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HomeMy WebLinkAboutMiscellaneous - 16 KINGSTON STREET 4/30/2018 (2) 16 KINGSTON STREET 210/023.0-0004-0117.1 Dat//-.!. . .. ... .� NORTH °f ,tea° . 3j �`` TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION SACMUSE� This certifies that s w.GL has permission for gas installation . . l'./. . . . . . . . . . . . . . . . . . . in the buildings of . . ./� . .krry��r�-✓ . . 14^--1. " . . . . . . at . . . . . . t'�. . .e*l-, North Andover, Mass. Fee. <:).,-:-"Lic. . . . . . . . . . . . . . . . . . . . . GAS INSPECTOR Check#' �Y 7020 e- MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS FITTING (Type or print) Date � / NORTH ANDOVER,MASSACHUSETTS Building Locations 6 r ` � f�v 4 r Permit# 1 C /'P e /' `/- 4 ��Owner's Name Amount$ New❑ Renovation Replacement Plans Submitted /Y �U z C4 zW Cr F vi F rQ O O O O W F w wv w x w F a x w C7 F z [= z Fx„ EW W C7 cpqq > w EW., U xa PW C w > W CD4 Z d a Q d O O W O w F CC44 x O x w 3 A c7 a U x > SUB-BASEM ENT BASEM ENT 1ST. FLOOR 2ND . FLOOR 3RD . FLOOR 4TH . FLOOR 5TH . FLOOR 6TH . FLOOR 7TH . FLOOR 8TH . FLOOR (Print or type) K /e / �� r Check one: Certificate Installing Company Name L Corp. Address G t47 �(� / Partner. 11)^ -, C /V I C,YJ OfIr G usmess Telephone ,,? Firm/Co. Name of Licensed Plumber or Gas Fitter y /e re:s INSURANCE COVERAGE Check one: I have a current liability Insurance policy or,it's substantial equivalent. Yes No 0 If you have checked Les,please mdi the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity 0 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 above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed der Permit Issued for this application will be in compliance with all pertinent provisions of the Massachuse s Stat a5 CQdrand Chapter 142 of the General Laws. i By: / S ature of Licensed Plumber Or Gas Fitter Title Plumber �J o;? d City/Town Gas Fitter License Number OMaster APPROVED(OFFICE USE ONLY) 11 1�eyman D The Commonwealth of Massachusetts Department ofIndustrial Accidents Office ofInvestigations 600 Washington Street Boston, A"-02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/OrganizationAndividual): �' ` 7 CC', Address: 63 v,� Art- City/State/Zip: O (�64hone#: nT ,> ciS 7,f r,,y y Are you an employer? Check the appropriate bog: Type of project(required).- El I am a employer with 4. ❑ I am a general contractor and I e ployees(full and/or part-time).* have hired the sub-contractors 6 F-1 New construction 2. I am a sole proprietor or partner- -.listed on the attached sheet t 7• ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working kutg for me in any capacity. workers comp. insurance. 9, ❑Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.El Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp. c. 152, §.l(4),and we have no 12•0 Roof repairs insurance required.] t -employees. [No workers' comp.insurance required.] 13.0 Other t;,.y applicant,that checks box;fl a:;:;�alto fill out the section below showing their workers'compensation policy information- Homeowners 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 nzy 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 P c3' date . ) i 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. Ido hereby certify u der Oe pains and penalties ofpedury that the information provided above is true and correct Si afore: 7 G 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 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-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 tine. 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 Iicense or permit to bum leaves eta)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 Invesf ptions 640 Washington Street Bbost-on,MA 0.2111. Tel. # 617-727-4900 ext 4,06 or 1-977-MAS.SAFE Fax # 617-72.7-7749 Revised 5-26-05 u7NAr"7.mass.eov/dia Date/--/—?•�� a',"•��T:�ti, TOWN OF NORTH ANDOVER p PERM IT1�FO,R`PLUMBING SACNUS� � 2.This certifies that . �61. . . . . . . . . . . . . . . . . -�' has permission to perform . . . . . . . . . . ..////B1./. . . .i��f.� . . . . . . plumbing in the buildings of .!. .1�. (.�/ �� . ... . . . . . . . . . . . at . . . . . ���1 . . . . d�/</li, North Andover, Mass. Fee. '/�. . . .Lu. No.. 11.34' . . . . . . . . . . . . . . . . . . . . . . 5 7� PLUMBING INSPECTOR Check N 8293 r d MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS /6 r f-o�,� Building Location / / ^ r DatePermit# Owner V" /I f y lTs'�e ti �o cnc�Q f — Amount New ❑ Renovation 0 Replacement �/ Plans Submitted Yes 0 No FIXTURES SUNEW ��IVIIvr i 1 ]ST IIDQt �II1loe 3M EL" 4M EUM ski 1rTf 6MEEM 7MEUM sM RDM (Print or type) 1 t-�, Check one- Certificate Installing Company Name ^y e �� Corp. Address 1/s ff Q ❑ Partner. C,,c /" c- 5` f ❑ Business Telephone "7 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 licensee of this application does not have any one of the above three insurance Signature Owner Agent rl 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 p rmed under Permit Issued for this application will be in compliance with all pertinent provisions of the Mass ch s tate yrnbin Code and Chapter 142 of the General Laws. BY e oi Licensectum Type of Plumbin License Title 9 o � City/Town License Numm Master Journeyman APPROVED(OMCE USE ONLY 10 The Commonwealth of Massachusetts M LX,1 Department of Industrial Accidents Office of Investigations 600 Washington Street_ Boston, AlA-02111 www.mass goyldia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): y �L �� Yz v' Address: 0 City/State/Zip: t9 rte" t Phone#: Are you an employer? Check the appropriate bog: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6 E]New construction employees(full and/or part-time).