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HomeMy WebLinkAboutMiscellaneous - 1253 SALEM STREET 4/30/2018 1253 SALEM STREET 210/106.A-0133-0000.0 I I The Commonwealth of Massachusetts Department of Industrial Accidents i .� Office of Investigations 600 Washington Street Boston, MA 02111 www.nzass,gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): 00At Ct,1101c✓1 (mow, Address: �— City/State/Zip: Nw�l /7 d / - Phone 7S- 3 SUs Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I an a employer with 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6 ❑ New construction 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 1 7• ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its rered.] officers have exercised.their 10-ElElectrical repairs or additions 3.[!?'f—am a homeowner doing all work right of exemption per MGL 11.❑ 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. insurance required.] 13.0 Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. Homeowners wlio submit.tinis affidavit indieating r;ey a e duiiti-iii wurk and then hire outside contraciors must submit anew 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: Policy#or Self-ins. Lie.#: 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 a unde e p ins nd penalties of perjury that the information provided above is true and correct Siartature. p Date: Phone#: [ 7 ?7S SG� 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 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 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# 617-727-7749 www.mass.gov/dia �N ( ,41 ��yo l 2�;-3 3 1011 &8 / 1h J'� Ar M�� O;Flce Wee Only ne Commonwealth of-Massachusetts - '.,� 5 r ' Department of Public Safety per-it se.. _ s` Occuruecr L Fee owcke. BOARD OF FIRE PREVENTION RECUl1ATIONS. Sr, CMR 1200 3/90 (,sii" blank) APPLICATION FOR PERMIT TO PwRFORM ELECTRICAL WORK N performedElectrical t. SZ7 CMR I2:00 (PLEASE PRINT IN INK OR TYPE AM I 0 ON) Date -- t't,`2(, "0 f City or Town of To the Inspector of Wires: The undersigned applies for a permit to perform the electrical work described below. Location (Street & Number) j!1'1 Owner or Tenant Phone No. � �� 7 yO Owner's Address 5 C/`M`(?, `his perait in conjunction with a buildpg rtzt• r--yes No U (Check Appropriate Box) ase of Building (� j )C /I I A Utility Authori_.=tion 40. :ting Service 'aooAmps / Volts Overhead --<dgrd ❑ No of Heters�_ i Service Asps / Volts Overhead ❑ Undgrd ❑ No. of Meters ober of Feeders and Ampaciry. ,cation and Nature f Proposed Electrical Work � /ham 2i to. of Lighting Outlets No. of Hot Iubs No. of Transformers Loral KVA d. d No. of Lighting Fixtures SwimmingPool Ave 11 . Q Generato>'s I.VA. No. of Receptacle Outlets �No. of Emergency Lighting p No. of 011 Burners Battery Units i No. of Switch Outlets No, of Cas Burners FIRE ALARMS No. of Zones No. of Ranges No—of Air Coad. Total No. of Detection and tom Initiating Devices ' Beat Total Total ! No. of Disposals No. of Pt s Tons rw No, of Sounding Devices r No. of Dishwashers Space/Area Heating KW No. of Self ContainedDetection/Sounding Devices ,. ; t:,;nicipal 1.. " Dryers Heat1. IkvS.a.:.es R"7 �.c� r L:onnection'--j No. of Water Heaters KN No, of No. o ILow Voltage Sims Ballasts kirine No. Hydro Massage Tubs No. of Motors local HP OTHER: INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws I have a current L14,0'flitT Insurance Policy including Completed Operations Coverage or i substantial equivalent. YES NO I have submitted valid proof of same to this office. YES or [] If you have checked YES, please indicate the type of coverage by checking the appropriate box. INSURANCE [!rMND ❑ OTHER ❑ (Please Specify) _ . _ piration- ate . _ Estimated Value of Electrical Work S j / Work to Start —19 Inspection Date Requested: Rough Final y� Signed under he penalties of per ury: / � LIC. 60. Licensee LIC. N0. Address us. Iel. No. r Alt. Ie1. No. OWn'S INSURANCE WAIVER: I an aware that the Licensee does noc have the insurance overage or acs suo- stantial equivalent as required by Massachusetts General laws, ane Chat my signature on this permit i ..