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HomeMy WebLinkAboutMiscellaneous - 100 MOLLY TOWNE ROAD 4/30/2018c s Date ....a/...`..........°.. .. ................ TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that .............. .... ................................................................ -C- has permission for gas installation ..... ........C......................................... in the buildings of .......... .4 V ............................................................................................................ at ...... 'le '000, ..................................... .................. —..e- C-/ North Andover, Mass. ;�$� , ................... 9 Fee............. Lic. No.. 3.53.. 4 ..... ..................................................................... GASINSPECTOR Check# (01 --)?3 V TYPE OR PRINT CLEARLY MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY: 1 �' ' `JaW-411, I MA. DATE: oZ PERMIT # b f 1 JOBSITE ADDRESS: jCjO L�D� kj-�-�\Al)OP �d OWNER'S NAME: Aymttravela OWNER ADDRESS:16 o 1\4 I V (7lAJ (IQ __ TEL: T?� - M ` ` 04 ( FAX: OCCUPANCY TYPE: COMMERCIAL E EDUCATIONAL ❑ RESIDENTIAL, NEW: ❑ RENOVATION: ❑ REPLACEMENT:0 PLANS SUBMITTED: YES ❑ NO APPLIANCESZ FLOOR--+ Bsmt 1 2 31 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE S FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCK MAKEUP AIR UNIT OVEN I POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER (-7 3 -"701 q d I INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES �0 ❑ If you have checked YES, please indicate the type of coverage by checking the appropriate box below. LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ❑ BOND ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee lioes not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this p, rmit application waives this requirement. CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information 1 have submittdd (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 all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 1142 of the General Laws. PLUMBER/GASFITTER NAME: Af +J tv LICENSE # i 355 SIGNAT RE COMPANYNAME: ADDRESS:�i &rts+ Sr CITY: STATE: A ZIP: �_ FAX: 97 k I TEL: g36- Z/ 5.3 CELL: f(36- Z./ 5!3 EMAIL: MASTER (JOURNEYMAN ❑ LP INSTALLER ❑ U! C3a PARTNERSHIP ❑ # Department; oflndustrial Accidents Office, of Investigations I Congress Street, Suite 100 Boston, MA 02114-2017 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lejibly Name (Business/Organization/Individual): A Address: S >� City/State/Zip: L" !, � I -e-- Phone #: �' �� �" �-��' Z 15 � -3 Are you an employer? Check the appropriate bog: 1.2 I am a employer with 4. [] I am a general contractor and I Type of project (required): .3 employees (full and/or part-time).* have'hired the sub -contractors 6. ❑ New construction 2. ❑ 1 am a sole proprietor or partner- listed on the attached sheet 7. E] Remodeling ship and have no employees These sub -contractors have g, (� Demolition workingfor me in an capacity. Y P t3'• employees and have workers' comp. insurance. # 9. ❑Building addition [No workers' comp. insurance required.] 5. � We are a corporation and its 10.❑ Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have exercised their 11. ❑ Plumbing repairs or additions myself. [No workers' comp. right', of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' 13.�,Other Q 0 U� coma. insurance reouired.l _ �AT 20�, *Any applicant that cbecks 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. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: Ao, � //` T Tv I j Policy # or Self -ins. Lie. #: a/,+O 0 d Expiration Date: 3 a kr/ Job Site Address: City/State/Zip: 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 verificaiion. I do hereby certify under the pains and penalties of perjury that the ormation provided above is true and correct. Phone #: L— % 7. - R 3 6' Z,, 5 3 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 #: A� V CERTIFICATE OF LIABILITY INSURANCE 3iZo� oiY ) 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 Ileu of such endorsement(s). PRODUCER EA Stevens Company, Inc. 389 Main St. P. 0. BOE 188 Malden MA 02148 CONTACT Eva Ca exon NAME: p PHONE (781)322_2324 p/X (781)397-7672 E•MAII ESS:evac@eastevensins.com INSURERS AFFORDING COVERAGE NAIC s INSURER A Martf Ord Fire Insurance Company 19682 INSURED MAGNIFICO BROTHERS PLUMBING HEATING & GAS FITTING, LLC. 31 FOREST STREET MIDDLETON MA 01949 INSURERB-Safety Insurance Company 9454 INSURERC:Twin City Fire Insurance Co. 29459 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER -15-16 Master REVISIAN Nl1MRERe 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. IR LT TYPE OF INSURANCE POLICY NUMBER POLICY EFF POLICY EXP LIMITS A GENERAL LIABILITY X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE ® OCCUR DSSBAUQ5370 /24/2015 /24/2016 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED PREMISES Ea occurrence $ 300,000 MED EXP (Any one person) $ 10,000 PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: 