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HomeMy WebLinkAboutMiscellaneous - 136 BRIDLE PATH 4/30/2018 (2) / BUILDING FILE 2012 assachusetts EIectrical Code Amendments 527 CMR 12.00§Rule S: in accordance-with the provisions of M.G.L.c.143,§.3L,the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be Med- on the prescribed form.Atter a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166,§32,an electrical permit shall he 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 shalLbe limited as to the time of ongoing construction activity,and mayhe.deemed_bythe Tnspector-of_Waires 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 of2010 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 otherwis a applicable expiration date,any permit or approval that was "in effect or existence'during the qualifying period beginning on August 15,2008.and extendiag'through August 15,2012. ,, �ule 8—Permit/Date Closed: Dote:Reapply for new permit �_ Permit Extension Act—Permit/Date Closed Date ......... .......... AL TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING A- 0 A so C14US This certifies thatj........................ ....... d/.................... has permission to perform .;/....../'.. wiring in the bu .,yding of . ...6Dy......... ..oed.i.,4�........................ .. ... .. North Andover,Mass. Fee..................... Lic.NoA.�.-)l................ ... .... e. e�� cm CTIU 'B� LE CALL INNS�PWMR Check f/ 8873 Commonwealth of Massachusetts y -: Official Use Only Department of Fire Services Pemlit No. BOARD OF FIRE PREVENTION REGULATIONSOccupancy and Fee Checked [Rev. 1/07] (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 W INK OR TYPE ALL INFORMATION) Date4j M b City or Town of: NORTH ANDOVER al By this application the undersigned gives notice of his or her intentio Location(Street&Number) 13L Ktt)6 Pn to perform the electrical work described below. To the Inspctor of Wires: 1�tl Owner or Tenant s4e.$_4 LA Telephone No. Owner's Address Q P.JL.m L 3 p. No ❑ Is this permit in conjunction with a buil ' g permit? Yes �F O (Check Appropriate Bog) Purpose of Building St Utility Authorization No. E3isting Service 20C Amps 1RQ/2_1P_V0lts Overhead ❑ Und rd g ❑ No,of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: PX,O t *tLh l td sWiwt vw� deck MeW Com letion of the followin table may be waived by the ns ector o Wires. No.of Recessed Luminaires No.of CeiL-Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets L No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above In- o.o mergency ig g f d• ❑ d. ❑ Batte Units — No.of Receptacle Outlets No.of Oil Burners FIRE ALARMe No of Zones No.of Switches 0 No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total V Tons No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons K_W No.of Self-Contained / Totals: _ __.__. __.__. Detection/Aler[in Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal Connection E] Other t No.of Dryers Heating Appliances KW Security Systems:* J o.of Water No.of No.of Devices or E uiv ent Heaters KW SLEMS Ballasts Data Wiring: of Devices or E uiv 'It No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: � OTHER: No.of Devices or Equivalent Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: 6, SCX (When required by municipal policy.) 1 Work to Stark Qq Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE CO GE: 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 coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE �BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and pen ties of perjury,that_information on this applicatio is true and complete. %FIRM NAME: (�• ,I� C.NO.: )9 �se�G. Uta. /$O Licensee: p �I�O10 Signature �r (If applicable, ent e "in the license umber n1p. LIC.NO.: Address: e7 Bus.Tel.No.: No.:14& 7 *Per M.G.L c. 147,s. 57-61,security work requires Department of Public Safety"S"License: L c.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 ❑owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ c� -a� � � � � I^� � . ���� �, � yZ ^ t, J �` t M 4 r 4 Y The Commonwealth of Massachusetts Department of Industrial Accidents i' Office of Investigations 600 )W ashington Street Boston, MA 02111 www massgov/dia Workers' Compensation In Applicant Information Insitra.nce Affidavit: Builders/Contractors/Electricnmers ians/Plbi Please Print Legibiv Name(BusinessioTwization/Individual): Address: �ey City/,State/ZipQtg3cphone#:_t�r�= Are you an employer? e appropriate ro ��PP Priate box: Type of pro'ec' (required): 1.❑ I am a employer with- 4. 111 am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6 ❑New truction 2.