HomeMy WebLinkAboutMiscellaneous - 11 WALKER ROAD 4/30/2018 (2)8973
Date. .141 /� .
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that ...... ff11 1 ..... ............__........... .
has permission to perform ..h� 2... ��►-�..... �"!f�S�¢t.
plumbing in the buildings of . ................ .
at ,... ff . �(%..1.� ? ...%�� .... !�?�. � .. !� .. , North Andover, Mass.
Fe#- 3 7.. <%. Lic. No. P?. ? ./. � ..... .. �.. .
PLUMBING INSPECTOR
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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
City/Town: %)O4)9AL&e, , MA. Date: - i /'a0 t/Permit#
Building Location:_ 1) �^% �/4� (�„ Owners Name: U/4h �v
Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential
New: LJ Alteration: [] Renovation:
FIXTURES
Installing Company Name: 1 V I C APS �lv,�i ^%
Address: "t CI CIC City/Town MC, -/'j yI., ygg State: N6
Business Tel: 1—'0&-77�-- -106 Fax:
Name of Licensed Plumber:
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Plans Submitted: Yes n No
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Installing Company Name: 1 V I C APS �lv,�i ^%
Address: "t CI CIC City/Town MC, -/'j yI., ygg State: N6
Business Tel: 1—'0&-77�-- -106 Fax:
Name of Licensed Plumber:
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Plans Submitted: Yes n No
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Check One Only Certificate #
❑ Corporation
❑ Partnership
❑ Firm/Company
INSURANCE COVERAGE:
I have a current lig_ bility insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes ❑ No ❑
If you have checked Yes, please indicate the .type of coverage by checking the appropriate box below.
A liability insurance policy. ❑ 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 ❑
1 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:
By Type of License:
Title ❑ Plumber Signature of L�'censed Plumber
City/Town ❑ Master
APPROVED (OFFICE USE ONLY) Journeyman License Number: �b
r www.mass gov1dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information . Please PrinfLeaibly
Name (Business/Organization/Individual): 1 V , C 10. S
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Addresso l� J �' C,�C 1,
City/State/Zip: n4ic P44 D 1t6a Phone ##:
Are you an employer? Check the appropriate box:
The Commonwealth of Massachusetts
r
Department of IndustrialAccidents
,ham
LI, yj'
Office
Office of Investigations
x1r.
600 Washington Street
ship and have no employees
Boston, MA 02111
r www.mass gov1dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information . Please PrinfLeaibly
Name (Business/Organization/Individual): 1 V , C 10. S
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Addresso l� J �' C,�C 1,
City/State/Zip: n4ic P44 D 1t6a Phone ##:
Are you an employer? Check the appropriate box:
Type of project (required):
1. ❑ I ama' employer with
4. ❑ I am a general contractor and I
6. [] New construction
employees (full and/or part-time). �
2. �aia a sole proprietor or partner-
have hired the sub -contractors
listed on the attached sheet. T
�• ❑Remodeling
ship and have no employees
These sub -contractors have
8. ❑ Demolition
working for mein any capacity.
insurance
workers' comp. insurance.
5. ❑ We are a corporation and its
9. ❑Building addition
[No workers' comp.
required.]
officers have exercised their
10.❑ Electrical repairs or additions
3. [:11 air a homeowner doing all work
right of exemption per MGL -
I Q'�J.'dumbing repairs or additions
inyself. [No workers' comp.
c. 152, § 1(4), and we have no
12.0 Roofrepairs "
insurance required.] i
employees. [No workers'
13.❑ 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 are 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 acid 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. e_�7
Insurance Company Name: M)t, 1_II [112&Q q C �'/�� w>gC PW Y4 -
Policy # or Self -ins. Lie. Expiration Date:
Job Site Address: on I,f 0 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 maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby C0fJ1 under the pains andpenalties of peifuiy that the information provided above is true and correct.
F Date:
Phone #: ( -- t %� 7�� %j 2 6
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 aparthnents 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 cant' 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 confinnation of insurance coverage. AIso be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the pen -nit 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 Departnent 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 pennit/lieense 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 pen -nit 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 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 CQrnmonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
604 Washington Street
Boston, MA 02,111
Tel. #fi 617-727-4900 ext 406 or 1-877-MA.SSAFE
Revised 5-26-05 Fax # 617-727-7749
www.mass.gov/dia
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LICENSED AS A JOURNEYMAN PLUMB
ISSUES THIS LICEAE TO E
'HENRY THOMAS NICKLAS b.
.3 OA ROLE
_..NERRrMAC�,�.MA U1860,-16,26
25170 05/01/12 754122
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Dat ./. ?//. s(..
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that ... Jf'1F??t`.F.... u.R�.SA.t.............
has permission to perform ..�, . l-! ... . ................!...... .
plumbing in the buildings of .. D. .I: ................
at .. �� ..l!L.<.�'/% .�.� .. ? .� ........... , North Andover, Mass.
Fee. 3�. �.Lic. No.. Y. �.�.. ........ L .7? ,_ . r.. .-)......
