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Home My WebLink AboutMiscellaneous - 1 HIGH STREET 4/30/2018 (10)Date ..... ............ TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION Z /-, This certifies that .................................................... ... .... i;;(—/ ................ 0 ae— has permission for gas installation ...... ..... ................ in the buildings of ........ L ...................... at ......... 14 /", L Nooh Andover, Mass. Fee....................... Lic. No. ...... ............................... Check # �/GASINSPECT(OR U *,I e U MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK PERMIT # lk��1 I CITY � _ MA DATE �i n��J JOBSITE ADDRESS -110WNER'S NAME GOWNER ADDRESS TELL �FAx TYPE OR OCCUPANCY TYPE COMMERCIALY EDUCATIONAL ® RESIDENTIAL 0 PRINT CLEARLY NEW: [ RENOVATION: ® REPLACEMENT: PLANS SUBMITTED: YESF-1 NO Q APPLIANCES Z FLOORS- BSM 1 1 2 3 4 5 6 7 8 9 10 1 11 12 13 14 BOILER(.. - BOOSTER CONVERSION BURNER COOK STOVE I -r --- T _ L -J. - - DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR .... GRILLE__. E -.- r- =------- - - --- �1 - -- --- INFRARED HEATER_ LABORATORY COCKS MAKEUP AIR UNIT OVEN _ I POOLHEATERHEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST _ - [ UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER .___. _ INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES VO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERA E BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY E] 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 �1 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 rt' a provision the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. FITTER NAME ENSE # S NATURE PLU7MGF MP JP J JGF .-( LPGI I CORPORATION 0# ( PARTNERSHIP 0#= LLC [:Jl#= COMPANY NAME;_r/�/�/,I,,,��,,�,/,__- IIADDRESS� CITY f _ STATE P TEL FAX ------ CELL - - e U H O z 0 H U W W a 0- "of 0 El z OyEl W � � W OH w O W � � a w w O w � w w C a o a a a I J a a a co Eli x w [-- w r F O 0 H v w a CODz c� o a The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street, Suite 100 Boston, ALL 02114-2017 www mass.gov/dia Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMUTING AUTHORM. Name Address: L. . _ ✓�n�< Phone 4: City/State/Zip: Are: you an employer? Check the appropriate box: 1. 4111", a employer with /) employees (frill and/or part-time,).' 2.❑ I am a sole proprietor or partnership and have no employees working for mein any capacity. [No workers' comp. insurance required.] (No workers' comp. insurance required.] t 3.0 I am a homeowner doing all work myself 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. I will 5. ❑I am a general contr4ctor and I have hired the sub-confractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.* 6.FJ We are a corporatiori and its, officers have exercised their right of exemption per MGL c. 152 § i(4) and we have no employees. [No workers' comp. insurance required] Type of project (required): 7. ❑ New `donstruct[on 8. 0 Re odeliiig 9. Demolition l0 ❑ Building addition 11.0 Electrical repairs or additions 12. D Plumbing repairs or additions 13%n Ro6f repairs 14. Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information: 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 -contractors and state whether oy not fhose, entities, have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. X am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: �� ExpirationDOm Policy # or Self ins. Lie. #: ,,,// (0,6-7,,A&7 3 b, l Job Site Address: % f77 ti1 9 %1 �� /U�a}1c�t�1'✓ City/State/Zip: /v �&_Oe- Atiach acopy of the vvoxkers' 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 $I, 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. X do hereby cerunde� the pains ar�Z *penalties ofperjury that the information pi ovidehove 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 # Issuing Authority (circle one): i 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Phone #: Contact 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 We, 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 b6 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 iequi'red." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance ofpublic 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 certificates) 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 thai 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-NUSSAFE Fax # 617-727-7749 Revised 02-23-15 wwwmass.gov/dia : COMMQNWEALD B ti l SSIIES : (HE AND GASF IM"Pt FOLLWING Er!„! FNS