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HomeMy WebLinkAboutMiscellaneous - 16 SUTTON PLACE 4/30/2018 (2) / 16 SUTTON PLACE J 210/060.0-0115-0000.0 i 7 0 5;:t Date. NORTp TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ,SSACMUS� ...^- This certifies that .7-V\0V `.5 . . . . . ., f has permission to perform . T v'h. . �(X A. 4t-�! plumbing in the buildings of . .t'.UL.y. . .Sl.�.�ArV.' . . . . . . at. . �?. s.v . . .�1 . . . . . , . . . North Andover Mass. Feed �:`�. .Lic. No.. .�AhY. . . . . . . !di�7/(. C. . . . . . PLUMBING INSPECTOR Check # 16 d. Dat . . . . . sem. . ...... . ,�ORTM R pf „ao ,e,h0 TOWN OF NORTH ANDOVER 41 PERMIT FOR GAS INSTALLATION • o a . y �9SSACHUSEtt This certifies that . . . . . . . . . . . . . . . ' has permission for gas installation in the buildings of . . . ... . . . . . . . . . . . . . . . . . . . . . . at North Andover, Mass. Feer'.. . tic. No./ . . . . .. . . �. ; .�J,�-�-,�� � .'. . . . . . GAS INSPECT& Check#':�f 6/J U r 6613 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING City/Town:_&0 L7-1 A n.Ds G L� � MA. Date: Permit# Building Location: Z& S t�T vU Fz 4 C r Owners Name: �v e y S lv b�S e � Type of Occupancy: Commercial❑ Educational❑ Industrial❑ Institutional❑ Residential[�- New:❑ Alteration:❑ Renovation: ❑ Replacement: Plans Submitted: Yes❑ No❑ FIXTURES DEDICATED N c z SYSTEMS Z Y 0 W h LU Ln 0Z LU Q G' Z _z Ln In Q m [n = = W y f"' W Z to CI Z F N V¢7 W w 0 Q W a Q z fY = = =C Z H U d X ¢ ~ ¢ ¢ = 3 o m 3 = o o w W j `3 z m LL s _� ¢ u }" � vni O 1 V ¢ O '� a Y Z v2—i w w w oZ► O h w Q Q 0 O H � O O Z f- F- = p � Q �- �Fif ¢ m m o o LL x g 3 3 3 o u a it = ¢ -SUB BSMT. ¢ cc W 0 5 BASEMENT 1ST FLOOR 2ND FLOOR RD FLOOR 6 4T"FLOOR ST"FLOOR 6TH FLOOR 7TH FLOOR 8T"FLOOR installing Con-opany Name:114014tdS /02� O Cheap One Onix Certificate lac lVIC.�. ft Address:Iy�F9 6111"pce >2., ElCorporation City/Town:J State: 0,0., El Partnership Business Tel: g 9� -J-s'r-�'�} Fax: 9 `�Ja -�S2F—Orel/ ®-Finn/Company Name of Licensed Plumber: j�6�yt r9s INSURANCE COVERAGE: 1 have a current Iiab__i _lity Insurance policy or its substantial equivalent which meets the requirements of MAeN If you have checked Yes,please indicate the type of coverage by checking the appropriate box below. A liability insurance policy- Other type of indemnity ❑ Bond OWNER'S INSURANCE WAIVER:1 am aware that the licensee does not have the insurance coverage requMassachusetts General Laws,and that my signature on this permit application waives this requirement. Check One OnSi nature of Owner or Owner's A ent Ownep ❑ Ag1 hereby certify that all of ffie details and information I have submitted(orentered)regarding this appiatione andaccurate to the best o;my Knowledge and that all plumbing work and installations performed underthe permit issued forthis application will be in compliance with all Pertinent provision of the Massachusefts State Plumbing Code and Chapter 142 of the General Laws. By J� • Type of License: Title @member Signature of Licensed Plumber L'ity/Town 0-Master p 4PPROVED(OFFICE USE ONLY) ❑Journeyman License Number: O g�� r`> Ct?MMONWEALTH OF MASSACHUSETTS ! i LICENSED AS A MASTER PLUMBER.: ISSUES THIS LICENSE TO I _ THOMAS J TORODE d 41489 WHIPPLE RD ` T,EWKSBURY MA 01876=390.5, 8954 05/01/12 75941b i r MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) p 1. w dyEQ ,Mass. Date / l U 2or Permit# 4/- N / Building Location & SU�U/U l31- Owner's Name SI,)�SO/(,1 Owner Tel# �ype of Occupancy ,�5'/ New ❑ Renovation 11Replacement Plan Submitted: Yes ❑ No ❑ FIXTURES W o ° 0 H H Z m H ¢ 0 0 O F W w CO W z (¢ a �a w w x cn x Lu W F SUB BASEMENT 1ST FLOOR 2ND FLOOR 3RD FLOOR 4T"FLOOR 5T"FLOOR 6T"FLOOR 7T"FLOOR 8T"FLOOR ) / Installing Company Name CALL/ ( L t JtT& Check one: Certificate Address !?/ 8a oj�E ,< , IJ Corporation k_ Apo 0UE/Z /VA— Q( �Uj— ❑ Partnership Business Telephone#12 � 11Firm/Co. �/— Luil, Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE: I have a curre lity insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. Yes No ❑ If you have checked yes,please indicate the type coverage by checking the appropriate box. A liability insurance policy Other type of indemnity ❑ 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: Owner ❑ Agent ❑ Signature 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 issued fo plication will be in compliance with all ertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene By Type of cense: • um a Signa a ensed Plu er or Gas Fitter Titldl e /J ` License Number City/Town •-Journeyman APPROVED(OFFICE USE ONLY) Location k � Ste.+ r. �oW Na 3 YO Date �aRTN lln- TOWN OF NORTH ANDOVER O:O•�,`•O ,•,AOR a Certificate of Occupancy $ + ; ; Building/Frame Permit Fee $ ' 7� �7b''•°''<� Foundation Permit Fee $ ss�CHusa Other Permit Fee $ Sewer Connection Fee $ v Water Connection Fee $ TOTAL u Building f spector 48 80198 14:18 08/aoga 14:18 I 12746 7S- Div. Public Works Location 1 + ;- L _ No!', Date NaRT� TOWN OF NORTH ANDOVER Certificate of Occupancy $ # Building/Frame Permit Fee $ Foundation Permit Fee $ s�CHust Other Permit Fee $ Sewer Connection Fee $ :— Water Connection Fee $ TOTAL $ f �_ 01/ Building Building Inspector Div. Public Works T Pl_`R MIT NO. 34 �, APPLICATION ICOR PEIRMIT TO BUILD**"""NORTH ANUOVLR, MA hl%PND. II)T.ND. Z. RLCORD DF 0%%'NLIISIIII' DATE BOOK PAGE L�.� %))t,l- SUB DIV. LOI"No . � l hSc ��� 7, D a /`� 1.()( A 1 Il IN PI 1R 1'l ISE(ll III III I)I N(i An Ono m Owl'JER'SNMIE No .OFSIOft ILS SIZE / f AVNFR'S ADDRESSLG A n BASEMENT Oft SLAII AR(I111ECI'SNAME SIZE OFFI.(X)R IIMIIERS "� �^ )1 I TTT 2 3 III III DER'SNAME SIAN g I 1, DIS IANCF10NEARESIBUILI)ING /' DIMENSIONS(IFSILLS DISI"ANCEIROMSTREF1 DINIENSIlNJSOF![SIS DIS I ANCE FROM I.Or LINES-SIDE .j--y REAR r DIMENSIONS OF GIRDERS Va ARFAOrior O:3 FR(N NAGE IILIG)IF01 FOUNOAII(Xl -1-1 IICKNESS IS BUILDING NEW SIZl OF 10(Yl ING X ISI)IJILDINGADDITI(NI ;. 1/f �• MA TERIA].OFCI111,INLY ISB111LDINOALTERATION - is Bllli.im,m(N,Iso11)(NtFiILED LAND so11�-I _ 11.13UI 1.1A N(;C(NJFORM"10 R E(,Il II R E M Et I I S(X CI)(�E IS IIl 111 DI tiC,C(X 111E C 1 li 1)'11) 1 OW)I WA I E12 W)ARD OF APPEALS ACI I(XI. IF ANY ISBM1.DINGC(N),INEC11:DIUIO�V)JS1:WLIt IS BUII.DING CONNECI ED TO NA I MIAL GAS LINE ('S VNSiouIIONS 3. PROPER IN INFORNIAl ION I.ANDC0SI ESI. UI IXi.CC)dr PAGE I F111.(XIrSECTIONS 1-3 ESI'. BI IX;. COSI PLR SQ. 1:1. ES 1. 1311X;. COS IERR(X)ti EFLCI RIC METERS MUST BE ON OU USIDE OF Will IN NO; SEI'1 IC PERAII I NU. A I'I ACI IED GARAGES MI1ST C(NNF(NiM IO S I"A1 E FIRE REGI II.AIIOf lS a. :X I'I'ItO\'L.1)U 1'. PLANS MUST BE FILED AND APPROVED BY BUILDING INSPI:Cr(>tt Ul l l I. IN(;INSI'F.(:COR DAIS FII I:1) OWNERS 11:l N q-79) R9-- 7 COt II R.11:I"a l! ('ON I R.1.1(,9 SIGN.-A II IRI OF( :R OR Al 1111tHt171:1)AGENT % / 75 F t:l: 1; I'I:RMII GRAN II:1) rAd 19 +S �� �d - FORM U - LOT RELEASE FORM 1 • C INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. *****************************APPLICANT FILLS OUT THIS SECTION* --�_ APPLICANT & -5- l�t�/'V PHONE J�o aco LOCATION: Assessor's Map Number PARCEL SUBDIVISION LOT (S) STREET -Svc&0 n/l'Z-9-10� ST. NUMBER_Z(o ****************OFFICIAL USE ONLY******** M RECOM NDATLONS OF TO N GENTS: CONSERVATION ADMINI$TRA R DATE APPROVED — DATE REJECTED COMMENTS -VW - -Fa� acv( - S , TOWN PLANNER DATE APPROVED IJP DATE REJECTED COMMENTS FOOD INSPECTOR-HEALTH DATE APPROVED DATE REJECTED