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HomeMy WebLinkAboutMiscellaneous - 4 Royal Crest 4 S 'D ..^� r1 Date............................................ I OF Nonny , TOWN OF NORTH ANDOVER n PERMIT FOR WIRING SsgCMU9� This certifies tha .............�.e. has permission to perform�L6G S�o(A^cA 12 Q LU� �,, e.,l x S ...................... wiringin the building of......................................}.... ..d....................................................... at ............................ ...................................................... .,North Andover,Mass. �Fee.... Z ..."..........Lic.No)C)..�. f ............................... AECTRICAL INSPECTOR Check# I!� r i 26 47-. Commonwealth of Massachusetts Official Use Only Department ®f Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASEPRINTrNHKORTYPEALLMFORMATION) Date: qucw5t (�, , I 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) 'S(:) Q0_40-1 Cee--S+ b.2 Owner or Tenant 4 M,C® 1`1.6 RZ -h IA tv ©av- v, QL(I. Telephone No. Owner's Address bu i left t1 Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building 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: C�eCK G C n tc ('_6nr► C-F-t�s1`S 1l,4 P-34S,-0 m—ct e-LtdrL; c, ).ko—+ t L n e- vo I jceg e- 4-b tr m o s tgJS an cL C'-,rCo i4 b r ect-k e-r S P<e-D i n -t-V,-eS e- 'V n 14-- ° Completion of the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Cell: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- ❑ o.o Emergency Lighting rnd. rind. Battery Units i 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 No.of Alerting Devices Tons No.of Waste Disposers HeatPump Number 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 Equivalent OTHER: ry' Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: 3 ©� 00: (When required by municipal policy.) Work to Start:a(a Ig i Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify, cinder the pain wandenaltiers/of er.ury,that the information on this application is true and complete. FIRM NAME: A \e.1 F V l�J e— LIC.NO.: A 1579 Licensee e-l P..� U 1�l Signature 1 c LIC.NO.: 1 (If applicab eyy,enter "exempt"in the license number line.) Bus.Tel.No.- Address: —to D R I 1` S4-- WCt._1 W4pl IM A- O D A s i 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. I am the(check one)❑owner ❑owner's a ent. Owner/Agent PERMIT FEE. $ Signature Telephone No. The Commonwealth of.Mrassachusetts Department ofIndustrial Accidents Office of Investigations 600 Washington Street Boston,MA. 02111 UV www.mass.gov1dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly (� �k Name(Business/Organization&dividual): ���1 �� iPyt (� � (C7L).(L Address: (_c[d ��� � S-t-- City/State/Zip:C L)!�=L('(1c,.-W) Phone#: �)O&E(09-Lg Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4• ❑ I am a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet.t 7• ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. El Building addition [No workers' comp.insurance 5. El We are a corporation and its required.] officers have exercised their 10. Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.0 Roof repairs insurance required.]t employees.[No workers' 11dother comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. T-Homeowners who submit this affidavit indicating they tie 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 their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. �A � Insurance Company Name:. Policy#or Self-ins.Lie.#: W CC CJG()69`5 Expiration Date: Job Site Address: Jr 6 cZot,�e� Cr�� City/State/Zip: 1�,hJ 0OIr(r M A (516 U,S Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one=year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of .Investigations of the DIA for insurance coverage verification. Ido Izereb cert under the pains an 1d penalties of perjury that the information provided above is true and correct. - Signature: `y Date: (9(4- Phone# 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#: nix COMMONWEALTH O.F MASSACHUSETTS p i 1 . aOAtD _ ELECTRICIANS ISSUES THE FOLLOW L(CENSE AS A---- b ED MASTERELECTRICIAN ice ' DANIEL P VITALS ; =e q m , 190 DALE'ST \ e Z ` WALTHAM MA 02451-3773 15799 a 07/31116 35001 —� . COMMONWEALTH OF MASSACHUSETTS j BOAtiky Of i ELECTRICLANS