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Home My WebLink AboutMiscellaneous - 121 High Street X�Z 5 T BUILDING FILE DateP/� "oRTM TOWN OF NORTH ANDOVER -• o ° p PERMIT FOR PLUMBING . . 4o 4 ,SS�ICMUSEt This certifies that . .�l��./.� .5. . . ' `� t`. ` . . .� / . . . . . . . has permission to perform . . . ` plumbing in the buildings of . . . . . . . . . . . . . . . . . . . . at . . .f.? .G. . .�f.'. .�. . . . . . . . . . . . . . . . . . North Andover, Mass. Fee.//?—.— ee.//? . Lic. No.l i�!"1 . . . . . /. % . . . . . . . . . . . . CC 1 PLUMBING INSPECTOR Check # 8220 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS 11''11 z .. F Date Building Location �oKl / Owners Name �C6- "h1C Permit#— PyrOccupancy 2t�• _ _ Amount L Y v-�� N� T e of Occu anc �OM efC AL New Renovation Replacement Plans Submitted Yes No ❑ .FIXTURES > _w Ln H O w a rT.4 U W ~ C H x � � A W . A .•7 a w A W H ri L7 A � a � SLZ -FE RkSEU i' lS)C Ka R M ILOCR M FLOCIR 4M RJOCR SII3 FI1DQ2 6)iHi FIDtBi2 91H ROOM (Print or type) Check one: Certificate Installing Company Name TA mo-ty,,¢ 61-ea,y f �y,�,, ❑ Corp. Address �� !"/�i�P _)r� ❑ Partner. ten-► d A/# 0307 9 mess Telephone Y 7 y 1 yA 3 79-77 ® Firm/Co. Name of Licensed Plumber: CIF Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy M 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 threeinsurance Signature Owner ❑ Agent r 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 Massachuse State Plumb and Chapter 142of the gzneral Laws. By: igna ure icense um er Title Type lumbing License - City/Town i e se MITI= Master Journeyman APPROVED(OFFICE USE ONLY I n ! The Commonwealth of Massachuset><r kf ! Department of.fndusiri d Accidents or _ t' x' Office of Investibgations ✓ ilil}? ' 600 Mzshinefon Street U4 Boston, MA 02111 c W;~.mass gov/dia . ..Workers' Com ensafi on Ins' P urance Affidavit~ Builders/C APiicant afor�ation ontractors/Eiectricians/Plumbers I Please Print Le—gbf Name (Business 0rganirationAndividual); A/ Address: `�Y A 4 City/State/Zip. N 1,�, Phone [Are you an employer?Cheek.the appropriate bo❑ I'am a employer wi#h 4, F7O t (repaired): ❑ I am a genteral contractor and I employees(fun and/orpart-time)_.* have birsd the sub-contractors construction . I am.a sole proprietor.or partner.; listed on the attached sheet t odeling ship and have no employees These soli-contractors have working forme in any capacity, workers' comp.insurance. olition [No workers'comp.insurance S. ❑ We are a corporation and its ing addition required.] . officers have exercised their trical repairs or additions 3•Q I am shomeowner doing all work right of exemption per MC3L bing repairs or additions myseI£[Nowar[cers'comp. c, 152, §1(4),'and we have no insurance required.]t emPto ccs. [No workers! 12•[] Roof repairs comp. insurance required.] 13.[].Omer 'Atry applicant tient checks boZ Muse also f[i!out the section below showing their wurkerc''aom t iiomeownM who submit this affidavit indicating they am iiam an peesation policy information. =Cotrtraetors that check this box trout attached sn g work end than ham outside conuactors muat subentt a new affidavit' additional vtt mdi sheet showitlg the namt of the sub-contntctons and their wotkmrs come.Poli .•°�aE such Fo mfonnetion. am an ertaployer ctt is p;�:.dc.7g:r i�rirrrs'compensmron insuranceforTref'erriP�aYeec: Belfic�,and'ob site . in•formation ow it the po Insurance Company Name: ' Policy#or Self-ins.Lie.#: Expiration bete: Job Site Address: _cwstate/Zip. Attach a copy of the workers'.compensation policy declarnfiou page(showing the pofic} number and expiration bate), . Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of crim fine up to$1,500,00 and/or one-yeainal penalties of a r imprisonment,as well es civil penalties in the form of a STOP WORDE Of up to$250.00 a day against the violator. Be advised that a copy of R and a fine K OR Investigations of the DIA for insurance.coverage verification. this statement may be forwarded to the oqfice of I do hereby certify under the p and penalties of per`ary thar the information provided above is Brie and rorTeeL Si tare:. _,.