SEPTIC INSPECTOR-HEALTH DATE APPROVED DATE REJECTED COMMENTS PUBLIC WORKS - SEWER/WATER CONNECTIONS - DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE TOWN OF NORTH ANDOVER AFFIDAVIT Home Improvement Contractor Law Supplement to Permit Application MGL c. 142 A requires that the"reconstruction, alteration, renovation, repair, modernization, conversion, improvement, removal,demolition, or construction of an addition to any pre-existing owner occupied building containing at least one but not more than four dwelling units...or to structures which are adjacent to such residence or building"be done by registered contractors, with certain exception, along with other requirements. Type of Work: (7d 0-0 (ice vvi i�4 J Est. CostO S" Address of Work/(-, 50+, o� �� Owner Name: rXrY&W��[w9 ' Pa-^ OzA S )`e!V Date of Permit Application: I hereby certify that: Registration is not required for the following reason(s): For office Use Only Work excluded by law Pemit No. Job under $1,000 Date Building not owner-occupied Owner pulling own permit Other (specify) Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FIND'UNER MGL c. 142A. Signed under penalties of perjury: I hereby apply for a permit as the agent of the owner. Date Contractor Name Registration No. OR: Notwithstanding the above notice, I hereby apply for a permit as the owner of the above property: 4 Date r-Name ��G ' a Y �.. COLLOPY JOB D_/ ENGINEERING CONSULTANTS SHEET NO. cOF 7 65 Ayer Street CALCULATED BY / G DATE Z/z�/�� METHUEN, MASSACHUSETTS 01844 ' TEL/FAX (508) 685.8069 CHECKED BY /1 DATE SCALE a o ��f}/ �i/G �G •v ... .. ..... y l�� tie ` avE ....................:............:.........................:.............:,........:.......... ................ ...... y Vie : )9 .................S - __ _ .. .... _. 2x/Z:12,9FTE/Ls ............° _ - u o ..... ..... _ ...... 1 3�� L2) l >G �l /8_GvL ....... ,: ... ...... .... ............._... ......... 2 _ -ro P P LAr� s 2- $ 5 3 PLAc GS.......... I. . I . of v�G�1� T .... .. 2 jq FT�,2S ... C .... J. ..... ..... OFism hgs�,c FRANCIS H. ...cOLtOPv _ _. ._ ._._.._.. _._.... L2.�..._/ 20172 (V6-6— j5 m F,v c� . ...... ,4 C- -- . _. . . _ TNB� � • S7�evGr"�PA.�- 7i.� ....... II Bio M uNNEGT T© 7e✓lPL .... i PHOOLICT 204-1)SNle Sheets)205-1(Padded)®®Inc.Groton,Mass.01071.To Order PHONE TOLL FREE 1-8762256380 JOB sif�}/�/�G'�✓ 5 /,D EN c F_ CO LLO PY n ENGINEERING CONSULTANTS SHEET NO. Z of 65 Ayer Street CALCULATED BY DATE METHUEN, MASSACHUSETTS 01844 TEL/FAX (508) 685-8069 CHECKED BY DATE SCALETIV _..................................'.............., ..... ..... ...... ...... ...... ...... ...... ..... .... ...... ...... z.._..r.....3 ... .. ... �.7.. .. v..L 1 1 ........ ....:... . ....:.... X'. .........:............. .._:... . .................. I H .r' � ............................ .......................... _ - - ._ ...... ...... ...... ...... .. ...G.G.......... ..........................: ......... ................. .. _ 2 l Z� Fr2, ,_? ;Sr2- .. ...... . ......................... .. . . DB[. T713M... . ..... ....... 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PRODUCT 247.1(Siigk Shum)205-1(Padded)®m Im.Omim,Mam.01471.To Order PHONE TOIL FREE 14*225-M ' JOB �5 17, /5 �``1V 12 , S / v c E CO LLO PY ENGINEERING CONSULTANTS SHEET NO. 3 of 65 Ayer Street CALCULATED BY G DATE METHUEN, MASSACHUSETTS 01844 TEL/FAX (508) 685.8069 CHECKED BY /!1 I I� DATE SCALE .. ... 2 ..... .... .... ..... ...... ...... .... ... .. c��cDo N p Tu WIN Bu a�..E..................... w ...... .. Bot-T .....: 'T .......................................... .... .._.L... ......... ... ...... :... _.. .... — .. ... ... .... .. .. ' r sic ............:. . ( ............., .... ..........:..............,.......... ...... ..... .. 