❑ I am a.sole proprietor or partner- listed ori the attached sheet.I �• odeling ship and have no employees These sub-contractors have 8. ❑Demolition working for mein' 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 I00flectrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL I I.❑ Plumbing repairs or additions myself.[No-workers'comp. c. 152, §1(4),and we have no 12. Roof insurance_required.]t employees. ❑ repairs [No wonders' comp. insurance required_] t 3 ❑Clther i *Any applicant that checks boy #l t must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside con #Contractors tractors must submit a new affidavit indicating such that check this box must attached an additional sheet showing the name of the sub-cortractois and their workers'comp.policy infomsation. t am an employer that is.providwg:workers'compensation insurawe for my employees: Below is the policy and job site ` information. Insurance Company Name: Policy#or Self-ins. Lie.#: Expiration Date: Job Site Address:_ 13 6 -&ZAr— A. 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. I52 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 covera verification. Y I do hereby certi under the ains,and erjury that the information provided above is true and correct Si tore: Date.- 0 ate. l FFOth6r only. Do not write in t/tss area,to be completed by city or town official n: Permit/License# ority(circle one): Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing:Elnspe]ct]or. son: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute aneVY to ee is defined as"...every person erson in the service of another under any contract of hire, express lied,oral or written XP or implied, 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 trustoe 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 dwmaintenanee,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-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,notthe 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 dine. 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-rill 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-cuntrit 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 t 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. r— The Commonwealth of Massachusetts �. Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, lu1A 02111 Tel.#617-727-4900 ext 406 or 1-977-MASSAFE Fax#617-727-774 Revised 5-26-05 www.mass. ,ov/dia Date. ... . . . . . . .... qtr "OPTM 41 n TOWN OF NORTH ANDOVER 6• PERMIT FOR GASOA LLATION . � SAGMUSE� This certifies that . . . . . . . . . !- f-. . . . . . . has permission for gas installation `%' _ .. . . . . . . . . . . . . o in the buildings of . . . . `. .`. . . . . . . . . . . . . . . . . . . . . at . ... � North.Andover, Mass. o� Fee . . . . . Lic. No.. . . . . . . . . . . . . ,.� . . . . . . . . . �j J"INSP CMR (/ v Check# 7068 �I I MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS FITTING (Type or print) Date a a �� I NORTH ANDOVER,MASSACHUSETTS Building Locations 1-36 �f�� ��� Permit# Amount$ � Owner's Name L o P,' G�Th — Renovation © Replacement Plans Submitted U x xU � F• a �" w x z a c x > w Cw7 Fw- rA z F ¢z F w Cw7 p > w Fw. U a Fes' w z ¢ w ¢ c4 v� oa z O z O x c� w > w O z ¢ a ¢ ¢ O o w m o 3 c w U a > c N o SUB -BASEM ENT B A S E M ENT 1ST. FLOOR 2ND . FLOOR 3RD . FLOOR 4TH . FLOOR 5TH . FLOOR 6TH . FLOOR 7TH . FLOOR 8TH . -FLOOR (Print or type)^ f /` Check one: Certificate Installing Company NapA��Ly Q C 1,C-- r c ...� Corp. Address _ _��AYP . jT LA,k Partner. I-1 0 I C, SO Business Telephone J 3 777735 G © Finn/Co. Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes 0 No❑ If you have checked Les,please indicate the type coverage by checking the appropriate box. Lability insurance olicy, Other type of indemnity 0 Bond 13 rop&-,� 166oi3S�()p- 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 13 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 Stt to Gas Cod land hapter 142 of the General Laws. B Signature of Licensed Plumber Or Gas Fitter Y Title ©, Plumber 6 7� S LoeXP City/Town ® Gas Fitter License NUMber / Master APPROVED(OFFICE USE ONLY) Journeyman i The Commonwealth of Massachusetts fn Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LeQibl Name (Business/Organization/Individual): __Q a Address: 13 6' 574 f1 jC 9} City/State/Zip:_ L-41 tet., C-I 0/ � S Phone#: Z(ZS 7,3 �3 5 Are you an employer?Check the appropriate box: _ 1.❑ I am a employer with 4. Type of project(required): ❑ 1 am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6 El New construction 2^ I 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. com . insurance 5. 9. Building addition [No workers ' p ❑ We are a corporation and its required.] officers have exercised their 10.