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HomeMy WebLinkAboutMiscellaneous - 1001 OSGOOD STREET 4/30/2018102'08 Date .. /. �/V/X 3..... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING 1 1 This certifies that has permission to perform ...'a /1-A UZZ ........................................ .. . ...... plumbing in the buildings of ....... 7 ... L... at.—IN/ ....... ... .. ...... ...................... 7 ............. North Andover, Mass. Fee... ic. No. 3 ....... PLUMBING INSPECTOR Check # 12464 � jj 0, � k e- � �X� s MASSACHUSETTS UNIFORM APPLIC'ATION&ROR A PERMIT TO PERFORM PLUMIBING WORK CITY11 MA DATE PERMIT # ` O JOBSITE ADDRES OWNER'SNAME POWNER ADDR S T I en D, 07 � _ AX TYPE OR PRINT OCCUPANCY E G�ttqr EDU ATIONAL ❑ RESI ENTIAL C(��Nti�i5 CLEARLY NEW: ❑ RENOVATION: ❑ REPLACEMENT: � PLA S SUBMITTED: YES[I-.NO[] FIXTURES 1 FLOOR- BSM 1 2 3 1 4 5 1 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOIUSAND SYSTEM DEDICATED GREASE SYSTEM - - DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR / AREA DRAIN INTERCEPTOR INTERIOR KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE I MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING NM OTHER 11 1111 INSURANCE COVERAGE: I have a current liability -insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES53"'NO ❑ IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY e 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: 'OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this applicationaT true and accur to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will ben lance 'th 1 ertinent provisio f the Massachusetts State PI ing Code and Cha ter 142 of the General Laws. PLUMBER'S NAME LICENSE # a NATURE MPE?' JP❑ CORPORATION#®PARTNERSHIP❑# LLC []#0 COMPANY NAM ADDRESS CITY STATE N -A] ZIP TEL FAX,50, MP CELL EMAI Q Imo. s 1012-1 ) 3 " 440 )Pesf Farol lllz,?,II.3w The Commonwealth ofMassachusetts - Department ofIndustY glAccidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass:gov/dia 'workers'Compensation Insurance Affidavit- Builders/ContractorsfFIectricians/Plumbers Applicant Information Please Print Le ibl Name (Business/Organizaiion&dividual) 461 f A.�- 'D .Address: Le C.e City/State/Zip Phone #: to PQ j � Are you an employer? Check the appropriatebox: Type of project (required): 1. [� I am a employer with 4. Q I am a general contractor and I 6. Q New c6nstruction employees (full and/or pari time) x 2. Q I am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet.1 7. ❑ Remodeling ship and'have no employees 'These sub -contractors have 8. Q Demolition working forme in any capacity. — kers' comp, insurance. 9. ❑ Building addition [No workers' comp. insurance 5. We are a corporation and its 10.Q Electrical repairs or additions required.] officers have exercised their 3. Q I am a homeowner doing all work right of exemption per MGL 11.Q Plumbing repairs or additions myself. [No workers' comp. c.152, § 1(4), and we have no 12. Q Roofrepairs insurance required.] f employees. [No workers'• 13.Q other 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 anew affidavit indicating such. tContractors 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 forY.2y.ernployee3:.Below is the policy and job site information. Insurance Company Name.. Policy # or S elf -ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip:, Attach a. copy of the workers' compensation policy ileclaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL o. 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. fdo hereby ciftl# under information provided ah 711fl-3 is e and correct. nsta. /./) Official use on1y..Do not write in this area, to be completed by city or town official. City or Town: Permit/I,icense # Issuing Authority (circle 6ne): 1. Board of Health 2. Building Department 3. CitylTown Clerk 4. EIectrical Inspector 5. PIumbing Inspector 6. Other - - - CO.7MONWEALTH OF C;IASSACHUSETi'S �l►•040L 3 !]r a s r J-1,3 ; k PLUMBERS AND GASFITTERS L �I { ICEN ED ASA MASTER PLUMB .R ( ISSUES THE•ABOVE LICENSE TO: ROBERT ASAHMATARO !