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HomeMy WebLinkAboutMiscellaneous - 151 HILLSIDE ROAD 4/30/2018 151 HILLSIDE ROAD 210/025.0-0048-0000.0 I I 9296 Date,: TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ;,SSACNUSE� � � This certifies that .,llf 1,G�j�...Q.,. . . .�. . . l� . . . . . . . . has permission to perform . ./'�� . . CYt� . . . . . . .A. plumbing in the buildings of 7yr71.4110. . . . . . . . . . . . at. . . . . �S. . . . �,�,� . . .�i.�. hdover, Mass. Fee.' s�. .Lic. No.. . � PLUMBING INSPECTOR Check # Date......, `/�-..... OR7M J � O�H�,ao i•�1.0 TOWN GO N�QRT1�_�4NDOVER o ✓ p' t"';/� U /Cj PE MIT FOR WIRING Thiscertifies that ......... . ....................................................... . .................. has permission to perform ......... wiring in the building of ..... ..../Q�.. �1. at........................... .......................................,North Andover,Mass. es d Fee..,-).:?..n-:= Lic.No. LECTRICAL INSPECi'blt Check # 3 '10697 Date... ..... nr rn ......... pF NORTI�,� TOWN OF NORTH ANDOVER p3�• `• •• ppm 9 PERMIT FOR PLUMBING •• r PHI l This certifies tha t�1 d1M5 o.................................................... has permission to perform.................. . � .M! ........................ plumbing in the buildings of........ ! .A`` a-.................................................... at....... �.` ..�.: lc��........ . :................... North Andover, Mass. t Fee Q.- .......Lic. No.2 o t�0.. . M C ..... ...................................................................... 1 ^� PLUMBING INSPECTOR Check# bf4 - i ::� I I MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK I `' CITYMA DATE PERMIT JOBSITE ADDRESS L Z S �— OWNER'S NAME POWNER ADDRESS _ TEL —� 1FAX TYPE OR OCCUPANCY TYPE COMMERCIAL � EDUCATIONAL ETI RESIDENTIAL�J PRINT CLEARLY NEW: RENOVATION: PLACEMENT: Q PLANS SUBMITTED: YES EQ NO FIXTURES 7. FLOOR--' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM ! _J.— DEDICATED DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM I DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN __f --__._-{ --__-__! ._______f _._._f _ _! ._.___I __..___I •-____.J _.._...__( _-_....-_J _.__._f __...._! -.__..._J FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) _I [ � ! I _I _..__J -_-__.._! KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOI ET URINAL WASHING MACHINE CONNECTION _. If - --.J -( _! . ... _____J W ER HEATER ALL TYPES WATER PIPING OTHER _ f III [if INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. ll�YOU CHECKED YES,PLEASE INDICATE THE TY F COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW S LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY QI BOND El i 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 Q AGENT I SIGNATURE OF OWNER OR AGENT 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 in complianc II Peril pr the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME �LICENSE# d C SI -E —�— IVIP�I JP CORPORATION Q#� �JPARTNERSHIP DI# LLC .____-.__ COMPANY NAME� a r'o�t Zd ADDRESS CITY y STATE ZIP TEL FAX o CELL�]EMAIL n ROUGH PLUMBING ITNSPEjdION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES EL R, Yes No Q ( r6 Ul THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: PERMIT# PLAN REVIEW NOTES 4 The Commonwealth ofMassachusetts - Department oflndustrial Accidents Office Oflnvestigations 600 Washington.Street Foston,MA 02111 www.mass govIdIa Workexs'Compensation Ynsurance Affidavit:Builders/Cont°actor6/Electrxcxans/pliunberq ,A.�pplieant Information Please Print Lem ly Name(Busynessiorganizationffmdividual): Address: 0 c1 Phone �T a Tj City/State/Zip: ��yy /� Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with. 4. ❑I am a general contractor and I 6. ❑New construction f employees(fall and/or part time).* have lured the sub-contractors 24LJ-r`a­m_ a sole proprietor or partner- listed on the attached sheet 7. ❑Remodeling ship and'have no employees. These sub-contractors have 8. E]Demolition working for me in.any capacity. workers'comp.insurance, 9. Building addition [;No workors' comp.insurance 5. ❑ We are a corporation and its 10.[]Electrical repairs or additions required.] officers have exercised.their 3.❑ I am a homeowner doing all work right of exemption per MGL 11.El Plumbing repairs or additions myself.[Eo workers'comp. c.152,§1(4),andwehaveno 12.Q Roofrepairs insurancerequired.]i employees.[No workers' 13.[]Other comp.insurance required.] 'Any applicantthat checks box#1 must also fill outthe section below showingtheir workers'compensationpolicy information. t'Homeowners who submit this affidavit indicating they ftre doing all work and then hire outside contractors must submit a new affidavit indicating such. TContractors that checkthis box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy o#the workers'compensation-policy declaration page(showing the policy number and expiration date). Failure to secure coverage.as requiredunder Section 25A ofMGL o. 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 WORD ORDER and a fine of up to$250.00 a day against the violator. Do advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA.for iissurance coverage verification. X do hereby certQ u ' a ai and penalties of perjury tliat tlae information prove ecl ab a is tr a/and correct. Si atare• Date: [ Phone#• 2.a Official use only. .Do not write in this area,to be completed by city or town official. City or Town: PermiAlcense# 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 Instrnctions ' 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 coiitract ofhire, express orimpliec7,oral or wxittemll An employer is defined as"an individual,partnership,association,corporation or other legal entity,or anytvvo ormore of the foregoing engaged in a joint enterprise,and including the legal representatives of a:deceased employer,or the receiver or trusteed an individual,partnership,association or other legal entity,employing employees. Ifowever the owner of a dwelling house having notmore 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 bean.employes." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or p ermit to op erate a business or to construct buildings in the commonwealth fox 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 ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapterhave beenpresented 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)andphonenumber(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 notrequired to carry workers'compensation insurance. If au LLC or LLP does have employees,a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for confhmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be retumed 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 andprinted 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 thatmust submitmultiple 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 offlcially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit-ii on file for future permits or licenses. Anew affidavit must be filled out each year.Where a homeowner or citizen is obtaining a license ox 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 oflnvestigations would like to thank you in advance for your cooperation and shouldyou have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: `l'he CQmmonwoaftofMossarhv&ettq - Dop.aftent o faduMal,Acc%donta o f x0e othvestiga-&ng ' 600�ashi�.gt�a-S�xe�f: Boston,MA021X1 Tel#61M-27,4900 at 406 ox x•-8,77-:MAS��� Revised 5-26-05 FaY,0 617-727-7749 E" COMMONWEALTH OF MA►SSA�CH�S� Ts GAS>F>l T :Ft`5 ' 1 PLUMBE`R:S' VCE "SND SSU;E,S_,THE FOLLOW FRG L LIEhiSEq AS A JOURNEYMAN- " OURNEYMAN- t1S J DE FRQNZO 14 CAN- E-RwLfRy H 1.':% Li f D..t `S`rJ, :{,•,.�`` 0'P:S N E h;R.:>>:.; >> < A 0198 3 2'2 7 2 2 ' - L.._..- .