17 POLICYFX PRO LOC PRODUCTS - COMP/OP AGG $ 2,000,000 $ B AUTOMOBILE LIABILITY ANY AUTO ALL OWNEDXSCHEDULED AUTOS AUTOS NON -OWNED X HIRED AUTOS X AUTOS 5053635 /24/2015 /24/2016 COMBINED SINGLE LIMIT Ea accident 11000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per acddent $ Medical payrnents $ 10,000 A X UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE DBSBAUQ5370 /24/2015 /24/2016 EACH OCCURRENCE $ 1,000,000 AGGREGATE $ 1,000,000 DED I X I RETENTION$ 10,000 $ C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY y/ N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? [flN/A (Mandatory in NH) H yes, describe under DESCRIPTION OF OPERATIONS below 1D8MCRJ905O 3 /24/2015 /24/2016 X WC STATU- OTH TORY LIMITS E.L. EACH ACCIDENT $ 500,000 E.L. DISEASE - EA EMPLOYEE $ 500,000 E.L. DISEASE - POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS / LOCATIONS! VEHICLES (Attach ACORD 101, Additional Remarks Schedule; it more space is required) i,.. R" Hartford Fire Insurance Company One Hartford Plaza Hartford, CT 06155 r+vvnv w jcV I W VU) INW195 /gninnsi nl SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Cares, Jr/EC e 1 stR1-2070 ACORD CORPORATION. All rights reserved. The annan nerna snrl Inns era ranielarerl rnaAre of Af nan ,c-TU-e� J�- qD, cUd Cv'v' JIQ.lVVEALTH OF jAASSACLEUSETTS BOAT OF PLUMBERS AND GASFITTERS ISSUES THE FOLLOWING LICENSE REGISTERED AS A PLUMBING CORP l¢ t MARK MAGNIFICO IV. Z MAGNIFICO BROS PLB&HGT,GAS FITTI `\'� 31 FOREST 5T ti �U .z U M I DDLETON��� MA 01949-2015 `.+ ` - - 3266 05/01/1620kb6b :.. _.-. _ .._... _.. ..... ..—r-�7a...--r�:_y. COMNiQNjWgALTH OF MASSACH63 T S BOARD OF PLUMBER'S AND GASFITTERS ISSUES THE FOLLOWING LICENSE LICENSED AS A. MASTER PLUMBER T MARK B MAGNIFICO E •� DC7 }1 �5 x .. w 31 FOREST STREET W MIDDLETON MA 01949-2015 13559 6;5/01 / t 6 20#667 MMO !: Cc r,ASSACHUSETTS _ �. BOARD OF _... - PLUMBERS AND GASFITTERS ISSUES THE FOLLOWING LICENSE LICENSED AS A JOURNEYMAN PLUMBER = MARK B MAGNIFICO c f 31 FOREST ST Z i ! ► 601LETON Ma 01949-2015 = 25002y 05,/01/16 204668 - -_ -- - -- Ir,47' 4 R Date ..... 71 7 � TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that��/ V ...........................�................................................................... has permission to perform ........-P..�-'� ................................................................................................ wiring in the building of.......�r!1.�?.�l ...�^� 5 .............:. /' ^ ...................... ............................... j...... Urt ndov �, MassFee........qU7� Lic. No.'t�w"y ELECTRICAL INSPECTOR Check # 20-2- V. Commonwealth o f Waijachueetb v c�r� c7 40 2epartment of ire Service] BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. 121 7A Occupancy and Fee Checked [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: -i t) I--/ a 7t) / J City or Town of: To the Inspead r of Wires: By this application the undersigned gives notice of his or her intention to perform the elecl work ddescri ed w. Location (Street & Number) L, d , �' 1 v LL l d � &, r--> tr a , 60 V `&I I Ls-, t " Owner or Tenant 0 /i'-'Qc>L L, 0X► elephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ET No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Z6 z. -i 15* 3 3 Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Trsand Amps /'-O / -z v volts Overhead ❑ Undgrd No. of Meters % Number of Feed Ampacity Location and Nature of Proposed Electrical Work: ifz�y4 oP- lei /W119—: Com letion of the followingtable may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: Sus Fans p (Paddle) o. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ In- E] rnd. grnd. o. o Emergency Lighting Battery Units No. of Receptacle Outlets Q No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches �' No. of Gas Burners of o. InDetection and Initiatin Devices No. of Ranges / No. of Air Cond. Tons No. of Alerting Devices No. of Waste Disposers p Heat Pump Totals: Number Tons KW o. oSelf-Contained Detection/Alerting Devices No. of Dishwashers S ace/Area Heating KW P g Local ❑ Mumc'pa ❑ Other Connection No. of Dryers Y Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. o atero. Heaters KW o No. o Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Equivalent No. of .Devices or E uivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: 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 cov age 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 enalties of perjury, that the information t i application is true and complete. :. FIRM NAMEtw ` o LIC. NO.:,2 3,1'902 Licensee: -"5 Signature LIC. NO.:o? - A Z- (Ifopplicable, enter "exempt" in the license number line.) Bus. Tel. No.:J%.F 4' L 4691 Address: Alt. Tel. No.: *Per M.G.L. c. 147, s. 57-61, security work requir€s Depa ent 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 ❑ owne :;s a ent. Owner/Agent �- Signature Telephone No. PERMIT FEE: $ IP The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street, Suite 100 Boston, ALL 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Leiribly Narne (Business/Organization/Individual): y>� T Address:�6 DA Z_M -r-A 0(,)1,u City/State/Zip: "ii1-eA,& ,_ Phone #: Are you an employer? Check the appropriate box: 1. ❑ I am a employer with employees (full and/or part-time).* 2.[�f�1 a. a sole proprietor or partnership 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 4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with .no employees. 5.❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.1 6. ❑ 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.] /i5-664/ Type of project (required): 7. ❑ New construction 8. ❑ Remodeling 9. ❑ Demolition 10 ❑ Building addition 11. E] Electrical repairs or additions 12. ❑ Plumbing repairs or additions 13. ❑ Roof repairs 14. ❑ Other *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 are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: 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 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. I do hereby certify ulldkr the zs d penalties of perjury that the information provided above 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 # % -.44 - / 5, 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: Phonel 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 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 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 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 compliance 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 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 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 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-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia w J. Date .. .. I.�.�.`�....... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING 1 This certifies that .... .`...!.�.................... 2 ' :'............................ has permission to perform .. N. Q. -- ....................................................... �-�G�� plumbing i the buildings of...........:.................................�:�1�..'. [i �� at ..... CSU o E•► P..... ,North Andover, Mass. Fee....... "'.... Lic. No. .................... ................................................................................. PLUMBING INSPECTOR Check # oZ cM-2,�t� i MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ' CITYi _ IMA DATE � PERMIT # I JOBSITE ADDRESS OWNERSNAME[J� POWNER ADDRESS TEL FAX I TYPE OR OCCUPAN Y TYPE COMMERCIAL © EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: _ RENOVATION: REPLACEMENT: Q PLANS SUBMITTED: YES Ell NO© FIXTURES Z FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUBaml CROSS CONNECTION DEVICE j ( i j DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OILISAND SYSTEM DEDICATED GREASE SYSTEM ^j DEDICATED GRAY WATER SYSTEM i - ._—( l ___..E _ � _i I J - ! l Jif DEDICATED WATER RECYCLE SYSTEM I DISHWASHER �( . __J DRINKING FOUNTAIN FOOD DISPOSER FLOOR/ AREA DRAIN INTERCEPTOR (INTERIOR) L-3 _____l .____, { ___.__j _.._._, ! _I ) �J 1 _..__j I .. .__I 1 i ._.._...J KITCHEN SINK i ..- -JI LAVATORY ROOF DRAIN ( � _..__.J __.I � ___J SHOWERSTALL ! .___. (_ J I � _J ____mJ SERVICE / MOP SINK ._I TOILET f -- - ._ J _J _111_1 URINAL f ......__ I _J J f ........___J _____. (_...._._.1 __._.._._1 .._ J .__._. J WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING _- l _I J I OTHER —_ IF INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES [dNO M IF YOU CHECKED YES, PLEASE INDICATE T YPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW �qz LIABILITY INSURANCE POLICY _-i OTHER TYPE OF INDEMNITY ( �i 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: OWNERF-11 AGENT IFJ SIGNATURE OF OWNER OR AGENT 0 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 compliances ithal�nt provision of Massachusetts State Plumbing Code and Chapter 142 of the General Laws. OO�C PLUMBER'S NAME I LICENSE # S I SIGNATOR MP V JP I] CORPORATION 0#=PARTNERSHIPO# LLC _( COMPANY NAME_ ; ADDRESS CITY-- t STATE ZIP TEL 1 FAX CELL_ _ .._MAIL - - - - H 0 H U W W o❑ z cn d❑ O � W H � a z c a w w � �c co p z a � a U J a a � w z w W H O O H U W a z a a W'. The Commonwealth of Massa.chusetts Department of IndustrialAccidents 1 Congress Street, Suite 100 Boston, M4 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERNHTTING AUTHORITY. Name (Business/Organization/Individual): Address: City/State/Zip: JJ14g4n ai Are you an employer? Check the appropriate box: Phone #: 66.3" 95 � 3 _131T1 l.Tam a employer with . ..: employees (full and/or part-time).* 2. I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3.FJ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. S. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.$ 6.[I 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): 7. ❑ New construction 8. Remodeling 9. ❑ Demolition 10 Building addition 11.0 Electrical repairs or additions 12.0 Plumbing repairs or additions 13. F1 Roof repairs 14.0 Other *Any applicant that checks box 91 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 or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees.' Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lie. Expiration Date: Job Site Address: City/State/Zip: 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 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. I do hereby certify under the pains andpenalties of perjury that the information provided above is true and correct Signature: Date: 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 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 oihire, 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 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 compliance 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 fillout the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) 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 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 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 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-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia Date . 7.1? �.� (�....................... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that .......... ...... A. .... ......�-.P has permission for gas installatio Q w �Nv%,-�.- ........................................................................... in the buildings o.. ..._....!,....... at .......................................... .... ......A ............ , North Andover, Mass. Fee 1 LOD Lic. No_ Check 4,2 2 -?' IGj/- .......................................................... GASINSPECTOR 6P 10C-\-IS 3I 1, 1 1S G TYPE OR PRINT CLEARLY MASSACHUSETTSUNIFORMAPPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY 41 14 MA DATE ti PERMIT JOBSITE ADDRESS A OWNER'S NAME ! OWNER ADDRESS TEL I FAX= OCCUPANCY TYPE COMMERCIAL [J] EDUCATIONAL [3 RESIDENTIAL 7 NEW: it RENOVATION: El REPLACEMENT: PLANS SUBMITTED: YES D NO 0 APPLIANCES -1 FLOORS—mom � • 7 FFF�--- F�-F�-i X11 CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES 70 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COBY CHECKING THE APPROPRIATE BOX BELOW OD LIABILITY INSURANCE POLICY [VERA OTHER TYPE INDEMNITY BOND EJ1 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 Q AGENT SIGNATURE OF OWNER OR 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 knqwled< and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all AerVnt pr50/0e Massachusetts State Plumbing Code. and Chapter 142 of the General Laws. .4„ // // PLU7M-GF GASFITTER NAME — —--- ! J K. LICENSE LICENSE # . / / SIGNATUR MP 0 JP ® JGF 0 LPGI CORPORATION E= PARTNERSHIP 0#= LLC E]#= COMPANY NAME:ADDRESS`q _ CITY STATE ZIP �JTEi (� FAX CELL — AIL - �_ H O O U W W z° o O �El W r � W HH a Z U w �* F- W F- U) -NQ w < C0 a LU 0 w C a a o a � cc a U J H a Ix �. Q � w = w F- U- 0 0 H U a o The Commonwealth of Massa . chusetts Department of IndustrialAccidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 yJyy'' www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERAUTTING AUTHORITY. Name (Business/Organization/Individual): Address: City/State/Zip: Fes . [///P 'r''J (o Phone #: Are you an employer? Check the appropriate box: 1. [:] a employer with ...: employees (full and/or part-time).* 2. I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3.FJ I am a homeowner doing all work myself [No workers' comp. insurance required.] t 4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.$ 6. ❑ 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.] 3 -c55? - r 3 � Type of project (required): 7. ❑ New construction 8. 0 Remodeling 9. ❑ Demolition 10 ❑ Building addition 11.❑ Electrical repairs or additions 12. [] Plumbing repairs or additions 13. E] Roof repairs 14.0 Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. f Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. #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 employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees.' Below is the policy and job site information. Insurance Company Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: 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 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. Ido hereby certifyoder the ins an penalties of j that the information provided above is true orrect. Signature: �' Date: ✓ and r Phone Vicial 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. EIectrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #• 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 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 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 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 compliance 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-contractor(s) 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 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' compensatiori'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 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. 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