HomeMy WebLinkAboutMiscellaneous - 129 WINTER STREET 4/30/2018Date........ .W ....................... .
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ..... P, Ave
has permission to perform
wiring in the building of............
..........................................................................................
at ....... �2-c� ....... ...... No hAndover, Mass.
Fee.:n .... I .............. Lic. N31(9-6[ . ...... .. . ...................... ......
ELECTRICAL I SPECTOR
Check
12544 vvt"�
,}
N :.)
Commonwealth of Massachusetts
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
Permit No.
Occupancy and Fee Checked
[Rev. 1/071 (leave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00
(PLEASE PRINT IN NK OR TYPE ALL INFORMATION) Date: C)--. i S
City or Town of: NORTH ANDOVER To the Inspector of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number) J'C)-9 WIA)kt- S�-
Owner or Tenant 5GL M iM C Ss1 V,..J q Telephone No.
Owner's Address
Is this permit in conjunction with a building permit? Yes).
Purpose of Building V Jai
Overhead ❑
- Existing Service
New Service
Amps
Amps
Volts
No ❑ (Check Appropriate Box)
Utility Authorization No.
Volts Overhead ❑
Undgrd ❑ No. of Meters
Undgrd ❑ No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: W ,Ve. t4:' 3 C 1i2-C)C)AA
('mmnlptinn nrthp fnllmvinu tahle may be waived by the Inspector of Wires.
No. of Recessed Luminaires p
Z
o. Nof Ceil: Susp. (Paddle) Fans
s Total
of
Trsformers KVA
Tran
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Above ❑ In -
Swimming Pool ❑
rnd. rnd.
o. of Emergency Lighting
Battery Units
No. of Receptacle Outlets 30
No. of Oil Burners
FIRE ALARMS
No. of Zones
No. of Switches Z 8
No. of Gas Burners
No. of Detection and
Initiating Devices
No. of Ranges 1
Total
No. of Air Cond. Tons
No. of Alerting Devices
Heat Pump
Number
Tons
KW
No. of Self -Contained
No. of Waste Disposers
p 1
Totals:
.......
...
Detection/Alerting Devices
No. of Dishwashers
S ace/Area Heating KW
P g
Local ❑ Municipal ❑ Other
Connection
No. of Dryers
Y
Heating Appliances KW
Security Systems:!'
No. of Devices or Equivalent
No. of Water KW
No. of No. of
Data Wiring:
Heaters
Signs Ballasts
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wiring:
No. of Devices or Equivalent
OTHER:
--F
Attach additional detail if desired, or as required by the Inspector of rvtres.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The
undersigned certifies that such cove e is . force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:)
Icertify, tinder thepains and penalties of perjury, that the information on this application is true and complete.
FIRM NAME:. CG C 6 �_�-fC' K- .�C- LIC. NO.: ?,O !S.
Licensee: Signature LIC. NO.:�I
(If applicable, enter "e�empt" int icense number line. Bus. Tel. No.: 1� �`
Address: ���'yb e-( �-D � CJS Alt. Tel. No.:
'Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner -El owner's agent.
Owner/Agent PERMIT FEE: $ ��
Signature Telephone No.
❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the q
permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed
on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an w(
electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the
notification of completion of the work as required in M.G.L. c. 143, § 3L.
Permits shall.be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he
or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written
application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written
request of either the owner or the installing entity stated on the permit application.
❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of
the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this
purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With
limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was
"in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012.
❑ Rule 8 — Permit/Date Closed: *** Note: Reapply for new permit ❑
❑ Permit Extension Act — Permit/Date Closed:
Trench Inspection
Pass 0
Failed Ed
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
SERVICE INSPECTION:
Pass 0
Failed
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
PARTIAL ROUGH INSPECTION:
Pass 0
Failed IN
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
ROUGH INS CTION:
Pass
Failed IN
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date: �Id
FINAL, INSPECTION:
Pass 0 V. -I
Failed 0
Re- Inspection Required ($.) ❑
Inspectors Comments:
4
041
Inspectors Signature:
Date:
DEB WEINHOLD ... TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com
r'"
.,� :7")
The Commonwealth of Massachusetts
Department oflndustrialAccidents
F
M_ 'sem - - r X Congress Street, Suite 100
Boston, MA - 02114-2017
www mass.gov/dia
Workers' Compensation insurance Affidavit: Builder/Contractors/Electricians/Plumbers.
