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HomeMy WebLinkAboutMiscellaneous - 104 MIDDLESEX STREET 4/30/2018o M Date. rLED TOWN OF NORTH ANDOVER, •'�, ,,, PERMIT FOR WIRING ` This certifesthat ..................0 /..A/.............. has permission to perform .... 0. wiring in the building of ....P. '96."' .................... . at ....... ANoh Andover, Mass. ..-�/` ' �. ELECTRICAL INSPECT lJR Check # ` 11056 1�c2012 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 t c persoripfirm 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-iflme--.. _ 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 d extending through August 15, 2012. ule 8 — Permit/Date Closed: �� ***Note: Reapply for new permit." 0 Permit Extension Act — Permit/Date Closed: -IT Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. I to 6 Occupancy and Fee Checked [Rev. 1/071 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: gb-sl %I 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 DIA M;ad1#_ Scar Owner or Tenant Zprh Q; eco G Telephone No. Owner's Address ins_ Is this permit in conjunction with a building permit? Yes ® No ❑ (Check Appropriate Box) Purpose of Building '.-nam �km-m DwC.\y, (NJ Utility Authorization No. \3$ (D 3o (e(p Existing Service Amps Volts Overhead ❑ Undgrd ❑ No. of Meters New Service tM Amps 110 /;,L10 Volts Overhead E4 Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: R"V, .k �: hW% or, rr%SC. 00 wort + r, &-CA#,c 'hmosr Completion of the following table may be waived by the Inspector of Wires. No. of Recessed LuminairesNo. S of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA o. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above [I In- E]o. rnd. rnd. o Emergency Lighting Battery Units No. of Receptacle Outlets 3o No. of Oil Burners FIRE ALARMS No. of Zones No. of SwitchesS l No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges7.No. of Air Cond. TotaTonal No. of Alerting Devices No. of Waste Disposers p 1 Heat Pump Totals: Number Tons KW ......... No. of Self -Contained Detection/Alerting Devices No. of Dishwashers I Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW SecuriNotoyf Devic s or Equivalent No. of Water Heaters KW No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications ns No. of Devices or Equivalent OTHER: Attach additional detail if desired or as required by the Inspector of Wires. Estimated Value of Electrical Work: SIC (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 coverage 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 penalties of perjury, that the information on this application is true and complete. FIRM NAME: ?Zcacr�; E\tt tC •C LIC. NO.: Licensee: %;t- 1L Pie=a, Signature 'KIjZ LIC. NO.: (If applicable, enter "exempt" in the license number line) Bus. Tel. No..ZM— IR -17 Address: %,A- GCC/ tmkO f sio zlow -us rNP► 01901 Alt. Tel. No.: 2144r-1661 *Per M.G.L c. 147, s. 57-61, security work requires epartment 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 ❑ owner's Owner/Agent Signature Telephone No. PERMIT FEE. $ I O -K 9533 Date. eflwl TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING NzACNUS�- This certifies that .... !1.!440 -a-l"Vwr .................. has permission to perform ............... plumbing in t Veuildings of .................... AAl1 at ........ 1: 26 ndover; Mass . ..... A �-e .. -Nol5A Fee.4VIOO. . Lic. No...-Zu—? 4.- PLUMBINGIN/P TOR Check MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK a _ I MA DATE / ` PERMIT # yCITY -- JOBSITE ADDRESS OWNER'S NAME POWNER ADDRESS / _ 7" % { TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL Q EDUCATIONAL © RESIDENTIAL!'' PRINT CLEARLY NEW: RENOVATION: 0 REPLACEMENT: ® PLANS SUBMITTED: YES 0 NOD FIXTURES 7 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE- DEDICATED SPECIAL WASTE SYSTEM _._J DEDICATED GAS/OIL/SAND SYSTEM ! _,-....._I (I (_ I _IK___ f _ AlA.-_J 4 .... I _I DEDICATED GREASE SYSTEM ( __[ DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM I __..