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HomeMy WebLinkAboutMiscellaneous - 1348 SALEM STREET 4/30/2018 (2) 1348 SALEM STREET J 210/106.A-0163-0000.0 i 9251 °':��o TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ,SSACMUSE� / / This certifies that . d 4, rle..;. . . . . . . . . . . . . . . . has permission to perform . . 614. . w4 . . . . . . . . . . . . . . . . . . plumbing in the buildings of . . Ai.,/ - -6q,0,71A . . . . . . . . . . . . at . . .�/�?'��� . . .4zt?`?. �. . . 4o h Andover, Mass. Fee. V ? .Lic. No../9✓4 . . w. :. . . . . . . . . PLUMBING INSPECTOR Check # dZ©� MASSACHUSETTS UNIFORM E9 PPLICATION FOP,PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS Building Location J �1 r/e fij,� Date [� r Permit# Owner Amount New Renovation © Replacement Plans Submitted Yes No FIXTURES S[B19�MC I�igM!Nr ]ST IIDQ.t 2M ELOM �II� 4M IIOM 7M RaR SIS bIOQt (Print or type) fCheck one: Installing Company Name S Check Address ' ��4 4 11 Corp. �fci ��` 07 a `z 06 ri Partner. Business Telephone •' _ `W Firm/Co. Name of Licensed Plumber: Insurance Coverage-: Indicate the type of 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 threeinsurance Licensee of this application does not have any one of the above Signature Owner Agent I hereby certify that all of the details and information ve submitted or enter best of my knowledge and that all plumbing work d. alio erfomz )m above application are true and accurate to the compliance with all pertinent P Permit Issued f s application will be in pectin provisions of the ss lumbin de and Chapter 144 OF the General Laws. By: noire o kens uin Title ype of Plumbing Li e iCityaown icenseMinimr APPROVED(oFncE USE oNLY Master Joumep The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations _600 91'ashington Street Boston, MA 02111 www mas&gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): S Address: - � City/State/Zip: w`(1� '( Q 76 phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with Q 4. ❑ I am'a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6' New construction 2-E I am a sole proprietor or partner- listed on the attached sheet.# 7• ❑Remodeling ship and have no employees These sub=contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. [No workers comp. insurance 5. 9• ❑Building addition ' p ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.[1.1 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 insurance required.] t 12.[�Roof repairs Q ] employees. [No workers' comp.insurance required.] 13.0 Other `:.ny applicant that checks box#1 must also rill out the section below sho«V... +W Wonx. _ t Homeowners who submit this affidavit indicating they -on policy information. 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 is providing workerscompensation insurance for my employees Below is the informapolicy and job site tion. 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 g 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 o Investigations of the DIA for insurance coverage verification. f thts statement maybe forwarded to the Office of I g I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: Phone#: 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 6. Other Contact Person: Phone#: I 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." I 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 t w �1hat the application the pernait or license is being requested,not the Depa ent of be returned ei'�tC1 t1P.city or town at app tiCat'esSn for 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 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 Investh atdons 600 Washington Street Boston, MA 02111 Tel. # 617-72.7-4900 ext 406 or 1-8.77-MASSAFE Fax#617-727-7749 Revised 5-26-05 wwur.rnass..govldia COII/dIV9®NWEA LICENSED AS A JOURNEYIAA Pt...... ISSUE�_THE ABOVE LICENSE T0: CHARLES B GREENWOOD N6 199 MARSH . RD .PELHAM NH 03076-33 F 18580 05/01/12 78 I 9079 Date''/`�• •:t. � ,1 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ,SSACMUS� This certifies that . . . . . . . . . . . . . . has permission to perform .�/l!7•� G/� . . . . . . . . . . . . . plumbing in the buildin sof . !�: r'�lr,�rf ' . . . . . . . . . . . . . . . at. 13.10 . .��!�. .s� . . . . . orth Andover, Mass. Fee. 'f . :'�7Lic. No.. . �. .�. . . . . . . . . . . . PLUMB GINSPECTOR Check it ` 0�� 1 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING City/Town MA. Date: � I Permit# Building Location: Owners Name: P�IcapI Type of Occupancy: Commercial❑ Educational❑ Industrial❑ Institutional❑ Residential New:❑ Alteration:F1Renovation:❑ Replacement: 1[�] Plans Submitted: Yes No FIXTURES DEDICATED H z SYSTEMS N z o V) u Fes- w D Z F � w O Zg 3aZ= wH Z yZO aU wa wM x dx¢ °O 0 O Z° y FQ iwQnLL SUB BSMT. o d BASEMENT 1ST FLOOR 2ND FLOOR 3RD FLOOR 4T"FLOOR ST"FLOOR 6T"FLOOR " 7'FLOOR 8T"FLOOR Installing Company ruame:_I� 17 r I '�iG��i!'/�i Chep k One C?r!y teetificate nn� Address: o� )Crnl �Q j,�] /(� ❑ City/Town:��Ib� State• 1 '� Corporation i Cg7g G-��3� El Partnership Business Tel: h J Fax: Name of Licensed Plumber: El Firm/Company� INSURANCE COVERAGE: 1 have a current Iia_ bit insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Yes ❑ No❑ If you have checked Yes,please in cafe the-type of coverage by checking the appropriate box below. A liability insurance policy Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER:I am aware that the licensee does the insurance coverage required by Chapter 142 of the assachusetts General Laws,and that my signature on this permit applicati Mon waives this requirement. Check One Only Si nature of Owner or Owner's Agent Owner ❑ Agent ❑ r hereby cerrify that all of the details and Information I have submitted(or entered)regarding this application are true and rr r Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in complianceao with all t of my Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. By Typ of License: ' Title Signature Plumber 9 ature of Licensed Plumber ^ity/Town ❑tester APPROVED(OFFICE USE ONLY) Journeyman License Number: 3141® The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MM 02111 '"V www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/individual) MC; c�j Address: Q lejh Ro City/State/Zip: r&66 0 A 01q(6 Phone#: [EEII an employer?Check the appropriate box: _ a employer with 4, Type of project(required): ❑ I am a general contractor and I loyees(full and/or part-time). have hired the sub-contractors 6. ❑New construction a sole proprietor or partner- listed on the attached shgaet. 1 7• ❑Remodeling and have no employees These sub-contractors have 8. ❑Demblition ing for me in any capacity. workers'comp.insurance. workers' comp. 5. 9• ❑Building addition p ❑ We are a corporation and its red.] .officers have exercised their 10.❑Electrical repairs or additions a homeowner doing all work right of exemption per MGL11.[�Plumbingrepairs or additions lf. [No workers' comp. - c. 152, §1(4),and we have no12,❑Roofrepairs ance 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. 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. lam 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.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 e fine u to$1 500 penalties of a p .00 and/or one-year 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 u der the ins es o andpenalties P fperjury that the information provided a veistrug and correct.. Si nature: Bate: • Phone#: �qM93610^3a 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 an contract of h' express or implied,oral or written." Y hire, p , 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 apartinents 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 buildingappurtenant the g PP thereto shall not because of such employment be d em 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 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 G0j-1U-U0nweaU- oa l�iassachusetts Department of Industrial Accidents Office of Investigations _ 600 Washington Street Boston;MA,02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFB Revised 5-26-os Fax#617-727-7749 Www.mass,gov/dia