` application waives this requirement. Owner Agent (Please check one) _ eJ P7/ Ft- c-P XA�CA'L-t T(i C cj 0-7( 12 C 71 P *tyL A13-3 The Commonwealth ofe•` r F. _Massachusefts - t`Ce T t permit Xa., Dcpartment of Public Safcty Occurwftcy i fee Oviceted- •/= BOARD OF FIRE PREVENTION REGULATIONS.ST CMR 100 1/90 (tee" 61aAk) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK NI.wrk to be performed in aeeoidance with the Maasachrucru Eieeuiul Codc. SZ7 CMR 12:00 (M ASE PRINT IN nmOR TYPE 0q=) Date 6�i te-21z::7 ®J City or Tour of d'-•• . IYAWve To the Inspector of Wires: Ilse undersigned applies for a permit to perform the electrical work described below. Location (Street & Number) �t� `'YI Owner or IensatZ -t Phone No. �� Owner r s Address Q`�4 - rh-is_ner'ait-in eonjuncticnlvit:h a buildg rpttrYes 0"N. [j (Check Appropriate Box) fi t. .. i or:_ation 40. No 2x` 27 ............................... . _ �To Date.�l.�.. I a d ❑ No. of Meters 1� .................... Undgrd f NORTH ❑ No. of Meters 0. TOWN OF NORTH ANDOVER I• -^ 9 i 1 - PERMIT FOR WIRING � , , �,ssACMU D. of Iransformers TKVtA Phis certifies that ....................- t.0 Lc_ enerato�s F.VA has .... o. of Emergency Lighting •• Permission to perform r� attery llnics wiring in the building .... �•'f- �/ � ALARMS No. of Zones g of.�...... lo. of Detection and at...�y'. ... ....................................... "..................................................... �o. Initiating Devices ~� ......•......e ,North Andover Mass.� of Sounding Devices Fee..................... Lic.No. �o. of Self Contained ELECTRICAL INSPECMR................ Detection/Sounding Devices Check # t:.:nicipal t:onnection`1 Low VoltageWHITE:Applicant CANARY: Building Dept. PINK:Treasurer 'Brine OTEZR: INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or i substantial equivalent. YES©/ NO a I have submitted valid proof of same to this office. YESNO (] If you have checked YES, please indicate the type of coverage by checking the appropriate box. INSURANCE E BOND ❑ ❑ (Please Specify) Es - ��. _ _ -..- . piration-Dace)timated Value of Electrical Work S ��ry`. Work to Start —?"Of_ Inspection Date' Requested: Rough g Final Signed -71 .4 Lunder he penalties of per ury: .10t 71111111 LIC. NO. Licensee gnatu LIC. No. Lr �� Address ` C"C/,;►,(�48us. Iel. No. �J Alt. Iel. No, OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance overage or its suo- stantial equivalent as required by Massachusetts General Laws, ane that my signature on this permit !" application waives this requirement. Owner Agent (Please check, one) / Date . .`. .. . . .. N° 4 3b TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ,SSACMUSEt This certifies that . . . . . . . . . . . . . . . . . . . ... . . . . . . . . . . . . . . . . . . . . . . has permission to perform . . . . . . . . . . . . . . . . . . . . plumbing in the buildings of . ~.! '.r :x--Z.. . . . . . . I . . . . . . . . I at . . . . . . . ... .. . .... �'. ! <-�"! . . . . . . . . , North Andover, Mass. Lic. No/. . . . . . . . fid. . PLUMBING INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK:Treasurer MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Print or Type) ,/ ��T/t /f'[/Q���l Mass. Date �� 9,� Permit # Building Location .2 3 ,,�� / er's Name�"�e /Vi z Sc� -s UL Type of Occupancy Fe New ❑ Renovation ❑ ReplacementrFd' Plans Submitted: Yes ❑ No O ' FIXTURES CK • z rn z a N X X < • .. o Z 0, ) z > W y� J Nr' Y U < y O d W O _ L O Z N < Z M N Z O Z N p� .1 N W N N = H F' U W 0 Y < N 4 Z a a !� ¢ w 0 ¢ d W ¢ 2 d W z C a ar Z ¢ a a 0 16 4N N <G O W X O ti U < O LL X W O NO ZK J 0j < C V C a < O < !- j Y .J I C1 N O O .J 3 = �.. N U. n O O < t�Th " y SUB-BSMT. ' BASEMENT 1 1ST FLOOR i 2ND FLOOR 3RD FLOOR 4TH FLOOR 16TH FLUOR 6TH FLOOR 7TH FLOOR I f 8TH FLOOR �wl Installing Company Name ANDOVER PLBG & HTG. INC. r CO. , Xporation co one: t^,ertlflcate • Address 20 AEGEAN DR. UNIT 10 2122 • METHUEN _ MA_ 01844 ❑ Partnership Business Telephone 9 7 R F R 5-g, A O Firm/Co. Name of Licensed Plumber -FnRnE I AROSE .� INSURANCE COVERAGE: I have a currentJLK6Uity Insurance policy or Its substantial equliMent which meets the requirements of MGL Ch. 142. Yes' Iff No ❑ If you have checked,yas, please i icate the type coverage by checking the appropriate box A IlbIbInsurane 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. Check one: Signature of Owner or owner's Agent Owner ❑ Agent❑ 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 the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts Slate Piumbing a and Chapter 14 of a General Laws. BY _ nature censed Plumber True_ _ CrtylTown Type of 13cense: Master Journeyman A,' '7N License Number qqA A