' Permit#
Building Location: Iso k w( -STN Owners Name: ��� ba S
Type of Occupancy: Commercial❑ Educational❑ lndustrial❑ Institutional❑ Residential
New:❑ Alteratlon:❑ Renovation:❑ Replacement: Plans Submitted: Yes ] No❑
FIXTURES
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8
a v W
to w
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Q W o Q a o o w .�� z ' v a
0 W G tr v?
W d a o tai > p O O Z Z- `tn
Q 4 N O� Q ® O = .d de r� Q Q Q I..
SUB BSMT.
BASEMENT
1 FLOOR /
2NO FLOOR j
3 FLOOR
4 FLOOR
5 FLOOR
61"F R
7 FLOOR
FLOOR
�� i Check One Only Certificate#
Installing Company Name:
C n j �1(1W
S S 1�� Ci `.lC�"1�0-0 ,� f�� �� ❑COrporatiot!
Address: rtyRown: State: �v rr--
JJII ❑Partnership
Business Tei:(G6� `� � � Fax:
(Firm/Company
Name of Licensed Plumber: '1
INSURANCE COVERAGE:
have a current flabilftyinsurance policy or its substantial equivalent which meets the requirements of MGL.Ch.942Yes No[I
pIf you have vhecked Yes,please indicate the type of coverage by checking the appropriate box below.
'vA liability insurance policy Other type of Indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 942 of the
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
Check One Only
Owner ❑ Agent ❑
Signature of Owner or Owner's Agent
I hereby certify that all of the details and Information t have submitted for entered)regarding this application are true and accurate to the best of my
Knowledge and that all plumbing worts and installations performed under the permit Issued for this application will be In compliance with all
Pertinent provision of the Massachusetts State Plumbing Code and Chapter 942 of General ws.
I
By Type of License:
Title ❑Plumber Signature of LicensedPlumber
cityfrown gMaster
eyman License Number.
APPROVED OFFICE USE ONLY
! `\ t�tJfr 1n1JYc?+'
�--�. -- \ said, oI.Massachusetts Rrtnt Form
� De
parrment oflndustrial Accidents
k Office of In vestigations
= ^r 600 Washington Street
` Boston,MA 02111
-`- t+'ww.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information
Please Print Leaibl
Naive(Business/Organization/Individual):11/� C
Address: Irl 1 4
j City/State/Zip: KJ4 a� J�
F2 ,
employer? Check the appropriate box:
Phone#:
employer with 4. 0 1 am a general contractor and 1 Typeofproject(required):
ees(full ander part-time).* have hired thesuh-contractos 6 ❑New construction
ole proprietor or partner- listed on the attached sheet. 7.d have no employees These sub-contractors have ED Remodeling
for nee in any capacity, employees and have workers' g' ❑Demolition
rkers' comp. insurance comp.insurance.$ q• Building addition
❑ zrquired.l 5. [] We are a corporation and its 10.❑Electrical repairs or additions
,,am a homeowner doing all work
officers have exercised their 11. Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL
insurance required.] t C. 152, §1(4),and we have no 12• Roof repairs
employees. [No workers' 13.[] Other
comp.insurance required.]
applicant that checks box#1 must also 8ll out the section compensation policy information..,
below showing the,T workers'
Homeowners who submit this affidavit indicating they are doing all work anthen hire outside contractors must submit a new affidavit
d indicating'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
am an cnrplgper'til oyees
enruloyees. I;the.sub-conuactors have empl ,they must provide their workers'comp.policy number. g such.
I
at is providing it,orkerc'cornpensatinn insurance for nr�,emplo��ces Belo, is MePolicy information p cy and•lob site
insurance Company Name:
Policy#or Self-ins.Lic.#:
Expiration Date:
i Job Sit.',Address:
Attach a coley of the workers, compensation policy declaration page(showritt City/Stale/Zip:the
Fallure to secure coverage as required under Section 25A of MGL c. 152 can lead to die imposition of criminal
fi policy number and expiration date).
fete up to 51,500.00 and/or one-year imprisonment, as well as civil penalties ni the form ofa STOP WORK ORDER and
of up to 5250.00 a day against die violator. Be advised that a co y of this s a± Y A penalties of i
sti_eiions of the DIA f'or insurance coverage verification.
p t. e',nt ma ' a fine
hon. ) be forwarded to dee Office of
T lio L-r•oh .ri fi•
-;-S a d E1d1IddleS U'7�'e,'•�
d' .ir'ry that the inforatatiort provided above
Sigraturt: is true and cornet;
Phone = G�
Official use nrrlt: Do trot 1,ring iJr this area, to he completed by ciO!or toxin official
Cite or Town:
Ic�u, Permit/License#
3z rit, (circle ane):
i Boarc r,`Health 2.Building Depariment3. City/Towyn Clerk 4.Electrical cal I 5.Plumbing
6 O tJ r Inspector
{ Ccnt4 t Person:
Phone#: