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Home My WebLink AboutBuilding Permit #8190 - 440 MAIN STREET 5/1/2018 Date. V2. C7. . . `NpRTM TOWN OF NORTH ANDOVER PER IMT FOR PLUMBING SSACHUSE� .� This certifies that . . ��<'��`. . . .!?L .`�. . . . . . . . . . . . . . . . . . . ' has permission to perform . . . . .LA- .G. . . . . . . . . . . . . . . . . . . . . . . . . plumbing in the buildings of . . . .`'.f�.�" ��.� �. . . . . . . . . . . . . . . . at . .'. . . . . . . . . . . . . . . . . . . . , North Andover, Mass. Fee. . . . . . . . .Lic. No.. . .. . . . . . . . . . . . C L. . . . . . . . . . . PLUMBING INSPECTOR Check #0.6K' 8190 of P MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS Building Location `, //�(tD St: Owners Name � 2e pr, Date Permit# Type of Occu ancv Pr _ p Pt /� L Amount q o �f New Renovation Replacement E1 Plans Submitted Yes No ❑ FIXTURES V. ° Un z A w w x a 3 flA.��IIvi' . lS1C)HIDCgt y MMOM 3M RfM 4II31C1'IM M yFLOCIZ� i 7MDR H�yy� 9M 1FL" (Print or type) `n � R.- Check one: Certificate � �{ Installing Company Name 1i , in ,—J " '.�� Corp. Address 60'C ^4 ri Partner. Business Telephone — Firm/Co. Name of Licensed Plumber: Insurance Coverage: Indicate the a of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity ❑ Bond ❑ Insurance Waiver. I,the undersigned,have been made aware that the licensee of this application does not have any one of the above three insurance Signature ❑ A t F I hereby certify that all of the details and in ation I have sub 'tter entered n ab plication are true and accurate to the best of my knowledge and that all plumbing ork and installa' ns p Orin nd P sued for this application will be in compliance with all pertinent provisions of th assach e umnar Code d apter 142 of the General Laws. By: igna ure o ice se um Title Type of Phu, bing Li se G City/Town wense lNumDerMaster F1APPROVED(OFFICE USE ONLY Journeyma(OFFICE 'fes !` The CoMAwnwealfh of Maysachuse&S kj ii Department of Industrial Accident t OffXe of Investigations `coq 600 ffYashin�on Street Boston, MA 02111 wlVw. =s:.gov1dla Workers' Compensation Insurance Affidavit: Builders/Contractors/ElectriciansTiambers Applicant Information Please Print Leeibl Name(Busincss/Qrganiion/(ndividct14 , Address: City/'Sta&Zip: P`j. 1 __ Phone#: . FjAyou an employer?C wk.the appropriate'box: am a employer with 4. ❑ I am a general contractor and I Type of project(required):employees(full and/or part-time).* have hired lite sub-contractors . D New constructionI am.a.sole proprietor or partner_ listed on the attached sheet.= 7• ❑Remodeling ship and have no employees These su&conttactors have working for me in any capacity, workers' comp.insurance. g' D Demolition [No workers'comp, insurance 5. ❑ We are a corporation and its 9• D Building addition required.] officers have exercised their 10.0 Electrical airs or 3. P additions ns D am a homeowner doing all work right of have per MOL 11.❑ Plumbing repairs or additions myself,[No-workers'camp, r 152, §1(4),and we have no insurancerequired.].t .employees. [No workers' 12•❑ Roof repairs 1 , comp. irzsttrartcxrequired.] Homeown13.D.Other `Any applicant that checks ho*r#(moat also ffii out the section boiow showing their workers'compensation policy information t ers who submit this affidavit indicating they ars doing all work and th=hire outside con 1Contract m that check this box trust attached an additions!shaershaw' tots t submtt a new affidavit indicatias such. +ag the name of the suh-contr ICtum and their worb=,come.Policy irtnmistion. I ar rpt employer that& prq%=dwg:workers'corn ensatrorr informaffom ! P insurmwefor my..enFloye= Below irTheP-El y and joh it, . Insurance Company Name: Policy#or Self-ins.Lie.#: /�� Expiration Date: ------------ Job Site Address:_ 11 r! dVi' ra r City/StatelZip: 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 a GL c. 152 can lead to the imposition of criminal fine p ;g d/ar one-year imprisonmen as 1 Peres of a of to 5250.00 a civil penalties in the form of a STOP WORK ORDER and a fine �3 tort the viol r. Be advis that copy of this statement may be forwarded to the Office of l vestigations of the DiA or ins v v fi ' Ido certify unde the d •es of e that the information provided above is true and torted Si Date: • Phone#: Of,}`icird use only. Do no wrilr in LWfarea,to be compLeYied bj,Chy or town o ciaL City or Town: Issuing Authority(circle one): PernaWLicense# 1. Board of Health 2-Building Department 3. City/Towu Cierk 6.Other 4.E{ectrical Inspector 5. Plumbing Insp r Contact Person- Phone#: Information a. nd Instructions Massachusetts General Laws chapter 152 requires all emp 3oyers 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 ormon of thelioregoing engaged in a joint enterprise,and includirag the legal representatives of a deceased employer,or the receiver ortrusteo•of an individual,partnership,association or other legal entity,employing employees. 'lioweverthe owner-of a dwelling house having not more than three apaa-trnents and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work m 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 shad withhold the issuance or renewal of a license or permit to operate a business or *o construct buMugs in the commonwealth for any applicant who has not produced acceptable evidence.of compliance with the insurance eovera„ge required." Additionally, MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract far the performance of public work until acceptable evidence of compliance with the insurance regruremeri s of this chapter have been presmrted to the contracting authority." . Applicants Please fill out the workers'compmrsadon.affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),addresses)mind phone nizrrber(s)along with their certificates)of insurance. Limited Liability Companies (LLC)or Limited'Liability Partnerships(LLP)with no employees other than the ' members or partners,are,not re lubvdito carry workers'ecsTripensation insrusnce. If an LLC or LLP does have employees,a policy is required. Be advised.that this afficlmvit may be submitted to the Department of Industrial �f. 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,notthl a Department of Industrial Accidents. Should you have any.questions regarding the law or if you are rKpired to obtain a workers' compensation policy,please call the Deparbnent at the nu tuber listed below, Self insured cra*rpa4i ehuum aunt ti, r self:-insuran=e license number on the-appropriate tine. 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 wilI be used as a.reftrrerrcc number. In addition,an applicant that must submit multiple pmmit/license applications in any given year,n=d only submit one affidavit Indic atirj-current policyinformation(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 fidwe permits or licenses. A new affidavit must be filled out each year.When 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 pennit'to bum leaves etc.)said p=D'In is NOT required to complete this affidaviL The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Depart{nent of I.ndaastrial Accidents Office of Lnvest igatiotns 600 Washington Street Boston, MA 02111 TeL # 617-727-4900 ext 406 or 1-977-MASSAFE Revised 5-26-05 Fax#617-727-7749 www.mass.gov/dia Date. .... .. ti ,ORTH li Of '941 . '6 TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION �9SSACHUSEt This certifies that . . . has permission for gas installation . . . . . . . . . . . . . . . . . . . . . . in the buildings of . . . .rl�. :.�:. ::.�. L: . . . . . . . . . . . . . . . . . . . . . . . . at . .it`!�. .!-x E .f�:�. . . . . . . . . . . . . . .. North Andover, Mass. Fee. .a?(3 . . Lic. No.. .: . .E . . . . . . ,-. . . ... ... .. . . . . . . GAS INSPECTOR Check# 4177 MASSACHUSETTS UNWORM APPUCATON FOR PERMIT TO DO GAS FITTING (Type or print) �+� � Date /�v 2 ' ® L NORTH ANDOVER,MASSACHUSETTS Building Locations 7 yU X14 r�� S `-. Permit# Amount$ Owner's Name New❑ Renovation ❑ Replacement Plans Submitted U w 90 U o W G7 U a A a O SUB-BASEMENT BASEMENT y 1ST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH. FLOOR 5TH. FLOOR 6TH. FLOOR 7TH. FLOOR 8TH . FLOOR (Print or type) 'j` C fi' one: Certificate Installing Company Name l ) ��C�lil ti�..r ` i" �" t–J Li Corp. Address S-D [I LN d n ❑ Partner. Business Telephone 7 K (a g(, 6 x i ( / 11-Firm/Co. Name of Licensed Plumber or Gas Fitter `�� l a / `�4-L-f INSURANCE COVERAGE Check one: i have a current liability Insurance policy or it's substantial equivalent. Yes E No❑ If you have checked ye—s please indicate the type coverage by checking the appropriate box Liability insurance policy 13- 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 Mass.General Laws,and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachus StatyGas Code an7hapter 14 tof th a mineral Laws. By. Signature of Licensed Plumber Or Gas Fitter Title Q P umber 7 City/Town ❑ Gas Fitter License Number aster APPROVED(OFFICE USE ONLY) ❑ Journeyman