__.-.I _._.__..J ...___.I ..___1 __-___i J __._.J __.____! __-__1 .__.__....I __.._( _ _.J DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR INTERIOR KITCHEN SINK LAVATORY ._._I ROOF DRAIN I __._._J SHOWER STALL SERVICE / MOP SINK TOILET URINALJ _...._.�?-..___-�-_____1 _._...._ I _____J ......_.__... _-_._._ ( --.__ WASHING MACHINE CONNECTION WATER HEATER ALL TYPES _i --J WATER PIPING _ €__i - OTHER ..__, (__.. 1. _I .--_--__� ._._._.__I ► _ '--..._._.I ........... .___—.-! .- ►----_.___i u1 _ _I `I INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES U/N'0 i IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Eq 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 0 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 ani accurate the best of y knowledge be in ith Pe ine the and that all plumbing work and installations performed under the permit issued for this application will c pliar� rov' on of Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME ., nn LICENSE # —I SIGNA RE MP Elf JP U/ CORPORATION Q# PARTNERSHIP P# LLC COMPANY NAMEI ADDRESS ' CITY _� ; S,) STATE ZIP- �I TEL � FAX CELL ' 7 - -_ � EMAIL __... �- -"-- ------..__..-_ ----- H O � � o � � H U � a � c M w H W g W D w O W CL z u LLI _ I-- Pik a w w a w co p o a a W Q � U J CL CL a 66 cn w LL rA H O z O H U W a z C7 z a w 0 a The Commonwealth of Massachusetts Department ofIndustrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address' City/State/Zip: Phone #: Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I e�ioyees (full and/or part-time).* 2. [V4 am a sole have hired the sub -contractors listed proprietor or partner- on the attached sheet. ship and'have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] 3. ❑ I am a homeowner doing all work officers have exercised their right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp, insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. [❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other -t——r­­.­, -a UVn tti ,l,ubt tubu ilii out me section below showing their workers' compensation policy information. Homeowners who submit this affidavit indicating they hie 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. 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 requiredunder 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 cer ' un the a' s and p nalti s of perjury that the information provided above is true and correct. Si ature:' 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): I. 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 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 bean 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 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 .A.ccidents Office of Investigations 600 Washington Street Boston., M.A. 02111 `Fel, # 617-727-4900 ext 406 or 1-877:MASSAFB Fax # 617-727-7749 Revised 5-26-05 Wvvw.znass,gov/dla Date • 'iSLTiDy . TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ...... k-7 r G •r �� 9/ q , �, has permission to perform.. wiring in the building of .............. 7... , ..... , . , , , , at. .... 117. North Andover, Mass, 'Pee .Y,5..... Lic. No.,/2/.?. (:". 7LECTRICAL INSPECTOR Check # � p 2 11096 (-TO (/7 { I' %ir f: �..,✓ � , Ci � r i• np +... �i=,s, Ll�:t1.. a A� ) `..�':, t�S�i i_.`�y i ['i:L 11'zEt(i D.N. :J��� 1'..�i i[.�L.1�t .f ON �' _'1,t ................. .. APPLI , TIO POI PERMIT TOP FRM.. ELECTRICAL WORK. r)6 *?.dot ,t?. a , , , t..k:L3, 3W< f <� :r� t~ ,` u� r,:,„ r< . L s r, �' �i aF; Friday, August 31, 2012 c t� .1 N.Andover 1.04 ... Middlesex.St ...... ............. Omm3 or.T4,13{311K. John Teti tlii)€#srNa.' 6173208488 Ovmir`a: +I 7 s . 104 Middlesex St. I, ftTi t01'.1€If M Isa j€Ir€C#iG i w Els: is #1 r ... ... i � . ( fC.��cl< t p1 fzr 3 t i�tk>1 :Nrlwj:_� All! 'i: 1 til# � ���31ir.�,� 1»J. undo:�....j `4 #tO.rtcm A31f Y<'�sl;:� lfutif�tsrt ....v;, 1EAT. jhd atp3eiq- �. _._ _ ........ ........ 