HomeMy WebLinkAboutMiscellaneous - 105 BEVERLY STREET 4/30/2018PhS
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Date...... ........
TOWN OF NORTH ANDOVER'
PERMIT FOR GAS INSTALLATION
This certifies that
.... � �............
has permission for gas installation
in the buildings of
at Noith Andover, Mass.
Fee?? . Lic. No. ..............
GAS INSPECTOR
Check#
70�3
MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS FITTING
(Type or print) Date/ 0
l— 7
NORTH ANDOVER, MASSACHUSETTS
Building Locations �d6 fir ly ST permit # C 93
� ✓
%0 ��f w%j1ib"f5 Owner's Name Amount $
New ❑ Renovation Replacement Plans Submitted
(Print or type) ���
Name �%j�% -4 �ll�//iPs - �W4
Address
fKame of Licensed Plumber or Gas Fitter 6-7?; 401 7OP✓I' E'i7
Check one: Certificate Installing Company
1-1 Corp.
El Partner.
11 Firm/Co.
;TSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes No
If you have checked Yes, please indicate the type coverage by checking the appropriate box.
Liability insurance policy Other type of indemnity Bond 13
Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the
Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one: _
Signature of Owner or Owner's Arent
Owner
I nereoy certtry tnat au or the oetaus and information 1 have subnutted (or entered) in above application are true and accurate to the
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts Stat9oQas Code and Q-an�2Qf the General Laws.
By:
Title
City/Town
APPROVED (OFFICE USE ONLY)
Signature of L ci ensed Plumber Or Gas Fitter
Plumber 1133-3
Gas Fitter License Number
Master
Journeyman
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SUB-BASEM ENT
B A S E M ENT
1ST. FLOOR
2N'D. FLOOR
3RD. FLOOR
4TH. FLOOR
5TH. FLOOR
6TH. FLOOR
7TH. FLOOR
STH. FLOOR
(Print or type) ���
Name �%j�% -4 �ll�//iPs - �W4
Address
fKame of Licensed Plumber or Gas Fitter 6-7?; 401 7OP✓I' E'i7
Check one: Certificate Installing Company
1-1 Corp.
El Partner.
11 Firm/Co.
;TSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes No
If you have checked Yes, please indicate the type coverage by checking the appropriate box.
Liability insurance policy Other type of indemnity Bond 13
Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the
Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one: _
Signature of Owner or Owner's Arent
Owner
I nereoy certtry tnat au or the oetaus and information 1 have subnutted (or entered) in above application are true and accurate to the
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts Stat9oQas Code and Q-an�2Qf the General Laws.
By:
Title
City/Town
APPROVED (OFFICE USE ONLY)
Signature of L ci ensed Plumber Or Gas Fitter
Plumber 1133-3
Gas Fitter License Number
Master
Journeyman
_r
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
Uf 600 Washington Street
Boston, MA 02111
www mas&gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): %�j e-1✓iC/f,�lijot� CG�
Address: ly 4yc,17 n
City/State/Zip: ,/��-,A�,��-j� Phone #:
Ar you an employer? Check the appropriate box:
I.r I am a employer with 1_
4. ❑ I am a general contractor and I
employees (full and/or part-time).*
2. ❑ I am a sole proprietor or partner-
have hired the sub -contractors
listed 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 m_s' also IM out the sect=_ beim � s_on^._b the iLVOM �' comps cation policy info.Wation.
Homeoi&rners 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 -contactors 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: CC,461e K 7—
y Policy # or Self -ins. Lic. M Expiration Date:
Job Site Address:/dot�- 02 �/
+Y r— 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 verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct
Phone #:
Official use only. Do not write in this area, to be completed by city or town official
City or Town:
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Permit/License #
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 pe=rson 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 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 Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Revised 5-26-05
Fax # 617-72.7-7749
www.masS..gov/dia
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that ..............................
has permission to perform ............
plumbing in the buildings of..............
at .............. North Andover, Mass.
.
Lic. No//? .. .................
PLUMBING INSPECTOR
Check # /,Q1 '1-16
6 4 6b
b
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Building Location
— Owner rJ ew c ey tai '1X"41 S
New ❑ Renovation ❑ Replacement 0
ryVmr ro mGo
Date -C-2-16
Permit #
Amount
Plans Submitted Yes ❑ No.
(Print or type)
Installing Company Name_ 7ie,�ri�/I ,o/a,,,d„�q � 7;,, Check one: Certificate
q❑Corp.
Address `1 /�Y�iI X aL i(/e�✓ iJ/�?c� T, � c, fZJ ..
77P- - a ss --;L& 7 Partner.
Business Telephone ❑ Firm/Co.
Name of Licensed Phrmber: STdi100q 7 -AP, -I"
Insurance Coverage: Indicate thetype of insurance coverage by checking the appropriate box:
Liability insurance policy Other type of indemnity ❑ Bond
Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above
three insurance
Signature Owner ❑ Agent ❑
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the
best of my knowledge and that all plumbing work and installations performed under permit Issued for this application will be m
compliance with all pertinent provisions of the Massachus and Chapter 142 of the General Laws.
By:Signature or LWF_MSWiuinb
Title
Type of Plumbing License
CiVaown //,3a3
rcense umo„er rj
APPROVED (OFFICE USE ONLY Master Journeyman ❑
0
. If
(� r
V
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www mass govldia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information
Please Print 1&ibl
Name (Business/Organization/Individual):-7—hr,—,—Ie,/
Address:_ CJ
City/State/Zip: �/e�,/( Ty irk— l► ef- Phone #: 5-5-- 067
Are you an employer? Check the appropriate box:
l .T2`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 sheet I
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
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.] 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
-_-- - nuc u:c �v.;L1L� neloW Enon1ing their womers camp--satlon policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then }sire 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 Name:— j 07 S
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 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 ofthis statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification
Ido hereby certify udder the pains andpenalties ofperjury that the information provided above is true and correct
_ass- _?&407
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 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 pernait 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 Street
Boston, MA 02.111
Tel. # 617-72.74900 ext 406 or 1-877-MASSAFE
Fax # 617-72.7-7749
Revised 5-26-05 wvvw.mass-gov/dia