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HomeMy WebLinkAboutMiscellaneous - 100 Milk StreetDate .. a. ? // 4.... . o? '` TOWN OF NORTH ANDOVER ' PERMIT FOR GAS INSTALLATION a iQ .f This certifies that ... S'L S. !.,!f/.�! J c ( �... _ ........ . has permission for, gas installation . FA n e.14. in the buildings of ........................................... at ....�.©�... '/ t � � ... ?. ........... North Andover, Mass. Fee.: 3 Lic. No.. :! GAS INSPECTOR Check # g 7311 F MASSACHUSETTS UNIFORM APPLICATON FORPERMIT TO DO GAS FITTING (Type or print) Date --7— — c� 3 —/zg? NORTH ANDOVER, MASSACHUSETTS � Building Locations _1'��1Q !'/E !�/ J / Permit #. ? l_ Amount $ b S+ Owner's Name New Renovation Q Replacement Plans Submitted ❑ (Print or type)8 Name Name of Licensed Plumber or Gas Fitter _,D&VfV 15 4'11j Com/ Check one: Certificate Installing Company .❑ Corp. ElPartner. Co. INSURANCE COVERAGE Check one•. I have a current Iiability Insurance policy or it's substantial equivalent. Yes No E] If you have checked Vis, please in 'cate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity ED Bond Owner's Insurance Waiver: I am aware that the -licensee does not have the Insurance coverage required by Chapter 142 ofthe Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner E] Agent 11Q1 UUy UM Lay Ludt an or me aemus ana mrormauon i nave 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 MassachusettsSta as Code Chapter 14 of the General Laws. ICity/Town (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter El Plumber A / Yf--4 Gas Fitter Licellse Number -� Master Journeyman rn iYi D 0 H • � O � Ny � H 0 U� � �~ W Cq rb W fWa 1�"� O � P O O W F' U W r� �i u� Z „0 0 R` H W >WEW,P_ k-4 CW7 wx a 0 ° w °�W�! F W oz W a Ug o > -wo o CW F• o SUB -BASEM ENT BASEMENT 1ST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH. FLOOR 5TH. FLOOR 6TH. F L 0 0 R 7TH. FLOOR - - 8.T•H. FL00R (Print or type)8 Name Name of Licensed Plumber or Gas Fitter _,D&VfV 15 4'11j Com/ Check one: Certificate Installing Company .❑ Corp. ElPartner. Co. INSURANCE COVERAGE Check one•. I have a current Iiability Insurance policy or it's substantial equivalent. Yes No E] If you have checked Vis, please in 'cate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity ED Bond Owner's Insurance Waiver: I am aware that the -licensee does not have the Insurance coverage required by Chapter 142 ofthe Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner E] Agent 11Q1 UUy UM Lay Ludt an or me aemus ana mrormauon i nave 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 MassachusettsSta as Code Chapter 14 of the General Laws. ICity/Town (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter El Plumber A / Yf--4 Gas Fitter Licellse Number -� Master Journeyman I the Commonwealth of Massachusetts 1.rr Department o f Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www mass gov/dia Workers' Compensation Insurance Affidavit; Applicant Information Please Frint Leoibiy Name (Business/Organization/Individual):� Address: City/State/Zip:_.1JQ- 41"/1l� Phone Are on an employer? Check the appropriate box: 1. �I am a employerwith Q 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2.. ❑ I am a sole proprietor or partner- listed on the attached. sheet I ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t These sub -contractors have workers' comp. insurance. 5. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp, insurance required.] Type of project (required):' 6. E5 New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions 11. Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other c�:e °ecuu- oe.,OW enol nnnb T. ^e:f n.nr�ers, Com,=afion poISC.L,' 0:�.,2.�Qn. t homeowners who submit this amdavit 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 their workers' comp. policy information. lam ann employer that is providing workers' compensation insurance for my employees. Below is the policy and job site Insurance Company Name: L//LI 1yl/S Policy # or Self -ins. Lie. #: Expiration Date: 3 - I — / / Job Site Address: ill/) City/State/Zip: N A)Oaaw4 Gt 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. I do hereby cert under the pains and penalties of perjury that the information provided above is true and correct 3%3-6 /// Official use only. Do not write in this area, to be completed by city or town of City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. PIumbing Inspector 6. Other -d 7 -le Contact Person: Phone # Information and Instructions ' J 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 perrson-m 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 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 aparimLents 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 be 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 co=mpliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public 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 certificate(s) 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 siban and date the affidavit. The affidavit should be returned to the city or town that the WECauon for the peraitor" license is being requested, not the Department of Ind'rs+s:al AcCiden+ Sho'Sld yC:l have any .�Sestions regurdiug `the taw 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 -incur- ce 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 that 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 bum leaves etc.) said person is NOT required to complete this affidavit. . 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 Department ofIndustrial Acc'idents Off ce of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900.ext 4106 or 1-877-MAS.SAFE Fax # 6.17-727-7749 Revised 5-26-05 vm,w.mass._govfdia