* have hired the sub-contractors 2.0,ram a sole proprietor or partner- listed on the attached sheet. 7• ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working forme in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5• ❑ We are a corporation and its requiied] officers have exercised their 10.❑ Electrical repairs or additions 3.❑ r1am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions q myself. [No workers' comp. c. 152, §.l(4),and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' 13.❑ Other comp. insurance required.] *; applicant that checks box 41 mus`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. I am an employer that isproviding workers'compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name: Policy#or Self4ris. 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 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 Signature: Date: /V /3 O 5 Phone#: 2 7r Official use only. Do not write in this are to be. .� y a, completed b rnp y 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 legat 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 0 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 Iicense 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)Investigations. 600 Washington Street Bost-on,MA.02111 Tel. # 617-7274900 ext 406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 5-26-OS vAivw.mass.govfdia f.• r ACORL CERTIFICATE OF LIABILITY INSURANCE DATE(MM/ Y) 11/12/2009 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION CLOUTIER INSURANCE AGENCY ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 1470 LAKF.,VIF.;W AVENUE;SUITE#1 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR DRACUT,MAO]826 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. PHONE#: 978-957-4881 FAXa: 978-957-7230 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: Safety Insurance Company LGC PLUMBING DBA LYLE CARTER INSURER B: 63 VALLEY ROAD DRACUT,MA 01826 INSURER C: INSURER D: INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDIN ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. lLSFIT DD' POLICY EFFECTIVE POLICY EXPIRATION LTR NSR TYPE OF INSURANCE POLICY NUMBER DATE MM/DD/YY DATE MM/DD/YY LIMITS A GENERAL LIABILITY BP00009191 08/27/2009 08/27/2010 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILI DAMAGE TO RENTED PREMISES(Ea occurence $ 100 000 CLAIMS MADE FIOCCUR MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AG $ 1,000,000 X POLICY PRO- JECT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO EA ACC $ OTHER THAN AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR FICLAIMS MADE AGGREGATE $ DEDUCTIBLE RETENTION $ $ WORKERS COMPENSATION AND WC STATU- OTH- EMPLOYERS'LIABILITY TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $ If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMI $ OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION TOWN OF NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REP ENTATIVE ACORD 25(2001/08) ©ACORD CORPORATION 1988 i I IMPORTANT If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s),authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend,extend or alter the coverage afforded by the policies listed thereon. i ACORD 25(2001/08) r dd''JJ ate. . . .!`.. '. - HORTM o� TOWN OF NORTH ANDOVER • - PERMIT FOR GAS INSTALLATION h y9SSACMUSEtS This certifies that . . has permission for gas installation ". . . . . . . . . . . . . . in the buildings of .c . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . at : .. .�:!. , North Andover, Mass. Fee,./-"" �--Li No.. . . . . . . . . . � .. . . . . . �� r �/� GAS INSPE�AB� 4 Check# v/ 1 MASSACHUSETTS UNUDRMAPPUCATONFOR PERM TODO GAS F1TI'ING` (Typeor print)rint \ Date l Y (. / � NORTH ANDOVER,,MASSACHUSETTS' Building Locations l - "�i� rl�l Permit# Am unt$ Owner's Name ' NewElRenovation ❑ Replacement ans Submitted ❑ U o vi w o ° H x CA G A a� 02 OU 1 1 O SUB -BASEM ENT BASEMENT 1ST. FLOOR 2ND . FLOOR 3RD . FLOOR 4TH . FLOOR STH . FLOOR 6TH . FLOOR 7TH . FLOOR STH . FLOOR (Print or type) few"` / Cec one: Certificate Installing Company Name �U f fZ ��-`� Corp. Address ✓ y ❑ Partner. i. 01- usmessTelephone Q -Z c y Firm/Co. Name of Licensed Plumber or Gas Fitter tem INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ©� No❑ If you have checked Yes,please indicate the type coverage by checking the appropriate box. 13Liability insurance policy � Other type of indemnity 13Bond 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 above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Pe it Issued for this application will be in compliance with all pertinent provisions of the Massac etts State Gas Co a and Cha r 142 o e General Laws. ti t Signature of Li ensed Plumber Or Gas Fitter By: r-11--plumber b Title City/Town ❑ Gas Fitter License Ni r 0- Master APPROVED(OFFICE USE ONLY) ❑ Journeyman