___ Date: Phone#: l Df j`tcia!use only. Do not write in this area,to be completed by city or tows offer City or Town: Per mit/Lit cure# Issuing,4athority(circle one); L Board of Health Z Building Department 3.City/Town Cier k 4.Electrical Inspector S. Plumbing Inspector 6.Other Contact Person• Phone#: tructians Information a. nd Ins Massachusetts General Laws chapter 152 requires all employ=to provide workers'compensation for their empioyees. Pursuant to this statute,an employee is defined as"...every person in the service of another undar any contract of hire, - express or implied,oral or written." ? I An employer is defined as"an.individual,partnership,mc)diatlon,corporation or other legal entity,or any two ormon of the'foregoing engaged in a joint enterprise:and including the legal representatives of a decaesed employer,or the receiver erinrstmof an individual,partnership,associatioin or other legal entity,employing employees. 'Howeverthe owner-of a dwelling house having not more than three apa -trnerrts and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work an such dwelling house or on the grounds or building appurtenant thereto shall not be=,m of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shag withhold the issuance or renewal of license or permit to operate a business or ito construct building in the commonwealth for any applicant who bas not produced aeeeptaMie evidence-of compliance with the insurance coverage required" Additionally, MOL chapter 152,§25CM states"Neither the commonwealth nor any of its political subdivisions shall . enter into any contract for the petformance of public work until acceptable evidence of wmplian with the insurance requiremcnts of this chapter have been presented to.the cdrttracting authority.".. Applicants Please fill out tate workers'compensation.affidavit completely,by checking the boxes that app to your situation and,if ` necessary,supply sub-contractor(s)name(s),addrms(es).aund phone number(s)along with their certificate(s)of ins mce. Limited Liability Companies (LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not ;to workers'co-rrt p requu'ed �' pensation insurance. lfan LLC or LLP does have empioyees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insuranct coverage.. Also*6e sure to sign and date the affidavit. The affidavit should be returned to the cityor town that the application for.tht permit or license is being requested,not'the Department of Industrial Accidents. Should you have any.questions regarding the law or if you are rmpimd to obtain a workers' oornpensation policy,please-call the Department at the nurinber.listed below. Self ntsr� d tmattMiPs atto�,ld e!++�+h!�s self insuranee-lieense number on the*appropriate line. City or Town Offieisis Pie=be sure that the affidavit is complete and printed legibly. The Department has Provided a space at the bottom affidav' of the rt for oa to fill out in the went the Office of o y Investigations has to eoni$ct you regarding th., licartf. Y �' g aPP Please be sure to fill in the permitllicense number which w-iIl be used as a reference number. In addition,an applicant that must submit multiple permitnicemse 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 be=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 fimae permits or licenses. A new affidavit must be filled out each year. When 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'bo bum leaves etc.)said pers6r3 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 Departinont's address,telephone and fax number The Commonwealth of Massachusetts DcParlmOnt of Fmdmstrial Aacid=ts Office of EnvestiDations 600 Washington Street Bosfon, MA 02111 TeL #617-727-4900 ext 406 or 1-9-77-MASSAFE Fax 4 617-727-7744 Revised 5-26-115 wwwmass.gov/dia „ i i i Date. OA& "oRT„ tiTOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ,SSACMUSE� This certifies that . . . �. . . . . . . . (�� . . . . . . . . . . has permission to perform . . .t. . . . . . . . ��s. . . . . . . . . . . . . plumbing in the buildings of . .PC.0%. . . . . . . . . . . . . . . . . . . at . . . . . . . . . l .f . . . . ,y' �? . . g --, , North Andover, Mass. Fee. .61.17. . .Lic. No,. . . . . . . 