3lI I ............: N f� ...... . ...... � ..... _ ..... CaG�ScM...�fG.....; . P, '� .. . .. z U41-c.pc,L, r�SS �f' } r.... ..,............:..........._......................:.............:.........._..._.......... ...... . ....... .??.. �T......... . ...... ............ ....................... .............. s . 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S�� Bo gs C J2 e:A9 PRODUCT 204-1(SgIe Sheets)205-1(Padded)®®Inc.,Groton,Mess.01471.To Order PHONE TOLL FREE 1-1100-225-W JOB COLLOPY ENGINEERING CONSULTANTS SHEET NO. OF 65 Ayer Street CALCULATED BY DATE ell METHUEN, MASSACHUSETTS 01844 TEL/FAX (508) 685-8069 CHECKED BY DATE SCALE .......... ... ...... ... ....... .............. ............. ........................... ............. ...................... ........... ............. ............. ............................ ............. ................. .... .................. ........... ......... ............. ........... ..............I......................................... .......... ............. ........ ................ ............................ 0—.................................................................... ............... .............. ........... 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FRANCIS H. COLLopy..... ...................................................... .............................. ........................ ............. ............. .......... .................. ... .................................... ........................- o st gu .......... .......... . ....... ....... .......................... .......... .............. ................ .............. ............. .......... ............... .............................. .................. ................................. ........... ........................ 0 N AlL. ......................... .............................. ..... ............. ............ ........... .......................... .......................... ................ ....................................... ................................... ............................ ....... ... ....... ... ........... ............................. .......... ..................... ............ ..... .............. ............. ...................... ........................... ... ................... ............- ............................................. .......... .............................. .......................... . .. ........... ........ .......... .............. ............. ............ ......................................... ...... ........................ PRODUCT 2014(Single WKS)205-1(Padded) Inc.,Groton,Mass.01471.To Order PHONE TOLL FREE I-M225-6380 j' . ; PL Or PLAN /;�300f'\ 0aa7,? P�qe o3��.3 T�-�� Novs� was hoc -off JL4 _ 16"xx ADDI �otV� ►(`te '- ' / 7 7. 6 /s NG Is-r��� R 4 C-,F IV )?5S 1�)r I .6 sUr�N PLM E No iM)Y A /M b vE MA , � v . NORTy = To' vm Of - _ - Andover 0 No. 3��6 - -�- : -7-4- � 199 * z dover, Mass., * '9LAKE COCIIICNEWICK iY 1`t�w '9 A�q`4 T 1) S BOARD OF HEALTH Food/Kitchen Septic System PERMIT T D BUILDING INSPECTOR THISCERTIFIES THAT......... ..as....... !R-. S. .................................................................................................._:............ Foundation has permission to erect.....f700.rwt k ....R.Y.!.'!. buildings on ......,�. ....5. !S. '. ( ► .......r...�a...�. ..................... Rough p ... Q t0138OCCU iedas....... ... . ........... .. . ................. ......... .. .. .��5. -... ...fk,.. (�..