ISSUES THE FOLLOWING LICENSE AS A!REG JOURNEYMAN ,ELECTRI.CIAN i DAN 1,,,:E1 P VITALS ' QbEL 190 DALE:`ST ' Z w J WALTHAM MA 02451-37T3 35002 31850 E :'07/31.116 ` !ioao as�cO© ® DATE(MMIDD/YYYY) A�o CERTIFICATE OF LIABILITY INSURANCE 8i26i14 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). PROWLER CONTACT NAME: LESLIE HANNON James O'Connell Insurance Agen PHONE (978) 667-6150 FAX No: (978) 667-0587 C.572 Boston Rd ADDRESS: JIMINS@OCONNELLINS.COM Unit 7 INSURE S AFFORDING COVERAGE NAIC# Billerica, MA 01821 INSURER A:Merchants INSURED INSURER B:A.I.M. Insurance DANIEL P VITALE ELECTRIC INSURER C: 190 DALE ST INSURER D: WALTHAM, MA 02451 -INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR AML SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS A GENERAL LIABILITY BOP9098053 9/12/14 9/12/15 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED X COMMERCIAL GENERAL LIABILITY (Ea occurrence) $ 500,000 CLAIMS-MADE a OCCUR MED EXP(Anyone person) $ 15,000 PERSO NA L&ADV I NJU RY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'LAGGREGATE LIMITAPPLIES PER PRODUCTS-COMP/OPAGG $ 2,000,000 X POLICY PRT LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE L IM Ff Ea accident $ ANYAUTO BODILY INJURY(Per person) $ ALLOWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPS D $ DAMAGE HIRED AUTOS _ AUTOS UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS IAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ B WORKERS COMPENSATION WCC5006538012009 10/11/13 10/11/14 X WC STATU- OTH- AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/ExECUTIVE Y� N/A E.L.EACH ACCIDENT $ 100,000 OFFICE RIME MBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If YYes,describe under DESCRIFTIONOFOPERATIONSbelow E.L.D IS EASE-POLICY L IM IT $ 500 000 i I DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is regui red) ELECTRICAL WORK CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN TOWN OF NORTH ANDOVER MA ACCORDANCE WITH THE POLICY PROVISIONS. 120 MAIN ST NORTH ANDOVER, MA 01845 AUTHORIZED REPRESENTATIVE , LESLIE HANNON ©1988-2010 A ORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD Phone: Fax: E-Mail: 9938 • Date....... t f NORT►,1 3?�•'�����+�-e�ppL TOWN OF NORTH ANDOVER PERMIT FOR WIRING ��SS�cHusf� This certifies that �..' has permission to perform �•��'��� �' � wiring in the building of..... L.... 'r-........................ Da at ...................... North,North Andover,Mass. .. ................ Fee..................... Lic.No.. d 73� ........ ;. ........... I9LECrRICALINSPECTOR ©?7 Check # tfommonweahk o f Waesachuaeffi Official Use Only cc�� cc77 Permit No. eLJepartme►xf ol.}ire�ervice� e Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank) 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: March 3, 2011 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) 50 Royal Crest Drive Building # owner or Tenant Royal Crest Apartments Telephone No. 978-681-1822 Owner's Address 50 Royal Crest Drive North Andover, MA 01845 Is this permit in conjunction with a building permit? Yes ❑ No Q (Check Appropriate Box) Purpose of Building Commercial -Apartment Building 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 A Location and Nature of Proposed Electrical Work: Install 6 Gell Packs! Completion o the Lollowing table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- Elo.o mergency Lighting rnd. rnd. Battery Units 6 No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS I No.of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons g No.of Waste Disposers Heat Pum Number Tons KW No.o. Self-Contained Totals Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection Security No.of Dryers Heating Appliances Key Y S ystems: No.of Devices or Equivalent ? No.of Water Kms, 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: $ 600.0Q (When required by municipal policy.) Work to Start: 03/03/2011 Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ® BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: The Electricians & Co. Inc. LIC.NO.: A10737 Licensee: Michael J. Parziale Signature IC.NO.: E20269 (If applicable, enter "exempt"in the license number line.) Bus.Tel.No.: 781-322-9344 Address: 50 Branch Street Malden, MA 02148 Alt.Tel.No.: 781-322-3100 *Per M.C.L.c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.No. SS CO 001021 OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑ owner's agent. Owner/Agent PERMIT FEE. $ 125.00 Signature Telephone No. 77 _ 7 Date.. 6:. �,. all. ..... WORTH TOWN OF NORTH ANDOVER • PERMIT FOR GAS INSTALLATION �4SSAC MUSE This certifies that . . . . . .