2�INSPE . . . . r)� PLUM Check # OR 7808 t, 04 3 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) r NORTH ANDOVER,MASSACHUSETTS Date Building Location S�rl2Owners Name Permit#_ '7 tr"1- Type of Occupancy Amount New . Renovation. Replacement "� Plans Submitted Yes No ❑ I FIXTURES � V A U 0 W C7 F > V) H C L7 A 0 M HJOQt 3M MOOR 4IS FLOC[t `1434 4 SIFT FLOC t 6II3)HIJJQZ 7IIIRoaz ' 9M FL" (Print or type) Check one: Certificate Installing Company Name f Corp Addres de-C .% Partner. D Bustness Telephone — FIFirm/Co. Name of Licensed Plumber: Insurance Coverage: Indicate the of insurance coverage by checking the appropriate box: Liability insurance policy ISJ ' 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 in compliance with all pertinent provisions of the Massachusetts S to Plu ing Co e and C r of the General Laws. By lana nrF Title Type of Plumbing License City/Town 45 7 rcense numDer Master Journeyman ElAPPROVED(OFFICE USE ONLY 'ate. . . . . 1. !. HORTM TOWN NORTH ANDOVER o�,,..o ,•�tio h PERMIT FOR PLUMBING - M4 LUMBING -M4 us� This certifies that . . M.! .(.'. t . . . .��. :L:�z f 1.. . .�. . . . . . . . . . . has permission to perform . . . . . . . . . . . . . . . plumbing in the buildings of . . . . . . . . . . . . . . . . . . . . . . . . . . . / t at. S. . . . . . . . . . . . : . . . . . . . . . .. I orth Andover, Mass. )" . � . �� . . . . Fee .�,,�. . .Lic. No..� . .!t. .�. . . . . . f PLUMBING INSPECTOR rCh�eck # R ff / 59 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS _ Date LtBuildin Location / / wners Name Permit# IZ a Type of Occupancy ?d Amount c�< New Renovation [] Replacement '❑ Plans Submitted Yes ❑ No FIXTURES U rA �1 ,r O O M U) 51&F�VIC M FLOM M FIfCIt 3M FIDCR 0 6 + 4IH FLOCIR $IH FLOOR 7M SIHFLOCR (Print or type) `� / Check one: Certificate /'/ Installing Company Name f t Pf r Corp. Address I Partner. us ess elephone F1 Firm/Co. Name of Licensed Plumber: Insurance Covera e• Indicate the type or insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity F1Bond Insurance Waiver: I the undersigned,have been made aware that the licensee three insurance of this application does not have any one of the above 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 in compliance with all pertinent provisions of the Massachuse to Plu ing de and a 42 of the General Laws. By: lonaLUX n ,rN. Title Type of Plumbing License _4 City/Town �c nse um er Master Journeyman ❑ APPROVED(OFFICE USE ONLY Date. .1 . . .r o'<".O°T:��o TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING sS�CHUS This certifies that . . .� � . . . . .. . . . . . . . . . . . . . has permission to perform . . . . . AJAf-�+. . ?�'= f� plumbing in the buildings of . . JEa � �-� '�rt�n at . . . . . a?n". �'�. . .,�.O h'Andover, Mass. Fee�x . . . . .Lic. No.:�.`;. .� . . . . . . . . ... .`. . . ,_--c��.,.�. .. . . . . . . PLUMBING INSPEtGTOR Check x t 7602 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS Date LcZZ / Building Location Owners Name ef lole,01� Permit# �6L Amount Type of Occupancy New Renovation Replacement E] Plans Submitted Yes ❑ No a FIXTURES U rz W x o En cc rzI Ca a D W 4 a C7 � a 04 O A d' Cl) Ca SIMM BAW&iT IR 11aR M RLOOR �RI1l�it 4GH IMM MR-" -" 6IH RIIOQ2 - 7M RIS gm HCM (Print or type) /� Check one: Certificate Installing Company Name / f f ❑ Corp. Address ❑ Partner. d 7 Business Telephone d — �S >*�/ Firm/Co, Name of Licensed Plumber: � Insurance Coverage: Indicate th pe 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 OwnerEl Agent11 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 Sta lumbi Cod and C ter 2 f the General Laws. /�� By: �)IgnaturFui zicenseaum er Title Type of Plumbing License -S%6--? City/Town icense FlumSer MasterJourneyman ❑ APPROVED(OFFICE USE ONLY 2(