FILED WITH THE PERMITTING AUTHOI2zTy
TO BE
Please ?Tint Lep-ibl
A''licant Information l 2 Cj
C
Name (Businessffligariization/Individual) 'CG�
Address:
0 (OPhone #:
City/State/Zip:
`
Are you an oyer? Check tiie appropriate box:
Type of project (required);
1 I am a employer with_employees (full and/or part-time).
forme in
'7. [] New'construeiion
$. F1Remo deluig
2. ❑I yin a sole proprietor or partnership and have no employees working
comp. insurance required.]
9, ❑ Demolition
any capacity. [No workers'
3.0 lam a homeowner doing all work myself. [No workers' comp. insurance required.] t
10 Q Building addition
4.[] I am a homeowner and will be hiring contractors to conduct all work on my property. I will
either have workers' compensation insurance or are sole
11.❑ Electrical repaysora ditioAs
ensure that all contractors
with no employees.
bill re airs or additions
12T -` Plum- g p
proprietors
5. ❑I am a general contra .. : and 1 have lured the sub -contractors listed on the attached sheet.
-contractors have employees and have workers' comp. insurance.t
13�. J Roof repairs
14.M Other
These sub
6. ❑We are a corporation and its, officers have exercised their right of exemption per MGL c.
comp. insurance required ]
52 1(4) and'we have no employees: [No workers'
*Any applicant that check's box #1 must also fill out the section below showing their workers' compensation policy information
Homeowners who submit<this affidabit indicating they are doing all work and then hire outside contractors must submit a new affidavit in sucb.
tContractors that checkthis liox must attached an additional sheet showing the name of the sub -contractors and state whether or not (hose entities have
employees. If the sub -contractors have employees, they must provide their workers' comp. policy number.
I am an employer that is providing workers' compensation insurance for my employees..Below is the policy and)ob site
information.
Insurance Company Name: C C� (�-s �'-
ExpirationDate
��
Policy # or Self -ins. Lie. #:
Job Site Address:
1 �q C a 7 � � City/State/Zip: nc SA �\ �U
mpensation policy declaration page (showing the policy number and expiration date).
Attach a copy of the workers' co
Failure to secure coverage as requiredwell as civer il 25A i
enalties in the form of aaSSTOP al violation
ORDER and a fine of up to $250.00 a
and/or one-year imprisonment, as w p
day against the violator. A copy of this statement maybe forwarded to the Office of In of the DIA for insurance
coverage verification.
Ido hereby cert^` nn �andpenalties ofperjury tliat the information shave is true and correct.
9 J
T�4u 9
official use only. Do not write in tllis area, to be completed by city or town official.
Permit/License #
City or Town-
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Phone #:
Contact
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 enierprise, and including the legal representatives of a deceased employer, or the
receivbf'di trustee 6fan individual, partnership, association or other legal entity, employing emplbyees. • However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant o£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 b6 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-wlio.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
Pleasb 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 certificates) of
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 permit or license is being requested, not the Department of
IndustrialAccidenis. 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 Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MA.SSAFE
Fax # 617-727-7749
Revised 02-23-15 www.mass.gov/dia
C,1
o 1 go6- 211"
E NSF
Date ..,F/,/r.,,0/) . .........
12 8 05
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that ..............................................................
has -permission to perform ......
....... . ............................................................................
plumbingin the buildings of ... .......................................................................................
at.'../
. ..... ......... ... .......... .. . No r1h Andover, Mass.
Fee,�� ic. No.c�.' ......