^A OA`. . .:`. . . . '.`. � �� Sh« ' .�_. has permission for gas installation . . 6l .�. . . . . . . . . . . in the buildings of . . . . `? c C A"t . . . . . . . . . . . . . . . . . . . . . at .i�'' .7.`. . .� �!�C . . . . . . . . . . . . North ndover, Mass. Fee a. Lic. No. �. . . . . -' . . . . . . . . . . . . GAS INSPECTOR Check# � � MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING City/Town: z-`9 , vim MA. Date: Sr--Z-// Permit# Building Location: 60 Owners Name:_ Type of Occupancy: Commercial❑ Educational ❑ Industrial ❑ Institutional ❑ Residential.®. New: ❑ Alteration: ❑ Renovation: ❑ Replacement: [5 Plans Submitted: Yes❑ Nom FIXTURES W Ui WW Y F— N Z F- N V = m W O W W U N H O = W W _ ~ Womww Z F- q Z W W W O I- yW W W to 00 Q a tW- o w X W V W W Lu Z W O� W 0 W > V W Z O J F- F O Z J (� LL N 2 W W W v o o u=. = z O a> > > O SUB BSMT. BASEMENT 15T FLOOR 2 FLOOR -3'FLOOR 4 TH FLOOR 5TH FLOOR 6 TH FLOOR 7 IHFLOOR 81HFLOOR _� Check One Only Certificate# Installing Company Name: //�i�i � y � �r�iZj �c�✓e- , iSZ ❑Corporation Address: eZl- gs --r7 City/Town: State: Ike* ❑Partnership Business Tel: Fax: ❑Firm/Company Name of Licensed Plumber/Gas Fitter: f p c c INSURANCE COVERAGE: I have a current liability,insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Yes ❑ No❑ If you have checked Yes,please indicate the type of coverage by checking the appropriate box below. Y A liability insurance policy ® Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. Check One Only Signature of Owner or Owner's Agent Owner ❑ Agent E] By checking this box❑;I hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in .� compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. Type of License: By ❑ Plumber Title F-1GasFitter El Master nature Sigof Licensed PI bei/Gas Fitter City/Town ❑Journeyman License Number: �l�D APPROVED OFFICE USE ONLY ❑ LP Installer i !I 9® 16 Date. "oRTM TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ,SSACNUSE� This certifies that .Coynv n c15 1A. . 6.���r'. . ���`� . . . . . . . . . has permission to perform `+ "`!. . hr�-�'. .ff.�1�! !' � . . . . . plumbing in the buildings of . .Ro r'A . .(, q� . . . . . . . . . . . . . . a . (dLcj t. . . � . . . . . . . . . . . . .. North AnVer, ass. Fee.,3P.. .Lic. No.. .j.�U . . . . . . . . �. �-. PLUMBING INSPECTOR Check # ! Z MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING City/Town: ,(� iL// / � , MA. Date: ._S-�?// Permit# Building Location:- 9!? 66-F-IL e y Owners Name: ,PvY146 4fxfz r Type of Occupancy: Commercial❑ Educational❑ Industrial❑ Institutional❑ Residential ] New:❑ Alteration:❑ Renovation: ❑ Replacement:,0. Plans Submitted: Yes❑ NI FIXTURES DEDICATED LU Z SYSTEMS Z Z LU Y U N LU LU Z yCr CA Ln CA V) Ln 0 Z tn n W Z ~ Y C Q ~ W ❑ ❑ a' Q a Z v� Z Q w C7 c D: Z rY O m h aaC Lu N w Q III 'n NO a r=- N N W FW- w ❑ z H C7 -' x Q r— ❑ Ln N Q W 0 ❑ W Z W Z U °' �- _ � Q v - H a O u > j .p 0 a Z Z cn W FW- W U. 07! O Ln a m m o o LL = Y g g N rQ- R 3 3 9 0 a❑0 W 0< W w a SUB BSMT. 3 BASEMENT 1ST FLOOR 2ND FLOOR 3RD FLOOR 4T"FLOOR ST"FLOOR 6T"FLOOR 77'FLOOR 8T"FLOOR I g Company Check One Only Certificate# nstallin 'Com an Name: �� ❑Corporation Address:Z.12&&640-s' City/Town: e State: El Partnership Business Tel•_-��/•��rf�,/�7 Fax: ❑Firm/Company Name of Licensed Plumber: INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Yes ❑ No❑ If you have checked Yes,please indicate the type of coverage by checking the appropriate box below. A liability insurance policy. ❑ Other type of indemnity ❑ Bond ❑ r , OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. Check One Only Signature of Owner or Owner's Agent Owner ❑ Agent ❑ hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. By Type of License: Title ❑Plumber Signature of Licensed Plu er 11? City/Town ❑Master /6 G r APPROVED OFFICE USE ONLY) ❑.lourneyman License