[]Electrical repairs or additions 3.❑ 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 12.0 Roof repairs q ] employees. [No workers' comp.insurance required] 139 Other > "AWy a,"-heant that checks box 1 must also IM out the section below shov^^b= eir wo txe s'comY sxtion 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. I am an employer that is providing workerscompensation 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 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 certify under the pains and penalties of perjury that the information provided above is true and correct fA Si ature: -- � D te.: Phone#: i F icial use only. Do not write in this area, to be completed by city or town official y or Town: Permit/License# uing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town CIerk 4.Electrical Inspector 5.PIumbing 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 1V beretained to the city or town that the application:for the permit or license is being requested,not the Department of L' 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 Investivations 600 Washington Street Boston,MA 021.11 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 5-26-05 wwu,.mass.gov/dia Date. . a TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING f < ,SSACMUSE� This certifies that . 7?. . . . . . . . . . . . . . . . . . . . . . . has permission to perform . ��.. �?!<. �.{. / .n.6`!�.' : . . . . . . . . . . plumbing in the buildings of . . . . . . . . . . . . . . . . . . . at. . ?.�. . .Jt' L�( �. .� �} f. , North Andover; Mass. PLUMBING INSPECTOR Check # 7 � 8182 P. M. MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS f -1,,!! Date v v Building Location 3 r 6 J IDW�(-Owners Name 10 Permit# Amount Type of Occupancy New Renovation Replacement Plans Submitted Yes ❑ No ❑ FIXTURES w a A • H A � . . �AgVIC )�SIIVII�ti' t 0 a 4M HDM s>�x>Frlo� 6][H I 7]HHIM M (Print or type) / Check one: Certificate Installing Company Name 'U C , ❑ Corp.' Addre s l `fa M T-t Partner. e (' Business Telephone 7 Firm/Co. Name of Licensed Plumber: A�ev\ b Insurance Coverage: Indicate the type of insurance coveragelby checking the appropriate box: Liability insurance policy13" 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 Massach e s hate Plumbi g C d anha ter 142 of the General Laws. By: igna ure ol J-1GUT[SeCl JVIUMDer Title Type of Plumbing License j f City/Town icense rqumDer Master ❑ Journeyman APPROVED toFRcE USE ONLY a li �f The Convwn>~vealth of Havachusefts J 171!1 1 Department o,f.Industrial Accidents ; '; Office o,f Invesdgations b It 600 9 ashin ton Street � Alt Boston, MA 02111 www Mmsgov/dia . Workers' Compensation lwiw nce Affidavit: Builders/Contractors/Eieetricians�pi��� Applicant Information Please Print Le—qblv(Business/Organization/Individual): Address: 0Al City/<State/Zig:_ LDCCV. ( �Q 2 i IS Phone � ,a9� FAmyou an employer?Cheek.the appropr�te.bo I am a employer with 4. (] I am a general contractor and I Type P�1 (regatredJ. employees(full and/or part-time).* 6• ❑New construction have Mired the sub-contractors uction 2.❑ I am.asole proprietor or partner- listed on the attached sheet.t 7. ❑Remodeling ship and have no employees These sub-.contractors have . workingfor me in 8• Q Demolition arty capacity. workers comp.insurance. [No workers'comp, insurance 5. ❑ We are a corporation and its 9 ❑Building addition required.) officers bout exercised their 10.0-131ectrical repairs or additions • 3.❑ lam homeowner doing all work right of have per MGL I!.❑ Plumbing repairs or additions mysell f [No workers'comp. t; 152, §1(4),and we have no insttrartce.rt quired.j t .employees. [No workers' 12.[] Roof repairs comp• insurance required.] 13•❑.Othet 'Any applicant that checks boi#1 mutt also MI out the section below showing their workers'oompmeation polity infnrmafion. t homeowners who submit this affidavit indicatin th arz t30in Contractors that check this box roust g OY , g an 10Ork send then bite outside contnxturs must'submit a new affidavit indicating such. atraobed an additions.shad showing•the namo of the sub-connectors and Pheir workers ce n:;.palm•infomt_tior.. I ar an empkyer then islssgtdfirlg:work=e compensadon insurance or inforniafio2 f �'' PIoJ' Below is the P09'mad job site . Insurance Company Name: Policy#or Self-ins.Lie.