LUMBING INSPECTOR
17
Check V -53 �(n
WASHING MACHINE CONNECTION
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES NKNO
IF YOU CHECKED YES, PLEASE INDICATE TH YPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY 01 BOND MI
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: OWNER R—I AGENT I[JI
SIGNATURE OF OWNER OR AGENT
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 1=npra—rrme:wVit Pentipent provision ofthe
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME —11 LICENSE SIGNATURE
MP ip CORPORATION RJ PARTNERSHIPPA LLC
COMPANY NAME 1ADDRESS
CITY jSTATE zip ol— TEL
FAX CELL W.3 IL
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY
MA DATE PERMIT #
JOBSITE ADDRESS
_j OWNER'S NAME -
POWNER
ADDRESS
TEL[ FAX
TYPE OR
OCCUPANCYTYPE
CO D
EDUCATIONAL RESIDENTIAL
PRINT
CLEARLY
C7CIAL
NEW: RENOVATION: REPLACEMENT: [31
PLANS SUBMITTED: YES Ell NO 01
BATHTUB
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/01LISAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
i IL ---j= f
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR / AREA DRAIN
INTERCEPTOR (INTERIOR�
KITCHEN SINK
-j
LAVATORY
I
--J=
ROOF DRAIN
SHOWER STALL
SERVICE / MOP SINK
TOILET
WASHING MACHINE CONNECTION
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES NKNO
IF YOU CHECKED YES, PLEASE INDICATE TH YPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY 01 BOND MI
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: OWNER R—I AGENT I[JI
SIGNATURE OF OWNER OR AGENT
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 1=npra—rrme:wVit Pentipent provision ofthe
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME —11 LICENSE SIGNATURE
MP ip CORPORATION RJ PARTNERSHIPPA LLC
COMPANY NAME 1ADDRESS
CITY jSTATE zip ol— TEL
FAX CELL W.3 IL
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Workers" Compensation Insurance Affidavit: Builders/Contractors/Electricians/�lninbers.
TO BE FILED WITH THE PERMITTING AUTHORI'1';'X.
Name (Business/Oigariization/Individual):
Address:
City/State/Zip:_
Are you an employer?
the appropriate box:
,o,&k,9n
�03�7
Phone #:
1,Va employerwith .. employees (full andlor part-time).2,sole proprietor or partnership and have no employees Working foz me in
pacity. [No workers' comp. insurance required.]
3. ❑ 1 am a homeowner doing all work myself. (No workers' comp. insurance required.] t
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers' compensation insurance or are sole
proprietors with no, employees.
5. QI am a general contract o , and T have hired the sub -contractors listed on the attached sheet.
These sub -contractors have employees and have workers' comp. insurance.t
6. ]� We are a corporation and its. officers have exercised their right of exemption per MGL c.
152 §1(4) and'we have no employees [No workers' comp. insurance required.]
Type of project ()required):
7. [] Nevv'constriciion
8. [] Remodeling
9. ❑ Demolition
10 [] Building addition
11.[] Electrical xep*s or additions
12T0°Plumbing repairs or additions
13•. [] Roof repairs
14. [] Other
*Any applicant that checks box #1, must also fill out the section below showing their workers' compensation policy information:
fi Homeowners who submit•.1)ox, ffidabit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such
tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not (hose entities have
employees. If the sub -contractors have employees, they must provide their workers' comp. policy number.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company
Expiration Date:.
Policy # or Self -ins. Lic. #:
City/State/Zip-
Job Site Address:
compensation policy declaration page (showing the policy number and expiration date).
Attach a copy of the workers''
al
Failure to secure coverage as ea well ased civil ivil penaltieser MGL c. ?in the form of25A is a aSOPtolation Punishable by a fiAb up to WORK ORDER and a fine of up to $200.00 a
and/or one-year imprisonment,
ment may be forwarded to the Office of Investigations of the DIA for insurance
day against the violator. A copy of this state
coverage verification.
Ido hereby cert ur�der tlZns anenalties ofperjury that the information provided above is true d.lue ancome,'
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):or 5. Plumbing inspector
i
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspect
6. Other
Phone #:
Contact Person-
The Commonwealth of Massachusetts
Department of IndustrialAccidefats
1 Congress Street, Suite 100
Boston, MA. 02114-2017
www mass.gov/dia
d�M SV'u�
Workers" Compensation Insurance Affidavit: Builders/Contractors/Electricians/�lninbers.