Number: 7 CORtT7® ATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE P0%j D 05/17/10 RODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION smith Buckley & Hunt Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Lgency, Inc HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER T.HE COVERAGE AFFORDED BY THE POLICIES BELOW. L00 Forest Avenue Irockton MA 02301-5749 NAIC# ?hone: 508-586-5432 Fax:508-587-4935 INSURERS AFFORDING COVERAGE JSURED INSURER A: The Charter Oak Fire Ina Co 25615 INSURER B: The Phoenix Insurance Co 25623 Commercial Boiler Systems, Inc INSURER . Twin City Fire Ins Co 29459 152 :Oldham St INSURER D: Travelers Indent Co of Amer 25666 Pembroke MA 02359-2522 INSURER E: :OVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. TR NSR TYPE OF INSURANCE POLICY NUMBER DATE MMIDD/YYYY DATE MMIDD/YYYY LIMITS EACH OCCURRENCE $1000000 GENERAL LIABILITY UAMAUEKLNIt A X COMMERCIAL GENERAL LIABILITY I6808466B288COF09 05/24/10 05/24/11 PREMISES(Ea occurence $300000 CLAIMS MADE XD OCCUR MED EXP(Any one person) S 5000 PERSONAL&ADV INJURY. $1000000 GENERAL AGGREGATE $2000000 rGEI'�LAGGREGATELIMITAPPLIESPER: PRODUCTS-COMP/OPAGG $2000000 ICY PE LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $1000000 B ANY AUTO 6243010009 05/21/10 05/21/11 (Ea accident) ALL OWNED AUTOS BODILY INJURY $ (Per person) X SCHEDULEDAUTOS X HIRED AUTOS BODILY INJURY $ X NON-OWNEDAUTOS (Per accident} PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS I UMBRELLA LIABILITY EACH OCCURRENCE $10000000 D X I OCCUR 7 CLAIMSMADE ISFCUP4275Y889-IND- 005/24/10 05/24/11 AGGREGATE $10000000 $ DEDUCTIBLE $ X RETENTION $5000 $ WORKERS COMPENSATIONJUIH AND EMPLOYERS'LIABILITY TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIV j OBWECIW8489 05/21/10 05/21/11 E.L.EACH ACCIDENT $500000' OFFICER/MEMBER EXCLUDED? LJ (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $500000 If yyes,describe under SPECIAL PROVISIONS below. E.L.DISEASE-POLICY LIMIT $500000 OTHER ESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS :ERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION t DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES, AUT ORIZED R PRE ENTATIVE ,CORD 25(2009/01) ©19ss-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Peerless SIEw BUSINESS 10�Insurance® Mcmbcr of Liberty Mutual Group =FFECTIVE DATE: 12/23/2010 ,licy Number: GL 5432321 Prior Policy: Billing Type: DIRECT BILL Coverage Is Provided In PEERLESS INSURANCE COMPANY-A STOCK COMPANY Named Insured and Mailing Address: Agent: TIMOTHY FOLEY SMITH, BUCKLEY & HUNT INSURANC 152 OLDHAM ST E AGENCY, INC L C/O COMMERCIAL BOILER SYSTEMS 500 FOREST AVE PEMBROKE MA 02359 BROCKTON MA 02301-5749 Agent Code: 6201120 Agent Phone: (508)-586-5432 COMMON POLICY DECLARATIONS In return for the payment of premium, and subject to all the terms of this policy, we agree with you to provide the insurance as stated in this policy. POLICY PERIOD: From : 12/23/2010 To: 12/23/2011 at 12:01 AM Standard Time at your mailing address shown above. FORM OF BUSINESS: INDIVIDUAL BUSINESS DESCRIPTION: PLUMBING CONTRACTOR rms policy consists of the following coverage parts for which a premium is indicated.This premium may be subject to adjustment. PREMIUM Commercial General Liability Coverage Part INCLUDED Total Premium for all Liability Coverage Parts $ 1 , 157. 00 Terrorism Risk Insurance Act of 2002 and 2005 Coverage $ 15. 00 Total Policy Premium $ 1 , 172. 00 FORMS AND ENDORSEMENTS Forms and Endorsements made a part of this policy at time of issue: Applicable Forms and Endorsements are omitted if shown in specific Coverage Part/Coverage Form Declarations Form Number Description CG2170 -0108 CAP ON LOSSES FROM CERTIFIED ACTS OF TERRORISM CG2176 -0108 EXCL OF PUNITIVE DAMAGES RELEATED TO CERTIFIED ACT rt IL0003 -0907 CALCULATION OF PREMIUM ` IL0017 -1198 COMMON POLICY CONDITIONS i21 -0702 NUCLEAR ENERGY LIABILITY EXCLUSION (BROAD FORM) 17-57 (06/94) INSURED COPY 919nrgnin 5432321 NN195291 2912 pnnunann D(•l1Fpom nnniS»�' ':COMMONWEAL'-H OF MASSACHUSETTS PLUMBERS AND GASFITTERS h LICENSED AS A JOURNEYMAN P UMBER ISSUES THE AB . 0VE LICENSE TO: TIMOTHY R FOLEY 310`'POWELL ST . STOUGHTON MA 02072-393 31607 _ 05/01/12 800768 1 ; ; v>< 77