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Home My WebLink AboutMiscellaneous - 103 FARRWOOD AVENUE 4/30/2018I w i3 rjeUeA S-4jo 9517 Date..�i: ijZ. TOWN OF NORTH ANDOVER ' PERMIT FOR PLUMBING This certifies that .. L. % .... ... ... .. �, has permission to perform ..%�.., .�l.. plumbing in the buildings o ..%Q, . . ..... SUt` a .. , ort Andover, Mass. at ... .. �"'..1'p ��...Fee ��f... Lic. No.. ?. 00 . � ........ . PI IIMRINr. I SPFCTnR Check." _//a,5 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK - 11-1 27 CITY _ I MA DATE , PERMIT # -/h 0 JOBSITE ADDRESS (,O #OWNER'S NAME �1 OWNER ADDRESS`� I TEL - - _ FAX Lj YPE OR OCCUPANCY TYPE COMMERCIAL Q EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: E! RENOVATION: REPLACEMENT: ® PLANS SUBMITTED: YES NOQ FIXTURES'l FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB ! _ ! �_-f ._.____ ! __1 i -_.-__.J !-_____{ ! �_-__I .( .__ _( .( CROSS CONNECTION DEVICEI DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOILISAND SYSTEM - ! _._......-,._. _ i ._.._ _...__._1 _ _..._.I _! .._...__ ____4 ___._._I _._._( .__ _._.-� DEDICATED GREASE SYSTEME DEDICATED GRAY WATER SYSTEM.-_-._._! DEDICATED WATER RECYCLE SYSTEM �( _..._ ....(---.__-._! _._____( ... ._.( _____ 1 _l ____._l .__-__f ..._-..__1 .-._-__-( ___._.._( DISHWASHER --.-__.! DRINKING FOUNTAIN FOOD DISPOSER _I ..- _-._{ __ _ __! ._____!-_-_._- .__! ..__._. ___....._I _.____� _..__._( .-.._.___( .__... _€ .. ___I FLOOR/ AREA DRAIN INTERCEPTOR (INTERIOR) KITCHENSINK _-�! _.. ____.f _.__._._l _..__-_� _.__.__.J ....__( _..._.___.I _.__-__1 _.._.._J _._.._� ___.-...._( ...... .-.f _ LAVATORY ! ROOF DRAIN - _ _( ___._ I ._ __.__( -___—( ..___ ( —._ I ___T { __._ (__._.J .__. _._.f _-..___J SHOWER STALL ( ...-___� ._...__ _( .___.-_ __..._I __._._..______I _....._J SERVICE IMOP SINK TOILET URINAL ° ___J= __.-... ___.__.1 ._..___-�-_.__._ WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER _ ._ _.� _ _� _ ! ( ! ..._...___! .__..._..l I { ______.( ._.._.I ......... __—! .......-_► 1 �.i �! INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES EINO �( IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY BOND Q 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 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 Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME IILICENSE # � � SI TRE MP i JP Q'' CORPORATION E1# PARTNERSHIP 0# _ 4 LLC COMPANY NAME ; ADDRESS S` t CITY - { STATE ZIP O l S —� TEL LuzIlk CELL IEMAIL - _FAX 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' 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 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 of Industrial Accidents Office of Investigations 600 Washington Stre. et Boston, MA 02111 Tei, # 617-727-4900 oxt 406 or 1-877rMASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass,govldia � C� n ;o _ n� n � ,r1 Zr O m -a cnc - ;u C-) MM z o d = �- c �W V) n U) N� D o c _0 m DtnD L w 07 -7 O r. o C:o p N j D m C r Xu-) D > ZD g. - • N m C)-<-n ui o N fT1 . U) 00 9-4 W n y lP Z� _ N I 'VN C -4r N lZ C m Ln CD i a, N �] N m .._�Q��..+ BU gn�'//