�..4....:�..l. .:. Chimney. provided that the person accdpting this permit shal! isfevery respect coni rm to thet�rms of ttrd application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Al+ratio and Coe s'ruction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTI N f:RTS Rough Service BUILDING INSPECTOR Final Occupancy Permit Required to ccupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove RouFinagh No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Rtyft 11 I a 7 Smoke Det. -�r'r^a_•-•mow--•�..;rr✓r'7��t-,.-�--..:-y�`^�.+c.' ..-...- -.....--•_..�;...�,,.,,r.,,i,�..-,..-,..s..:Y.;_.--�.:.---•�--' Date i f Z� _ p s� Q N' 3871 n 0 41, TOWN OF NORTH ANDOVER M PERMIT FOR PLUMBING f s ♦ .� dO f' SSACMUS- _ T This certifies that A has permission to perform . . . . . . . . . . . . . . . . . . . w plumbing int buildings o _ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . at.���. . . , North Andover, Mass. Fee. . . . . . . .Lic. Na�� 0 . PLUMBING INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK:Treasurer (Type or Print) ,•.:i: , , NORTH ANDOVER ,Mass. Oate:tt Building Location �. .�� Permi0✓ ', Owners Name ti'! v New D Renovation Replacement [� Plans Sybmi ted F T IJ F ' h z >c < I� N O -4 >- U < _ • .t W W W Y J P < h N a z to < � x o O — W F- w as .s a m 40 z < w m z p- d < < 3 x 1� v z o • Faw- VzY<►- NrY. a 71WG aoO 4cc 2 a yC o< aW IoL JW W n � -4 O R a <acrO O' 93 V T. • 3 >< .,.r ro W o n � � _ ►- to � v � o < � .a o O 0 t- SU6- 13SMT. • BASEMENT t 1ST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR 6TNFLOOR 6TH FLOOR 7TH FLOOR ' BTHFLOOR (Print or Type) Check one: Certificate installing Company Name IjAj,4 � 641 Corp. I ' Address /,F v Partner._ �J. 03 a7Firm/Co. Business Telephone 6o-3 kg 3,3 s y/ 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 i this application does not have any one of the above three insurance coverages. Signature of ownerlagent of property Owner Agent\� II bembr t.etlifr Wal all•f dm dclails and Wotnglion 1 ha.c submi(lcd lot camcd)in aMs.c arMkalian rise Ione aN pyais to a"bail 41 of - k"urkdge and that all plumbing work and inslallations lice(no mcd undct rc#444it Issucd(at this arrli"6"wi11 be PpU"µPt I whin"of d a bUs, usctls Slatc 1'lumbial;Cada and Cluptct 142 a(llic(:mull LAW L Title • Signature of•Licensed Pl=ber City/Town• soType of Plumbing License A DDor)vrn 70FFICF USE ONLY1 License Number Master 11 Journeym4 Date. h0q /.. .. NORTH `_ TOWN OF` /1LLNORTH ANDOVER PERMIT FOR GAS INSTATION ♦ p9 ^. SACMUSE� This certifies that `. . . . . . ! f° e-TA— This permission for gas installation . . . .1e ��. . . . . . . . . . . . . in the buildings of . . �.G. . . . .�. U�-` �"���'9 �.�. . . . . . . . . . . at . . ... .. . . . . . . . . ... . . . . . . . . . . ., North Andover, Mass. ' GJ Fee. . . . .4,..:!:,Lic. No.. P�tl%'. GAS INSPEC'�dR�, �' Check# D C� '�---.• J--� 6861 p. MASSACHUSETTS UNIFORM APPUCA MN FOR PERIVIIT'rp Dp GAS ,IN (Type or print) G NORTH ANDOVER,MASSACHUSETTS Date l Building Locations Permit At Owner's Name Amount S GcJ' New Renovation �. Replacement Plans SubmittedrA ❑ � a w �, a C C F w ad' x O z C z w G � ` a J W Q W o o w F F z d x a w o x > Z N. F W V p r�iU S C s p _z Q a oa z p z w SUB -B .a F w .-- M ENT c v j m 0 14 C BASEMENT 1ST. FLOOR 2N D , FLOOR 3RD , FLOOR 4TH . FLOOR 5TH , FLOOR 6TH . FLOOR 7TH , .FLOOR STH .' FLOOR. (Print or type) Name Check one: Certificate installing Company Address . /t;�X ® Corp. I J �`(� � �... �.�� —'1"C� t�K'�� f+� V..@ f/L. Partner. cruse►elephone &irmlCo. Name of Licensed Plumber'or Gas Fitter —P E7INSURANCE COVERAGE ! have a current liability Insurance policy or:ins, ntial equivalent Check one: If you have checked ves,please indicate the coverage b checking Yes 1-..1 No Liability insurance policy y king the appropriate box ©� ype of indemnity D ❑ `—+ Bond Owner's Insurance Waiver. !am aware that e does ndoeS n--- °�Ve the Insurance coveragere aired b Mass. General Laws,and that my signature ohit application waives this requirement. 