� 8 DUNRAVE14 RD C 'I WINDHAM NH• 03087- 1263 '- iM 9333 05/01/14 170 COMMONWEALTH OF MASSACHUSETTS AL REGISTERED AS A PLUMBING CORP ISSUES THE-AbOlk LICENSE TO: ROBERT A SAMMATARO;� ROBERT A SAMMATARO-�P&H, INC 8 DUNRAVEN RD WINDHAM NH 03087-1263 3373 050114* 140820• � ,k •rut :,, � Y1%�JJ�� . ;)Jr �f- =�3:9 't - Date .........!..... 4 ......... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ..1�.-. .! ............. ,. �P .`.!... - .... ......... .......... has permission to perform......... c cn. vv,.eA t � �QuJ ................................................................................................ wiring in the building of... C L! SS ......O..Vv-�.S x 1,.. at ............vo."�.......... O.Q�................................ . Nyip Andover, ass. Fee.111.-.�q .......... Lic. No.�.4:`��t� .......................... .............. ELE AL INSPECIO Check # �I 8'G2 s' Commonwealth of Massachusetts Official Use Only Permit No. �_ Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev -1/07] peaveblank 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 INIAK OR TYPE ALL IAFORMATI0A9 Date: 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) I©®l 05 C,Qa o j l` Owner or Tenant Owner's Address Telephone No. Is this permit in conjunction with a building permit? Yes [9' 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 ,t Location and Nature of Proposed Electrical Work: ",V& -W yl,� Vr-t� A,9 ,✓ Cmmnlotinn nfthP fnllnwinQ table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Cell.-Susp. (Paddle) Fans TransTotal Trsformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators IVA No. of Luminaires Above In- Swimming Pool rnd. Elrnd.. -0mergency ig ting Satter Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burgers J No. of Detection and Initiating Devices No. of Ranges g No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Dis osers P Heat Pump Totals: Number - Tons KW _ ..... ..... No. of Self -Contained Detection/Alerting Devices No. of Dishwashers S ace/Area Heating KW P g Local ❑ Municipal ❑Other Connection No. of Dryers rY Heating Appliances jar 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 TelecommunicationsNo. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. •v 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 ceBONDE] is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE OTHER ❑ (Specify:) I cert, under the ins a penalties/ ofper ury, that the information pn this application is true and complete. id FIRM NAME:7-2 LIC tel J/�%, ! �` i C.Gi / 'f�/'V i( (�?��j LIC. NO.: L 4A� Licensee: rpMr)�' C/Aj6,,,t J V Signature `7yr'r/` LIC. NO.: (If applicable, Wt r "exe pt" in the license numb r ine.) Bus. Tel. No.: Address: nil% ® Alt. Tel. No.: �T *Per M.G.L c. 147, s. 57-61, security work requires Department ofPublic Safety "S" License: Lie. 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 agent. Owner/Agent EP-kmT-FEE.-$� � Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed on the prescribed form. -After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an ' electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shall.be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012. ❑ Rule 8 — Permit/Date Closed: *** Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection Pass IN Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH. INSPECTION: Pass M Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass 0 Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPECTION: Pass 0 Failed 0 Re- Inspection Required ($.) ❑ Inspectors o e ts: r • Inspectors Signature: Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com 1 J The Commonwealth of Massachusetts - Department oflndustriglAccidents Office oflnvestigations 600 Washington Street Boston, MA. 