TO BE FILED WITH THE PERMITTING AUTHORI'1';'X.
Name (Business/Oigariization/Individual):
Address:
City/State/Zip:_
Are you an employer?
the appropriate box:
,o,&k,9n
�03�7
Phone #:
1,Va employerwith .. employees (full andlor part-time).2,sole proprietor or partnership and have no employees Working foz me in
pacity. [No workers' comp. insurance required.]
3. ❑ 1 am a homeowner doing all work myself. (No workers' comp. insurance required.] t
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers' compensation insurance or are sole
proprietors with no, employees.
5. QI am a general contract o , and T have hired the sub -contractors listed on the attached sheet.
These sub -contractors have employees and have workers' comp. insurance.t
6. ]� We are a corporation and its. officers have exercised their right of exemption per MGL c.
152 §1(4) and'we have no employees [No workers' comp. insurance required.]
Type of project ()required):
7. [] Nevv'constriciion
8. [] Remodeling
9. ❑ Demolition
10 [] Building addition
11.[] Electrical xep*s or additions
12T0°Plumbing repairs or additions
13•. [] Roof repairs
14. [] Other
*Any applicant that checks box #1, must also fill out the section below showing their workers' compensation policy information:
fi Homeowners who submit•.1)ox, ffidabit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such
tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not (hose entities have
employees. If the sub -contractors have employees, they must provide their workers' comp. policy number.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company
Expiration Date:.
Policy # or Self -ins. Lic. #:
City/State/Zip-
Job Site Address:
compensation policy declaration page (showing the policy number and expiration date).
Attach a copy of the workers''
al
Failure to secure coverage as ea well ased civil ivil penaltieser MGL c. ?in the form of25A is a aSOPtolation Punishable by a fiAb up to WORK ORDER and a fine of up to $200.00 a
and/or one-year imprisonment,
ment may be forwarded to the Office of Investigations of the DIA for insurance
day against the violator. A copy of this state
coverage verification.
Ido hereby cert ur�der tlZns anenalties ofperjury that the information provided above is true d.lue ancome,'
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):or 5. Plumbing inspector
i
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspect
6. Other
Phone #:
Contact Person-
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their empl'o`yees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract 04K
express or implied, oral or written."
An employer is defused as "an individual; partnership, association, corporation or other legal entity, or any two or more
ofthe foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiverfor 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 occripaii 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 xequiired"
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for theperformance 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 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 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 "fob 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 burn leaves etc.) said person is NOT required to complete this affidavit.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 02-23-15 wwwmsass.gov/dia
Date..
.........................
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
................. .....
This certifies that ... ....... C46a��
has perinission for gas installation.
. ..............................................
inthe buildings of ...................................................................................................................
at ... ............................................ No Andover, Mass.
Fee,\ .... Lic. No .... .......... . ... ..................................
GASINSPEC OR
Che& #.
09:6
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM / SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL. Ch. 142 YES J _ NO Ej
I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE 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: OWNER 0 AGENT 01
SIGNATURE OF OWNER OR AGENT
1 hereby certify that all of the details and information I have submitted or entered regarding this application are
and that all plumbing work and installations performed under the permit issued for this application will be in cc
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �
PLUMBER-GASFITTER NAME��N LICENSE #KWI
accurate to the best of my
SIGNATURE
of the
MP ED MGF Ej JIP JGF Q LPGI [:]I CORPORATION [Dl# �� PARTNERSHIP E]#=j LLC []#=
NAME: �- �' ;,�� ���/j_ ADDRESS
COMPANY