1-Ekaiim.ind Nara€'P ref ttromed Ueeriul 111:01. __......._... _ _ . 1 $4,910.00 y >, ''M w `.st••:tit:w-V ;'tFc `'b.;.. 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N- ions. u, llt'li?4dJ�ENs: `�Tk3EW:t k�Bt•LFE KW, Gf�31 :� 1!E# t13el'. Ptt31t'QB35ii +3 tbrDmtSP..��SiMI#r 8.00 N741 ti l { Ai.:? r ant 111V4 . iF O Water yy 1 i o )�. #k{ �:3� T �� �¢"ftl" Ak j ] ..fif -e ,.qCAUDM�€�23. keit 0.00 14�:tfflEteCflyi�4�3M�.vibs: i 0fNhstor5 kaa T Fu t' ',,G� 'rSi3ifv-Ap1$ 0.00 __......._... _ _ . 1 $4,910.00 y >, ''M w `.st••:tit:w-V ;'tFc `'b.;.. Ili1T" ii p t�:e- lig p 1ST?,7 E�, :{ '3 a1 ':w2 .k. 1Z:3 *i w'it 3k<:i t.a 't«ta'll a ; r "iI1 .t?{i: k ' �:(.VIlyv�l.�.: r�7a ��yy�tt:yo+lits ttuzsi et �± f. E?lac ,.c1x ^n tri Via` �> z, t i lig ..zal> e ^rte nl..l A ly V j � � �'Er1Zi rr Ci t"r a � F'. �' l ::1 l G 1 -erL��} !f#tfJ�Ft rtt?�LL'Fw auna. f��"rlrT�i if`Zxp?..1 � iltf.'tfi £t3f if€Fllw On N Ir (2�3�. t`t`�iil4f� ,,9'y �* s�tfd#r�'DTyC��efE Atli € 11 Ait5xf icm Al�#1#Ts &: l uETatl3eit�ii ,�fEa3;ns.IEke..w/ /� �� t IC��a..:l � 1 � c' I,t.: 3CfII"rE :: R 1 + -h:,,i r a L a it R,,041 , � r �42tftT£1•£ . -.lou S�C1. mil •-,r;' Ala'?::F ':># _ alt. TeI;-) 57-C..tlt ,: i Y�..i3y140 t?:.':t'f t..s?111 7i:<��T{ �Y3s'tb r^ a1 '31.t°` z+• yS M .1. '.,. h—: {)- ,5.'. �JJ �,T\.'V t<!`C F�•.I�U X1 1� 11-.S f<,rt?.,ttria; a,itrii. Vin. '31. J iil? A r CI}aC .T:: < s 45.00 LAWRENCE K OGDEN, P.E. 198 EAST MAIN STREET GEORGETOWN, MA 01833 978-352-8318 fax 978 —352-2858 cell: 978-502-5921 August 30, 2012 Mr. Kevin Murphy 169 Boxford Street North Andover, Ma 01845 RE: Pierog Residence, 104 Middlesex Street, North Andover, Ma. 01845 Dear Mr. Murphy As you requested I visited the site to review the installation of the Engineered Materials consisting of Flitch Beam in the framing of the above project. This is shown on drawings prepared by J.D. LaGrasse dated 11/15/11 and a sketch of the Flitch Beam design. Based on the above site visit and based on what I could visibly see provided the above additional work is completed I can certify that to the best of my knowledge the Flitch Beam utilized in the framing as shown on the drawings is installed properly and meet the loading conditions of the Massachusetts State Building Code for 1 &2 Family Residences. All other framing requirements of the drawings and code, including but not limited to materials, nailing schedules, blocking, connections and other details are the responsibility of the licensed construction supervisor responsible for the project. Should you have any questions please do not hesitate to call. Yours truly, L wrence H. Ogden P.E. Structural 27765 0 Of WM. a �y cHAROLD r DM tFIFL� FSS NAL ENG�� 9200 f NORTH 'I O 9 SSACHUS� This certifies that Date. ,�klZ . . TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING llorI� S;oe-wce ........................................... ................ L 141 has permission to perform .P//?!,,QQ�� T�?!�..�,J'Pe�'' plumbing in the buildings of .... V y �?../..'.� 1"a at . %°1�r. � ?'L .. 577 , North Andover, Mass. Fee. :3?.'..t3Z ..Lic. No..... 1�'G�.. ,. ....... PLUMBING INSPECTOR Check # �� N V6 I MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING City/Town:_ ! ��� �� MA. Date: • 8 I Permit# Building Location: 1�� M i ff ULSrt PIV�-06 Owners Name: � � . Type of Occupancy: Commercial ❑ Educational E] Industrial ❑ Institutional(] Residentiala/1 New: ❑ Alteration: ❑ Renovation: ❑ Replacement: ❑ Plans Submitted: Yes ❑ No ❑ FIXTURES sus BSMT. BASEMENT 1sT FLOOR 2ND FLOORR 3RD FL OO R 7 FLOOR R ?TFLOOR 6T" FLOOR STH FLOOR 8TH FLOOR LU z O LU Z OK 0 Z � W ZW o W Q Z w a Q LL Q men m F Q it y Q cn S V) O a. y z :;i ' a O U. y x Z ct 0 Z t7 W U ' a } O O g Wcn g sus BSMT. BASEMENT 1sT FLOOR 2ND FLOORR 3RD FL OO R 7 FLOOR R ?TFLOOR 6T" FLOOR STH FLOOR 8TH FLOOR Insimli!rig Eo11-1E,&r,} name: E� Address: ozc an City/Town: State: Business Tel:_ �(� (p(o`� %O� Fax: o I Name of Licensed Plumber: INSURANc� cnvGon��. Q C ,Dck rima �>ifil ❑ Corporation ❑ Partnership arm/Company DEDICATED SYSTEMS N z O Z OK 0 Z � W VI to W Z Q O w 0 Ln Y z LO o En y w -j0 z z = U ¢ 2 NW 3 ~ Ln O J V 3 U Z d ° F 3 cl: O u 0l Insimli!rig Eo11-1E,&r,} name: E� Address: ozc an City/Town: State: Business Tel:_ �(� (p(o`� %O� Fax: o I Name of Licensed Plumber: INSURANc� cnvGon��. Q C ,Dck rima �>ifil ❑ Corporation ❑ Partnership arm/Company DEDICATED SYSTEMS N O OK Z � W VI Q 1" Q df O LU 1 1 Ln VI csrt.ifiG ta£ g I have a current liabiitlr lnsurante policy or its substantial equivalent which meets the requirements of MGL. Ch. 942 Yes [ P<O ❑ If you have checked Yes, please indicate the -type of coverage by checking the appropriate box below. A liability insurance policy* [Y_ Other type of indemnify ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 942 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only nature of Owner or Owners Agent Owner [jAgent ❑ I hereby certify that all of the details and information I have submitted (or entered) regarding this application are true and accurate Knowledge and that all plunnbing work and Installations performed under the permit issued forthis application will be in Compliance omplian ato the best JV th all o, my Pertinen provision of them ch efts State Plumbing Code and Chapter 142 of therm Laws. J> i7 i7 _ :y/Town 1 DOn�lr Type of License: LJ'ber Signature of Lic nsed Plumber aster I t E USE ONLY) OJourneyman License Number:_ ` W The Commonwealth ofMassachusetts Department oflndustrial Accidents Office of Investigations, 600 Washington Street Boston, MA 02111 SY ' www. mass govldia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers rnliennf Y"fnz.r.,-44__ Name (Business/Organization/Individual): Address: City/State/Zip: Phone #: Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* 2. I am a sole proprietor or have hired the sub -contractors listed partner- on the attached sheget. t ship and have no employees These sub -contractors have working for me in any capacity. [No workers' comp, insurance workers' comp, insurance. 5. ❑ We are a corporation and its required.] 3. ❑ I am a homeowner doing all work officers have exercised their right of exemption per MGL myself. [No workers' comp. c. 152, §1(4), and we have no insurance required.] t employees. [No workers' comp, insurance required.] Type of project (required): 6. ❑ New construction 7. El Remodeling 8. El Demolition 9. El Building addition 10. El Electrical repairs or additions 11.❑ Plumbing repairs or additions 12, ❑ Roof repairs Un Other !Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. i 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 their workers' comp, policy information. lam 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 Section 25A ofMGL 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 civilpenalties 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. I do hereby certify under the pains and penalties ofperjury that the information pr ovided 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): I. Board of Health 2. Building Department 3. City/Town CIerk 6. Other 4. Electrical )Inspector 5. Plumbing Inspector Contact Person: Phone #: Date. �1�z% A.......... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that. A!',F... „.S?peece ..................... has permission for gas installation ..,74!� in the buildings of ... T'9:?`...PI"C6 °................. at .../©. ` ! � / ..,�T.... //, North Andover, Mass. Fee..:o�' Lic. No. 2 ...,cl�G?rZ,nr�. GAS INSPECTOR Check # 7912 . U'r MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING City/Town:_ Nv(t-H DWoz MA. Date:—[ 1-18) -- Permit# Building Location: 1 O� M I U DO Sle)C IT Owners Name: Tom � � fC0 G ' IC Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential New: ❑ Alteration: ❑ Renovation: ❑ Replacement: 9-11, Plans Submitted: Yes ❑ No ❑ L'IVT1 I--- Lu --- INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes Lt�'No ❑ If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy [T}-'--- 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 Signature of Owner or Owner's Agent Owner [:] Agent E] By checking this box ❑, 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 pro �J�ion�of the Massachusetts State Plumbing Cod"Id Chapter 142 of the General Laws. By�!i_1s Title City/Town T of License: Plumber ❑ Ofis Fitter 9 Master ❑Journeyman ONLYI 0 LP Installer Signature License Number: d Plumber/Gas Fitter 1138 i \1 VI\VV Z N WNe V/ us IY D 2 O co w W 0 0 ca H = 0= W IX w O Z Z O o: W X R 0 1— n W� w co w W 0 W m� m 0� 0 1-- W co 0 W W O Q I— = LL Z w? N Lu J 1-- tii W o I.- W W U O t=i. Cal Q (�7 = Q i m W O 0 a. Z 0 F- > > > O IWUj — SUB BSMT. BASEMENT 7 FLOOR 2 FLOOR 3 FLOOR 111fi— 4 FLOOR 5 FLOOR 6 FLOOR 7 1H FLOOR 8 FLOOR I Installing Company Name: Check One Only Certificate # Address: 7Q �Cj� Q City/TownState: ❑ Corporation Business Tel: � � � 6b 3 r%��� Fax: 0% ❑ Partnership irm/Company Name of Licensed Plumber/Gas Fitter: C_ (\I INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes Lt�'No ❑ If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy [T}-'--- 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 Signature of Owner or Owner's Agent Owner [:] Agent E] By checking this box ❑, 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 pro �J�ion�of the Massachusetts State Plumbing Cod"Id Chapter 142 of the General Laws. By�!i_1s Title City/Town T of License: Plumber ❑ Ofis Fitter 9 Master ❑Journeyman ONLYI 0 LP Installer Signature License Number: d Plumber/Gas Fitter 1138 i The Commonwealth o Massa f chusetts / �o Department oflndustrialAccitlents Office of Investigations 600 Washington Street Boston, MA 02111 www mass govIdia �/�/2, / Workers' Compensation lnsurance Affidavit: Builders/Cnntri��t��,�u Name (Business/Organization/Individual): Address: City/State/Zip: Phone #: Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ' ❑ I am a general contractor and I employees (full and/or part-time).* 2. ❑ I am a sole proprietor or have hired the sub -contractors listed partner on the attached shget. t ship and have no employees These sub -contractors have working forme in any capacity. Wo workers' comp. insurance workers' comp, insurance. 5. ❑ We are a corporation and its required.] 3. ❑ I am a homeowner doing .officers have exercised their all work right of exemption per MGL myself. [No workers' comp. - C. 152, § 1(4), and we have no insurance required.] f employees. [No workers' COMA insurance required l Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions I L ❑ Plumbing repairs or additions 12.0 Roofrepairs 13.❑ Other *Any applicant that checks box #1must also fill out the section below showing their workers' compensation policy information. I 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 their workers' comp, policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy andjob 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 winder Section 25A ofMGL c.152 can lead to the imposition nuof mber penalties t 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. I do hereby certify under the pains and penalties ofperlury that the information provided above is true and correct. Si ature: 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): I. Board of Health 2. Building Department 3. City/Town Clerk 6. Other 4. Electrical Inspector 5. Plumbing Inspector Contact Person: Phone #. 11 -e. 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 employeris 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 apartinents 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 Depahment 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 Office of Investigations would like to thank you iu 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 Co ome—aUt o:i Mmaclausetts Department of Industrial Accidents Office of investigations 600 Washington Street Boston; MA, 02111 TO. 4 61.7-727-4900 ext 4406 ox 1,877-MA.SSA..FE Revised 5-26-05 Fax # 617-727-7749 www.mamg-ov/dia. UCENS