9 y Chapter 142 of the of Owner or Owner's Agent Check one: 1 hereby certify that all of the details and information I have submitted(or ente red)ed)in rer �pp}ic one Agent best of my knowledge and that all plumbing work and installations performed under Permit issued for this application will compliance with all pertinent provisions of the Massachuse State d accurate to the as Cod d Ch er 142 of the General Laws. be in By: Signature of Licensed Plumber Or Gas Fitter Title [ Plumber City/Town, Gas Fitter ^� icense umber w� •��_ L. aster APPROVED(OFFICE USE ONLY) Journeyman -�. 't BE commonwealth of Massachusetts YE J'y �epart'nent Of Industrial Accidents. v Office of InuestiQatio �i a KS 600 Washieoton Street - L'os-to ft, 11L4 D�Ill iass.gov/dia Workers' Compensation Insurance.A::€fic>;ay.it. ,guilders/Contractors/Electric�an A Iica.nt Information s/pium6ers Please Print LeaibiF, Name (Business/Organization/lndividuai): :� r A- Address: 0 d Pd VL J City/State/Zip: Are�yov an employer?Check the appropriate box: 1.1J 1 am a employer with 27 4. 7I am a o� Type of ro eet berleml contractor and I p 1 (required); 2.❑ employees(frill and/or part-time).* have hired the sub-contractors .b. ❑ New c: I am a sole proprietor or partner_ listed construction ship and have no em io ems M the attached sheet$ 7. ❑ RemodeIing. P Y These sub-contractors have working for me in any capacity. workers 8. ❑ Demolition [No workers' comp. insurance 5. (] We .' camp insurance. a corporation and its 9' Build' addition I an a h ] oftic-urs have exercised.their 3.❑ I am a homeowner doing all work right of a 10:❑ Eiectri.cal repair or additions m self. xem tion y [No workers' comp. c 15� P P�MGL I l.❑ Plumbing repairs or additions _ insurance required.] t ' §1(4),and we have no employees. [No workers' 12'0 Roof repairs comp. insurance required.] 13•❑ Other Any appficant_that checks box#I.must also fill out the section below showing their workers,compensation ofi +Homeowners whu subtntt.fhts affidavit indicatiu,thej-Wn�doing lconuantors Iha�ch i+•1'L`a 4: P �'information. ec}c this box 'u n:rr outside coniraeiors muni su'omii a new affid."it indi�iin atmbhed an additional shit showittg the m—me of the sub-c;,;, !;such. I seer an ettrpla)e."thai is Providi:rao Workers,Wrrp raatinJz ' aaetors and their workers'romp,policy information. information trzsurance for 'employees. Below is the ofi P c.F and job site Insurance Company Name: Policy#or Self.ins. Lid.#: ' _ Expiration Date: Job Site Address:_ / 5 U ��t�, fo���� Attach a copy of the workers' compensation policy decEai'afion a City/State/Zip: �� e .Failure to secure coverage as required under Section 25A of pabe(showinu the policy number and expiration date). fine up to 51,500.00 and/or one-year imprisonment as well MGL c. 152 can I-ad to the imposition of criminal penalties of a of up to.5250.00 a day against the violator. Be a civil penalties in the form of a STOP WORK ORDER and a fine advised that a copy of this statement May Investigations of.the DIA for insurance coverage verification. ) be forwarded to the 'Office of ii Ido hereby,certi rider th pains and oer u P ! 7 at the information provided above is true Siand cnrrecl _onature: Date: Phone#: l (� ofj"ecial use onlp. Dn not write M this area, to be completed by cid or town officiaL City or Town: Issuing Authority(circle one}: Permit/License# 1. Board of Health 2. Buiiding Department 3. City/Town. eek 4. Electrical ector fi. Other los "P �. