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HomeMy WebLinkAboutMiscellaneous - 120 CARLTON LANE 4/30/2018 120 CARLTON LANE 2101106.C-0097-0000.0 Date.. NORTH pf 4o TOWN _- �� TOWN OF NORTH A OVER i O � P 40 - PERMIT FOR GAS4 STALLATION SACHUSEt This certifies that has permission for gas installation . . . !�.t� „1 �4.1.oA in the buildings of . . �.� . . .n ! .0~. . . . . • • • • • • • r at . . . . . . . . . . . . . . . . . . . Norxh.Andover, Mass. . . . . �. . Fee.. S . r". . Lic. No.. �. .Q ..�. . �� GAS INSPECTOR f Check# .7 Jr) J 6144 MASSACHUSETTS UNIFORM APPUCATON FOR PERMIT TO DO GAS FITTING (Type or print) Datej NORTH ANDOVER,MASSACHUSETTS Building Locations1 ?.0 ��f o-1_ Permit# Amount$ Owner's Name � �`� �L 0 New D Renovation D Replacement Plans Submitted Q a y W OU o0 F x v� Q C W E FN a z z p I w � V w e x w � � a 0 w d Z v w z a O A w z d w C z F H w cw7 O > w F w a F m a 0 z o x a 3 a a a > q a Fw• o SUB-BASEMENT BASEMENT y 1ST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH . FLOOR 5TH . FLOOR 6TH . FLOOR 7TH . FLOOR 8TH . FLOOR (Print or type) ,QQ �'` n ///� Che k one: Certificate Installing Company Name 1e,T f d 1i1T-/[i lie a-� r0 ,�d—l-7` _ Corp. Address y k e-'-70✓L ' Partner. "Yt u l✓P dL "l�-t�- tj Business TelephoneF- irm/Co. Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ©' NoO If you have checked Les,please indicate the type coverage by checking the appropriate box. Liability insurance policy ED-- OtherOther type of indemnity Bond D Owner's Insurance Waiver: 1 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 Agent Owner 13 Agent 13 I hereby certify that all of the details and information 1 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 or this application will be in compliance with all pertinent provisions of the Massachus tate Ga ode and ter 142 of a Ge al Laws. I � By: Signature of Licensed Plumber Or Gas Fitter Title [3-11fumber City/Town Gas Fitter 71cense lNurntier 13—master APPROVED(OFFICE USE ONLY) [3 Journeyman 7351 Date..T/////........ r HORT1y G Of 3= '` 0 0 TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION �9SSAG NO This certifies that !+.. .. . ... ... .. . . . . has permission for gas installation . ��. �!. .. . in the buildings of . . '.ckk n P. . . .. . .. . . . . . . . .. . . . . .. . . . . at �. . . .�f A- 1I.T ....... . . . . .. . .. North Andover, Mass. Lic. No.. .�. 4 ...�.. /f GAS INSPECTO. p Check#�7r- 10 MASSACHUSETTS UNIFORMAPPUCATONFORPERMITTO DO GAS FTFnNG (Type or print) Date t hd NORTH ANDOVER,MASSACHUSETTS Building Locations _ 12,0 0 OLA �T%-"— Permit# Amount$ Owner's Name New❑ Renovation Q Replacement Plans Submitted y o o. w d x o o z w y x d z oa > w rA x w w H w x a a z a o o° w o° z w SUB-BASEM ENT BASEMENT IV r 1ST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH. FLOOR 5TH. FLO O R 6TH. FLOOR 7TH . FLOOR &.T-H. FLO 0 R or type) /�+ � �9'i �� Check one: Certificate Installing Company Name JL., � � � � •❑ Corp. Address - 6-7) Q �� "� Partner. Business Te ep one -7 ro Fb D- 7,0 [aFiim7Co. Name of Licensed Plumber or Gas Fitter .,23 /6 INSURANCE COVERAGE Check one• I have a current liability Insurance policy or it's substantial equivalent. Yes No U If you have checked}_es,please' .cate the type coverage by checking the appropriate box. Liability insurance policyff 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 ofthe Mass. General Laws,and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner 0 Agent F] 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' allah s p rmed under Permit Issue for this application will be in compliance with all pertinent provisions of the Mass hose at as de and apter 142 the Ge —Laws. By: ignature of Licens lumber Or Gas Fitter Title Plumber City/Town r Gas Fitter lcense um e �C4aster APPROVED(oF =usEONLY) Journeyman The Commonwealth of Massachusetts w Department of Industrial Accidents Office of Investigations kVJ 600 Washington Street Boston, MA 02111 www.mas&,-ov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organizafion/Individual): Address: City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employerwith 4. ❑ I am a general contractor and I employees(full and/orpart-time).