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HomeMy WebLinkAboutMiscellaneous - 148 MAIN STREET 4/30/2018 (46) �'' �!l- Date.? r t r10RTM f� VaOR ;•_1"0 TOWN OF NORTH ANDOVER PERMIT FOR PLU:II(BING SSACHUSES This certifies that ... . . .!. . . . . . . . . . . . . . . . . . . . . . . . . . has permission to perform,.,� e.. p1 umbmg to the buildings of . ..�. . . . . .� .,r�c�t..,, ., . . . . . . . . . . . . . . . at AP. �-� / /, North Andover, Mass. Fee.q r-d r. Lic. No.:24<-:%—,:�,7 . ... . . . . . . . . PLUMB�G�$PECTOR Check # 2'/ 8261 jJ f,e MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS ,!� Date Building LocatiorV goG,/-/I'll, 3� '/�/01'f Owners Name �9?c.• Q // Permit# 33/ Type of Occu ancAmount ©v New Renovation Replacement Plans Submitted Yes ❑ No F TURES w U G a - �>�cZ 51H KjOCR 6Hi MOOR l 71H 1tiIlocYt SIH HJOOIZ ' (Print or type) � Installing Company Name- Check one:14 H -n-.0! ��'N Certificate ❑ Corp. Address t' -e - t � Manner. Business Telephone + �Finn/Co. R Name of Licensed Plumber: H� i Insurance Coverage: IndiYdersigned, ype of insurance coverage by checking the appropriate box: t Liability insurance policy Other type of indemnity Bond 1 ❑ Insurance Waiver: I,the u have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner 9(W Agent I hereby certify that all of the details and information I have tred)in above application are true and accurate to the best of my knowledge and that all plumbing work ' stal ons pe nder Permit Issued for this application will be in compliance with all pertinent provisions of the Massac Us Stat umbing Code and Chapter 142 of the General Laws. ..� ! . By: a ure oI 1-icensea k1lumDer Title Type of Plumbing License City/Town O� tcense um er Master ElJourneymanAPPROVED(OFFICE USE ONLY The Commonwealth ofMassachusetts j ji Department of.Industrid Accidents UP c# ! Office Of Investi ations s� 600 Mashington Street Boston, MA 02111 c j www n=s-g,ov/din . Workers' Compensation Insurance Affidavit: Builders/Contractors/ElApplicant Information ectricians/Pinmbe rs Pierint L bly aMe (Business/DrPoization/Individual)' . ✓I Address: 17 City/State/Zig: "(/R�l lq e ✓"'d Phone#: 1-� 33 Are you an employer?Cheek.the appropriate box: I•❑ am a employer with 4. Fject(required): ❑ I am a gentesai contractor and I emPlayees(full and/or part-time).* have)fired the sub-contractorsconstruction 2 I am.asole proprietor or partner- listed on the attached sheet.i deling ip and have no employees These sub-contractors have working for me in any capacity, workers' comp.insurance. lition [No workers'comp.insurance 5. ❑.We are a corporation and its ng addition 3.❑ required.] officers have exercised their ical 1 am a homeowner doing all work right of exemption MDL Pah or additions myself[No•warkers'co Im Pa PIumbing repairs or additions a I52, §I(4),'and we have no insurance required.]t employees [No work=? ❑Roof ropairs 00mp. insurance required.] *Arty applicant that decks bozo#1 must also f[i t out the section blow sbowing their workers'isompensation policy information t Homeowners wbo submit this affidavit indicating they ars doin all;Ccenaators that check this box must g wmt and than hire outside connacton must submit a new affidavit indica*M"".-- an edditimrai sheershow.' aFg the name of the sub- ° E ouch croanaetom end their workers'cxa.' peii=•irfam Won. F arr,an emploper: AV irP,lru v:worlrers'Compensation insurance or information, } 'emoloyees Below is thePn&J'andjob site . Insurance Company Name: ' Policy#or Self--ins.Lie.#: EkPiration Date: Job Site Address: . City/State/Zip: Attach a copy of the workers' eoatpensation policy deChtt'atiou page(showing the policy number and expiration dale Failure to secure coverage as wired un Section 25A of MGL C. 152 can lead to the imposition erOf criminal fine up t4$1,500.00 and/or one-year irrlpri nment,as well 8s civil penalties in the form of a STOP WORK penalties of a- of up to$250.00 a day against.the viol Be advised that a c of this statement or be forwarded to the UM and a fine Investigations of the DIA for Imuran" copy y Office of verage verification. I do he u er th and perm/ties o e ' .1�P rlmy that the irtfnrmotion provided above Si is true and confect tore: 1 - _ G�, G� Date: / -� ( true� Phone / �' �G — Official ase only. Do not write in this area,to be completed b or town o rra( y City or Town: Issuing Authority(circle one): Permit/License 4 Board 1.Other of ti.Other Health 2 n Building Department 3.City/TowCierk 4.Electrical Inspector 5.Plum bin g Inspector Contact Person: Phone#: 4. Information a nd Instructions Massachusetts General Laws chapter 152 requires all.emp Ioyers 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 ofhire:, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or mom of thelbregoing engaged in a joint enterprise,and includi"g the legal representatives of a dccaased employer,or the receiver ortnrstee•of an individual,partnership,association or other legal entity,employing employees: 'However the own6r.of a dwelling house having not more than that apa -cmen s and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work an such dwelling house or on the grounds or building appurtenant thereto shall not because of sucb employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"evergi state os-local Hedusing agency shall withhold the issuance or renewal of a license or permit to operate a business or *o construct bulklings 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 t3he commonwealth nor any of its political subdivisions shall enter into any contract for the pm fornmce of public work undl-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 appiy.to your situation and,if necessary,supply sub-contractors)name(s),addresses)nand 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 mquiredlo=TY workers'cr,=npensation insurance. lfan 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 cityor town that the.application for the peimit 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-cail the Department at the nur-nberlisted below. Self inswred o„npIT f.. e*tt,tfrens selfinsuuance'lieenme Dumber on the'approprim line. City or Tower Officials Please be sure that the affidavit is complete and printed legibly. At 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%,ill be used as a refi:=ce number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicatingcurrrent policy;information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy ofthe 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 flog license or perrriif'to bum leaves etc.)said person is NOT required to complete this affideviL 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 Depw=ent's address,telephone and fax number. The Commonwealth of Massachusetts Department of L-nd>sstrial Accidents Office of LnvestEivafriens 600 Wad ington Sttti ct Basfon, MA 02111 TeL # 617-727-4900 Ext 406 or 1-977-MASSAFE Fax#617-727-7744 FLvised 5-2t>-t15 wwwmass.gov/dia