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: B.udders/ContractorsfFlecWcians/Plumbers Name (Business/Organization/fndividual): f-,, LG C Serv/`ces Phone #: 9, 7P A,r /ou an employer? Check the appropriate box: Type of project (required): 1. LTJ I am a employer with P 4. ❑ I am a general contractor and I 6. []New construction employees (full and/or part-time).` 2. ❑ I am a sole proprietor or partner- have hired. the sub -contractors listed on the attached sheet. �• [-].Remodeling ship and'have no employees working for me in any capacity. These sub -contractors have workers' comp: insurance.g• 8. ❑ Demolition []Building addition [No workers' comp. insurance 5. ElWe are a corporation and its 10.E] Electrical repairs or additions required.] 3. ❑ I am a homeownerdoing allwork officers have exercised their right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. c.152, § 1(4), and we have no 12.1-1 Roof repairs insurance required.] t employees. [No workers' comp. insurance required.] 13.0 Other OAny 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 ire doing all work and then hire outside contractors must submit a new affidavit indicating such. a tContractors 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 thepolicy 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 requiredunder Section 25A of MGL o. 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 maybe forwarded to the Office of Investigations of the DTA for insurance coverage verification. I do hereby c rti rider the pamss nd-P alties ofperjjuury that the information provided above is true and correct. Date: Official use only. Do not write in this area, to be completed by city or town official, City or Town: PermitUcense # 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 ofhire,- 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 ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants P Please fill out the workers' compensation affidavit completely, y 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 anLLC or LLP does have employees, a policy is required. Be advised that this affidavit maybe 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 pennithicense number which will be used as a reference number. In addition, an applicant that miist 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 homeowner 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 Gommoamalth of Massachusetts Dopaztmeat off dustrial Accidents Oftlee of Iwestigati ons. 600 Washia� Street Boston, MA, 02111 Tel, # 617-727-4900 ext 406 or 1.-577, MASSAFF, Revised 5-26-05 Fax # 617-727-7749 �u�_mace anvfriia 4 c 0 E COMMONWEALTH OF MA55ACHu5ETr BOARMOF 4 V Date../O//Z t ... 11.3 ............ TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that A.:��..\5.�. .................... has permission for gas installation /..\ ...... ...................... in the buildings of ....... . 4 .. ................. at ....... ....................7..............., North Andover, Mass. Fee ./P . . ...... Lic" No.qj3.......... /t/P ........ .. GASINSPECTOR Check# 8921 v -n I� 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 gives this requirement. - CHECK ONE ONLY: OWNER _ AGENT SIGNATURE OF nI nP Ar=!I .....v.., w� �a _� « _ u -41m gnu inrurmation i nave suomitted or entered regarding this application are a and accurate t e best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in m Iia wit IIP ent provision of e M Massachusetts State Plumbing Cod and Chapter 142 of the General Laws. - PLUMMBBER-R-GASFITTER NAMES LICENSE # ATURE MP ` MGF JP ` JGF _ LPGI _ CORPORATION V # }� PARTNERSHIP _# 42 on LLC # COMPANY NAM ¢' ADDRESS CITY (,jkh STATE ZIP TEL FAX t t°. CELL .