CITY I/_�S I �/ _ STATE [IVIZIP
FAX CELL IL
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
I _
_
CITY
MA DATEPERMIT#
�-�
JOBSITE ADDRESS._� _ r'
C -II OWNER'S NAME
"
POWNER
ADDRESS
TEL 7� FAX
TYPE OR
PRINT
OCCUPANCY TYPE COMMERCIAL F, J-1
EDUCATIONAL RESIDENTIAL
CLEARLY
NEW: E3 RENOVATION: [d REPLACEMENT: El PLANS SUBMITTED: YES 0
NO
APPLIANCES 7
FLOORS- BSM 1 2 3
4 5 6 7 8 9 10 11 12
13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATERV
DRYER
FIREPLACE
FRYOLATOR
--
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM / SPACE HEATER
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL. Ch. 142 YES J _ NO Ej
I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE 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: OWNER 0 AGENT 01
SIGNATURE OF OWNER OR AGENT
1 hereby certify that all of the details and information I have submitted or entered regarding this application are
and that all plumbing work and installations performed under the permit issued for this application will be in cc
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �
PLUMBER-GASFITTER NAME��N LICENSE #KWI
accurate to the best of my
SIGNATURE
of the
MP ED MGF Ej JIP JGF Q LPGI [:]I CORPORATION [Dl# �� PARTNERSHIP E]#=j LLC []#=
NAME: �- �' ;,�� ���/j_ ADDRESS
COMPANY
CITY I/_�S I �/ _ STATE [IVIZIP
FAX CELL IL
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The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Name (Business/Organization/Individual): /.� �b / "��`/�1 /�n �)
Address: LF 1A mei (_4L_ 1 �- X4
City/State/Zip: ,15/�
Are you an employer? Check the appropriate box:
T Phone #: (olG 3 3 l
1. ❑ I am a employer with employees (fall and/or part-time).*
2.[ am a sole proprietor or partnership and have no employees working for me in
any capacity. [No workers' comp. insurance required.]
3.FJ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t
4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers' compensation insurance or are sole
proprietors with no employees.
5. FJ I am a general contractor and I have hired the sub -contractors listed on the attached sheet.
These sub -contractors have employees and have workers' comp. insurance.1
6.F-1 We are a corporation and its officers have exercised their right of 'exemption per MGL c.
152, § 1(4), and we have no employees. [No workers' comp. insurance required.]
Type of project (required):
7. 0 New construction
8. Q Remodeling
9. ❑ Demolition
10 Building addition
11.0 Electrical repairs or additions
12. rJ Plumbing repairs or additions
13.0 Roof repairs
14. ❑ Other
*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.
#Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have
employees. If the sub -contractors have employees,'ttiey must provide their workers' comp. policy number.
I a an employer that is providing workers' compensation insurance for my employees.' Below is the policy and job site
information. 4zl±:
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 MGL c. 152, §25A is a criminal violation punishable by 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. 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 p and p�nald ofpeijury that the information provided above is true and c ct.
Signature: Date
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 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 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 burn leaves etc.) said person is NOT required to complete this affidavit.
The Department's address, telephone and fax number: '
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-NIASSAFE
Fax # 617-727-7749
Revised 02-23-15 www.mass.gov/dia
3509
Date ..7--;.,?. 1. G� .....
HORTM TOWN OF NORTH ANDOVER
Oy Sao ,e,tiOL
p PERMIT FOR GAS INSTALLATION
:,
` 'his certifies that .. 13,.. . T.�`�`!�� ...ems . / ..........
has permission for gas installation ... ...................
in .the buildings of .... A// s s! ..L... .................... .
at North Andover, Mass.
Fee. Lic. No..1.7... 1�.... ........
GASINSPECTOR
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING Zo
(Printor T ) / p
100- 5 2 -.Mass. Date Q " - JW0 Permit # -S 4
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Building Location_- %�� �% /j �� Owner's Name--M*f�I OV4
Type of Oc panty rte' iC/i1et y
New Renovation ❑ Replacement I-1 Plans Submitted: Yes❑ No ❑
Installing Company Name BAY STATE GAS COMPANY
Address 55 MARSTON STREET
LAWRENCE, MA 01840
Business Telephone .68,7=1105
Name of Licensed Plumber or Gas Fitter Francis X. Corkery
Check one: Certificate #
HCl Corporation 1862
❑ Partnership
❑ Firm/Co.
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes K No ❑
If you have checked yes, please Indicate the type coverage by checking the appropriate box.
