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Home My WebLink AboutMiscellaneous - 12 Sutton Place „ SUTTON PLACE _ � � Date. .7.... . . WORTH TOWN OF NORT� ANDOVER PERMIT FOR GAS NSIrALLATION SAC" S EtS This certifies that . . ./.'. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . has permission for gas installation A.. . . . . . in the buildings of .w4e'l e! 40!?7.*,5. . . . . . . . . . . . . . . . . . . . . . . . . at . . . . . . . . . . . . . . . . North Andover, Mass. -3 o Fee. .3 A Lic. No.. . . . . . . . . . . . . . .. . . . . . GAS INSPECTOR Check# C/ o 6186 i MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) 97 An6oyiz , Mass. Date to City, Town Permit # l/ G Building Owner 's , AT: LocationQ ACLU Name Type of Occupancy: New Renovation ❑ Replacement Plans Submitted Yes ❑ No N N W N N N V Z W N N aY Vl ¢ Q N = oc W WN cc O V = N Z O W W Q Z Z Q F W yak W O d W 1" W Q H V! Q W X W. Z O W Z N W Q � C H = (7 H cc W Z h Z k. W W O O > W H Cl J kN. W Z Q W a OC f' !• N m Z O Z WO N x Q W >' !Y W O Z a a Q O O W Q W H x "x o c7 x y. 3 0 (1 v X > o c H Q SUB—BSMT. BASEMENT 1ST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR STH FLOOR 6TH FLOOR 7TH FLOOR STH FLOOR E fillQ (Print or Type) '' II Check One: n Certificate N Installing Company Name n d P n o1 I I nr. Corp. Address C31 Joh n f I e r d 3-tre Partnership Re ri" ma aquo ❑ Firm/Company Business Telephone Nameof 'censed Plumber or Ga fitter OOS On 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 in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. I have informed the owner or his agent that I do not have liability insurance including completed operations coverage. Signature of Owner/Agent I have a current liability insurance policy to include completed operations coverage. ❑ B Y TYPE LICENSE: Signature of Licensed Title El Plumber Plumber or Gasfitter City/Town .!. Gasfitter APPROVED (OFFICE USE ONLY) ❑ Master �® ❑ Journeyman License Number FORM 1243 A.M.SULKIN CO. 1989 BELOW FOR OFFICE USE ONLY FINAL INSPECTION SKETCHES PROGRESS INSPECTION FEE NO. APPLICATION FOR PERMIT TO DO GASFITTING NAME&TYPE OF BUILDING LOCATION OF BUILDING PLUMBER OR GASFITTER LIG NO. PERMIT GRANTED DATE GASINSPECTOR Vtr�' The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Aunlicant Information , 1 Please Print Legibly Name(Busmess�orpnizationdndiviaaal): �"7O /,`/e. I-Address: q l >_y IvAl :1 c L City/State/Zip: �a A Zi 0 6Y{q Phone#: 9 ZL-&a any Are you an employer?Check the-appropriate box: Type of project(required): i.P I am a employer with q5 4. ❑ I am a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.El am a sole proprietor or partner- listed on the attached sheet $ El Remodeling These sub-contractors have 8. Demolition ship and have no employees ❑ working for me in any capacity. workers' comp.insurance. 9. ❑ Building addition [No workers' comp.insurance S. ❑ We are a corporation and its 10.El Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL 1 I.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑ Roof repairs insurance required.]t employees. [No workers' 13.F1 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 a new affidavit indicating such tContmetors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. ' tt r ne or m employees. Below is the o ' andjob site � I am an employer that is providing workers cvmpensatwn i su a e f y ploy p kcy � information. Insurance Company Name:Ujhb4rSAijrIRer"L 3'el,��Ue7es Cc n��se4-9i CAD-cp Policy#or Self-ins.Lie.M inlC ODo 3 U- i/ Expiration Date: 01 o o ,Poa Job Site Address: City/Stattaip: 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. Si afore: Date: Phone#• 6779--5a eg 9 XF Ofyrchd use only. Do not write in this area,to he completed by city or town of x1al 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 lassachusetts General Laws chapter 152 requires all employersto provide workers' compensation for their eniployees. ursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire, xpress or implied,oral or written." ,n employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more f the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the sceiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the wner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the welling house of another who employs persons to do maintenance,construction or repair work on such dwelling house r on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." dGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or -enewal 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." kdditionally,MGL chapter 152,§25C( )states"Neither the commonwealth nor any of its political subdivisions shall :rater into any contract for the performance of public work until acceptable evidence of compliance with the insurance equirements of this chapter have been presented to the contracting authority." 1pplicants 'lease fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if ►ecessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of nsurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the nembers or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have .mployees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial kccidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should )e returned to the city or town that the application for the permit or license is being requested, not the Department of [ndustrial 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 afthe bottom Df 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 gown 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. Che Department's address,telephone and fax number: The Commonwealth of Massachusetts ` Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 92111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 vised 5-26-05 www.mass.gov/dia