#: EXPpiration Date: Job Site Address: Attach a copy of the worCity/state/Z'tp. Failure to s [ceZV compensation policy declaration page(showing the policy number and expiration date ecure coverage as required under Section 25A of MGL c. 152 can lead to the i fine up to 500 mposition of criminal $1, ,00 and/or one-year imprisonment;as well as civil penalties in the foss of a STOP WORK O of up to 5250.00 a day against the violator. Be advised that a copy R(y£R and a fine of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and torted Si tore: Date: Phone#: Of,�ieial etre only. Do not write in Ibis area,to he contpleried by a3'or town ofuid City or Town Permit/License# lssuiag Aathority(circle one): 1. Board of Health 2 Building Department 3.City/Town•Cietrk 4.Electrical Inspector 5. Plumbing Inspector b.Othez Contact Person: j Phone#: Information a nd Instructions Massachusetts General Laws chapter 152 requires all emp foyers 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." i An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or mom of the'fomping engaged in a joint enterprise,and includirig the legal representatives of a deceased employer,or the receiver ortrustee,-of an individual,partnership,association or other legal entity,employing empioyees. 'However the owner-of a dwelling house having not more than three apaatznertts 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 152,525C(6)also states that"every state or focal licensing agency shall withhold the issuance or renewal of a license or permit to operate a bnsmess or *a construct buildings in the commonwealth for any applicant who has not produced acceptable midence-W 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 insumce 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 apps' to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)a-ind phone number(s)along with their certificates)of ,r insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not requiredito carry workers'cc�--rnpensation insurance. Ifan 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.. Aiso•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,pleawed the Departrnent at the nwmber.listed below. Self h+sured Ern, n. af�rn�id ent�tfie_:r self insurance license number on the*appropriate line. City or Town Of iciais Please be sure that the afndavit is complete and printed legibly. The Department hes 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 applicam Please be sure to fill in the permidlicense number which%%-ilI 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,curr•ent 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 now 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 vwture (i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit• The Office of lnvesti ptions 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 Depart ncnt of Lmdusizial Accidants Office of Investigations 600 Washington Street %gon, MA 02111 TeL 9 617-727-4900 ext 406 or 1-977-MASSAFE Revised 5-26-05 Fax 4 617-727-774 wwwmass_govldia E Date.. . . HORTM 0E OWN OF NORTH ANDOVER • PERMIT FOR GAS INSTALLATION f ♦ �o i 1SSACMUSESSy This certifies that . . . . .. " ? . has permission for gas installation_ . ... . . . . . . . ...4.-.. . . . . . in the buildings of . . . . . . . . . . . . . . . . . . . . . . . . at . �`'� .. . . . . . . t. . . i , North Andover, Mass. E Fee- . '"'. . Lic. No../ 3.!. . . �' .IiA ��'' . . . . . . . . . . . . . . GASINSPECT Check# 6b5 � F MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) N ANDOVER Mass. Date 7/22 2009 Permit# � 136 BRIDLE PATH STEVE LOPILATO Building Location Owner's Name Owner Tel# 978-975-5291 OR 978-852-6633 Type of Occupancy RESIDENTIAL New W1 Renovation❑ Replacement F] Plan Submitted: Ye[]No[] FIXTURES a w U w ¢ z U) C4 a W w w 0 ° x F F � z z o 30.50 m w ¢ W W O 2 a 0 w Q w x a x o a E- w z ou LIL r Lu z - z H W w 0 > w z V a H w a —3 z Q w Q x F >• �„ go z o z O cn x w = O= u�. 3 A a ov a > A a F-- o w SUB-BSMT BASEMENT 1ST FLOOR 2"D FLOOR 3RD FLOOR 4T"FLOOR 5T"FLOOR 6T"FLOOR 7T"FLOOR 4 8TH FLOOR Installing Company Name Eastern Propane & Oil, Inc Check one: Certificate 131 Water Street Address ZCorporation Danvers, MA 01923 F]Partnership Business Telephone# 800-322-6628 Firm/Co. Name of Licensed Plumber or Gas Fitter ROBERT TALBOT 1239 INSURANCE COVERAGE: I have a cur liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes V No 11If you have c ecked y2s,please indicate the type coverage by checking the appropriate box. A liability insurance policy❑✓ Other type of indemnity ❑ Bond ❑ i 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: Owner ❑ Agent ElSignature of Owner or Owner's 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 the permit is �o�ris application will be in compliance v�ith all Bowled rand t n t of the Massachusetts State Gas Code and Chapter 142 of th ener By Type of License: lumber g ur of Licensed Plumber or Gas Fitter Title as fitter • -Master License Number 1239 City/Town •-Journeyman APPROVED(OFFICE USE ONLY)