A liability insurance policy P( 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 Own ,
Owner❑ Agent ❑
I hereby certify that all of the details and information I have submitted (or entered) in abo plication are true and accu�te to the best of my
knowledge and that all plumbing work and installations performed under the permit iss f r this application will n mpliance with all
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene s. (j i
By Tof License:
Plumber Signature of licensed Plumber or Gas
Title Gasritter
CitylTown Master License Number 8697
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Check one: Certificate #
HCl Corporation 1862
❑ Partnership
❑ Firm/Co.
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes K No ❑
If you have checked yes, please Indicate the type coverage by checking the appropriate box.
A liability insurance policy P( 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 Own ,
Owner❑ Agent ❑
I hereby certify that all of the details and information I have submitted (or entered) in abo plication are true and accu�te to the best of my
knowledge and that all plumbing work and installations performed under the permit iss f r this application will n mpliance with all
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene s. (j i
By Tof License:
Plumber Signature of licensed Plumber or Gas
Title Gasritter
CitylTown Master License Number 8697
O FIC SE ONLY
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GAS INSTALLATION ALHOR I ATION
Date
Issued to 66
Address lag
For Installation of:
ETU Input
Restrictions
BSG Representative
PERMIT ISSUED BY 1
INSPECTOR
This Portion of Authorization To Be Returned to BSG.
Inspection Has Been Made of the Following Gas Equipment:
❑ Heating System (BTU Input ) ❑ Range
❑ Water Heater ❑ Clothes Dryer
❑ Room Heater
Location
All Work Has Been Done In Accordance With The Massachusetts
State Gas Code And Is Ready For Use.
INSP
NO POSTAGE
NECESSARY
IF MAILED
IN THE
UNITED STATES
BUSINESS REPLY CARD
FIRST CLASS PERMIT NO. 721 LAWRENCE, MA
POSTAGE WILL BE PAID BY ADDRESSEE
BAY STATE GAS COMPANY
ATTN: SALES DEPT.
55 Marston Street
Lawrence, MA 01840
3433 Date ..'......:.c.......
NORTH TOWN OF NORTH ANDOVER
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This certifies that ... /!'�'�. `.`�.'...�=z �. • • . • .
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in the buildings of ......................
at f '1.. r� " ...' ...... , North Andover, Mass.
Fee../.> • .. Lic. No... i..�.. :�-.... �- 2� _...... .
GAS INSPECTOR
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WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print opprType)
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I V D RTI.4 A 00\16 L. Mass. Date_ �000,--permit #
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New 0 Renovation ❑ Replacement ❑ Plans Submitted: Yes❑ No ❑
Installing Company Name BAY STATE GAS COMPANY
Address 55 MARSTON STREET
LAWRENCE, MA 01840
Business Telephone -68.7—'1105
Name of Licensed Plumber or Gas Fitter Francis X. Corkery
Check one: Certificate #
DC7 Corporation 1862
❑ Partnership
❑ Firm/Co.
INSURANCE COVERAGE:
have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes 9, No ❑
If you have checked Yes, ,please Indicate the type coverage by checking the appropriate box.
A liability insurance policy f$(. 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 ❑
I hereby certify that all of the details and information I have submitted (or entered) in abo plication are true and accu%te to the best of my
knowledge and that all plumbing work and installations performed under the permit Iss f r this application will n mpliance with all
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene s.
Tg of License:
Plumber Signature of censed Plumber or Gas
Title Gasfitter
City/Town Master License Number 8697
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Business Telephone -68.7—'1105
Name of Licensed Plumber or Gas Fitter Francis X. Corkery
Check one: Certificate #
DC7 Corporation 1862
❑ Partnership
❑ Firm/Co.
INSURANCE COVERAGE:
have a current liability Insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142.
Yes 9, No ❑
If you have checked Yes, ,please Indicate the type coverage by checking the appropriate box.
A liability insurance policy f$(. 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 ❑
I hereby certify that all of the details and information I have submitted (or entered) in abo plication are true and accu%te to the best of my
knowledge and that all plumbing work and installations performed under the permit Iss f r this application will n mpliance with all
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene s.
Tg of License:
Plumber Signature of censed Plumber or Gas
Title Gasfitter
City/Town Master License Number 8697
MPFiONE TOTS _ ONLY
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