P�UMBING INSPECTdR
Check #
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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Print or Type)
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Mass. Date 19 Permit #
I Building Location IL OZA-Ifff_ a Ro Owner's Name
'tea Type of Occupancy
New Renovation ❑ Replacement 2"" Plans Submitted: Yes ❑ No 2'
FIXTURES
Installing Company Name Check one: Certificate
Address G// 5C- kk w l S 7� — ❑ Corporation
Gr6veGGe-,A NlA ❑ Partnership _
Business Telephone 7L 3 71/ V � ��� ❑
Name of Licensed Plumber J� x/� e 3 w�r�s h --e—
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes ❑ No 0;,—
If you have checked yes, please indicate the type coverage by checking the appropriate box.
11
A liability insurance policy ❑ 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 Mass.
General Laws, and that my signature on this permit application waives this requirement.
Signature of Owner or
Check one:
OwnerX Agent ❑
I hereby certify that all of the details and information I have submitted (or entered) in the above 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 be in compliance withrti nt provisio t e Mass husetts State Plumbing Code and Chapter 142 of the
General Laws.
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Title Type of License: Masters
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2nd FLOOR
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4th FLOOR
5th FLOOR
6th FLOOR
7th FLOOR
8th FLOOR
Installing Company Name Check one: Certificate
Address G// 5C- kk w l S 7� — ❑ Corporation
Gr6veGGe-,A NlA ❑ Partnership _
Business Telephone 7L 3 71/ V � ��� ❑
Name of Licensed Plumber J� x/� e 3 w�r�s h --e—
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes ❑ No 0;,—
If you have checked yes, please indicate the type coverage by checking the appropriate box.
11
A liability insurance policy ❑ 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 Mass.
General Laws, and that my signature on this permit application waives this requirement.
Signature of Owner or
Check one:
OwnerX Agent ❑
I hereby certify that all of the details and information I have submitted (or entered) in the above 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 be in compliance withrti nt provisio t e Mass husetts State Plumbing Code and Chapter 142 of the
General Laws.
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gy gnature of Licensed Plumber
Title Type of License: Masters
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City/Town License Nu-nber �7 �0 /
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Date, ?.".1. - 0. 1. .
°'• •° �'"o TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
'SSACMUS�
This certifies that ..� �'' �. "� .... �l �..�
has permission to perform ... ~
plumbing in the buildings of.1'......`..`.'`."""................
at. �G .. U �' `'t` ..... , North Andover, Mass.
Fee .� O - ... Lic. No.. ......
'PLUMBING INSEP CT04
Check # '3 1
5818
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MASSACHUSETTS UNIFORM APPLICATION'FOR PERMIT TO DO PLUMBING
t•
(Type or print)
NORTH ANDOVER, MASSACHUSETTS l63
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��r� / its_ ;� A!' - Date C)
Building Location tt �(
New Renovation
Owners Name
of Occupancy�'� .
f:
G 1 Permit #
Amount '.?�� 0
Replacement Plans Submitted Yes No ❑
(Print or type) / Check one: Certificate
Installing Compa ame tt^ 6 ., C� ❑ Corp.
Andress G 7 ` Partner.
/V- Q/Firm/Co.
Business Te ephone 7,J--- Gd- 7— 3 3 (o
Name of Licensed Plumbei: , J im U
Insurance Coverage: Indicate the type of insftdrice coverage by checking the appropriate. box:
Liability insurance policy Other type of indemnity E]Bond ❑
/ff
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
I hereby certify that all of the details and i
best of my knowledge and that all plumbin
compliance with all pertinent provisions of t
By:
Title
City/Town
APPROVED(OFFICE USE ONLY
Own � Agent ❑
formation I have su mitted (or ntered) in ab a lication are true and accurate to the
work and in talla 'ons perfo ed un P t ed for this application will be in
he achuse Sta bin d pter 142 of the General Laws.
igna re of LIcensegrylumly
Type of Plumb16�' g Lice e
6 . /. ❑
icense numoer Master �/ Journeyman
l,
'pill
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mr,11'r1ro11 '
------------------------
(Print or type) / Check one: Certificate
Installing Compa ame tt^ 6 ., C� ❑ Corp.
Andress G 7 ` Partner.
/V- Q/Firm/Co.
Business Te ephone 7,J--- Gd- 7— 3 3 (o
Name of Licensed Plumbei: , J im U
Insurance Coverage: Indicate the type of insftdrice coverage by checking the appropriate. box:
Liability insurance policy Other type of indemnity E]Bond ❑
/ff
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
I hereby certify that all of the details and i
best of my knowledge and that all plumbin
compliance with all pertinent provisions of t
By:
Title
City/Town
APPROVED(OFFICE USE ONLY
Own � Agent ❑
formation I have su mitted (or ntered) in ab a lication are true and accurate to the
work and in talla 'ons perfo ed un P t ed for this application will be in
he achuse Sta bin d pter 142 of the General Laws.
igna re of LIcensegrylumly
Type of Plumb16�' g Lice e
6 . /. ❑
icense numoer Master �/ Journeyman