* have hired the sub-contractors 6 ❑New construction 2,❑ I am a sole proprietor or partner- listed on the attached sheet t 7• ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. g. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 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' comp.msurancerequired.] 13.[1 Other Any apiicantthat chealks box#I must also rel out the section beEos,showing their workers'compensation policy f,;ma�on t Homeowners 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-contractors and their workers'comp.policy information. I am an employer that isproviding workers'compensation insurance for my employees Below,is thepolicy and job site information. Insurance Company Name: 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 of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cerkfy under the pains and penalties of perjury that the information provided above is true and correct. Simature: Date: Phone#: [6. ial use only. Do not write in this area,to be completed by city or town official or Town: Permit/License# ng Authority(circle one): ard of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector heract Person: Phone#: Information and Instructions Y 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 orother 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 Iocal 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 i 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 per�t'OI License us being requested,not the DeparEment of industra]Accidents. Showa 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.ext406 or 1-877-MASSAFE Revised 5-26-05 Fax#617-727-7749 wwul.mass-gov/dia 7� � C: Date.. . �f/7 / l.� . ... NORTI� Of „.o .,1ti0 0 TOWN OF NORTH ANDOVER . � • PERMIT FOR GAS INSTALLATION Io SACMUgEt This certifies that . T. . .✓ (.1'h".`?' .P . . . . t. . . i` . has permission for gas installation . . in the buildings of . .�/ ? c, L c�. . . . . . . . . . . . . . . . . at . �.l u. . . . �`. .1.d�.�"' . . . . . . . . . .. North Andover, Mass. Fee., s9.0 Lic. No..E .�' .. . . GASINSPECTOR Check# /J G 0 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING City/Town: Q, MA. Date: lam/ / Permit# Building Location: Owners Name: 4) Type of Occupancy: Commercial❑ Educational ❑ Industrial❑ Institutional❑ Residential[� New:❑ Alteration: ❑ Renovation: ❑ Replacement: Plans Submitted: Yes❑ No❑ FIXTURES W w Y = a W o I- m = O w W C) to H O = w C7 J >_ to O W W w Lu to �0 Q a IW— D a w X to v w 0 t9 W U) O Lu o = u. � W W z O J H F- O z J U' W F9 co y— = W lW_ W W Z 25 } W y a a M W O z o I- U 10 0 t=i. 0 _ _ O a W H > > > O SUB BSMT. BASEMENT 15TFLOOR 2 FLOOR 3 FLOOR 4 TH FLOOR 5 FLOOR 6 FLOOR 7 FLOOR t 8 FLOOR Check One Only Certificate# Installing Company Name: 44 A -e p 4( / CI Corporation Address-Ad/34).kS 7 ( City/TownQ7Il. A*Jd " — State: fM!�' El Partnership Business Tel:9)7-U fb D 9'—vo Fax: $i'!"'{/� El Firm/Company Name of Licensed Plumber/Gas Fitter: elv"e (IJ, INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Yes[1/No❑ If you have checked Yes,please indicate the type of coverage by checking the appropriate box below. A liability insurance policy Lam' 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 El Agent 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 provision of the Massachusetts State Plumbing Coda and Chapter 142 of a General Laws. TTypge of License: By OPlumber ` Title �7 ❑Gds Fitter nature of Lic sed Plumber/Gas Fitter aster Ci !Town [-]journeyman License Number: 2 7 APPROVED OFFICE USE ONLY ❑ LP Installer « I