` EMAIL �l�'!Q a ro r LD G19�i»� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK - - CITY MA DATE d PERMIT 7 , # U / JOBSITE ADDRESS OWNER'S NAME GOWNER ---- ADDRESS ar T TYPE OR �— OCCUPANCY TYPE EDUCATIONAL RESIDENTIAL PRVa CLEARLY NEW: RENOVATIdN; ._ REPLACEMENT: PLANS SUBMITTED: YES_ NO APPLIANCES Z FLOORS- BSM 1 2 3 4 5-T 6 7 8 9 10 11 1 12 13 14 BOILER _ BOOSTER 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 IF 9 ROOF TOP_ UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER TER OTHER INSURANCE COVERAGE 1 have a current Ilabilify insurance policy or its substantial equivalent which meets the requirements of MGL. . '- 4 Ch. 142 YES ,�NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Z OTHER TYPE 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 gives this requirement. - CHECK ONE ONLY: OWNER _ AGENT SIGNATURE OF nI nP Ar=!I .....v.., w� �a _� « _ u -41m gnu inrurmation i nave suomitted or entered regarding this application are a and accurate t e best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in m Iia wit IIP ent provision of e M Massachusetts State Plumbing Cod and Chapter 142 of the General Laws. - PLUMMBBER-R-GASFITTER NAMES LICENSE # ATURE MP ` MGF JP ` JGF _ LPGI _ CORPORATION V # }� PARTNERSHIP _# 42 on LLC # COMPANY NAM ¢' ADDRESS CITY (,jkh STATE ZIP TEL FAX t t°. CELL .` EMAIL �l�'!Q a ro r LD G19�i»� 0 .Pl -7he a°��onfvealth P stylzeylt° °.fh?assac .f�ntl htrses O.f ce °f- ,f .rzl�jccl�e 600 yy,hz esga.o�s �' vI Zfc tee's' Co14•peosa Bostoh 4 0 ;;eet` N -I�ioxntat�o� txo.4 s�,�ce zveyry ynass, 0 21II me i�usiness/prganizatio.� . • `�x�avit: dress; Cu 12al); �ttaetox•,�/EXec t�cia CitY/,stat%Zzp L.(Q� 'lease p bens _ tle Are you a� e bl 1•Ll Iauz a XUployer„CIzec G 2 employq�ployerWith ktheappxopri to X ifullsole box: SUP andkh o o o rp b x 4 a agenexaIContract- oru era to r ve fedor [XIO g forzue III Yees listed ou the sub-c0atracto dl %e °fprOject (re xe R'°r ers' co Y capaci Thesethe attached xs OX tl�red): 3• 4uired inp• his t3 : sub-cOu sheep x 1, W cb Q atn a h ] - uraace S L�xkers' c0 txactors ka-ve 7 V-Szucdoa myself nie°ferdo' �► We are gyp•uauce 18. V Remodeling eta e Viers. �g au R'oxk °-tu a col'oratio” and its g �DemOIW,04 ncere Wo coot have exe pireda t p righto fexe rasedthe. 0j3Q(1in t�YapPlic�tthat c. 152��1(4�ptiortperMGL 10.f�Eleciricgadditiou Icon ctoRnersyyhosub 111 11X IIISt�so employees. 'aIIdyyelzaye�0 11.j]pl alrepairsorad s that chec COml�• utsur �No R'oxkers' 12.bmgrepahs dZizons jam kisbtodavitindicaovtthesectionbel ancexe �Ro°fre orad�ttto Woryrzatzort, o.Yerthm. atfackedanadd�&o gal O!gnattheirworlce J 13.[Jother pairs ks provi is he co �urauce • 1 dln� workers' ho °gthenarneo t °*- C ontr�CtkonPoli o3'lnfo COmpanyco peflsatio s hesub-con�acto oamustsub anon 1'Oli�cy # or Sel f bi Name: n • ufance foryy1.Y. eyylpr eand fhe'r workers' co�P chdic gsuch. -rob Site # .Y eS.. Meloy, • Yinfo�ation, .Attach Address. rstizepolicyafirt• a Iobsite CO p3of ' Route to sec the Workers c - ne uP to $15 e coverage ompersal l i q xprrati°u bate; . °fupto$2500pOOpaud/oro xec edtWder p011cydeclaratio Ci Yeshb'atlo� a daYaga�st e�Year�priso SecOu 25A o u page (sho tY/State/2ip; °Ethel) the violator, mtteat� as wellforay, C, 152 �gthepolic tdo j�epeby c u ZA for u�cc CO $�ed*ed acoivUpcz ° ')ad to the ' P S uuzbe a Si a tr tit a. vera that pYoft� Stato the form o itto2 o fc • x ridercsEFtbeo-� phorte# e• �rsdp ttdesofpe , utektmaybeory°d dO O.t etnforynatrorzprotidedabo �craluseoyz� -borzoi �` —" b rs eaxrd ���°r Toyj.�• .fvrtte ih tlzts arert, to be coYnplet ate: �l /3 tori; 6.Oth d Otwe 1 b lcit ele ohe); ed b�' c1 ortoiyn of &Z tacer 2• BuildfubrDepaxtWeat 3.- 001, Deruiit/�,icense# t person,C.�ty/Tow4 Clerk 4. Flee trical-111speCtor lblumbhlgxuspector M i e�• V�V.��e�a.ila.! if v1 ;IMIRVVRVIIVV41 A V PLUMBERS AND :GASFITTERS _. LICENSED =AS;ARMASTER 'PLUMB��, ISSUES 7HE ABOVE EICENSE TO ROBERT A''SAMMATA`R0 �' a 8 DUNRAVEN IRD WINDHAM; r``r..r a NH = ,0:3087 I263 + 9333 05/01/14 _s. 170 COiVIMONWEALTH 01= 1MASSACHUSETT§ • Y :e -1,• u REGISTERED ASA PLUMBING CORP ISSUES THE ABOVE LL CENSE�TO "'RUBERT A AsAMMATARO �' L? 3 ROBERT - A SAMMAT.ARO .P,8H , INC . 8 DUN -RAI f # W.INDHAM �"��� � ° NH X03087 '1263 3373 4 05/01/14 ,"140820-- a .r�� 'o!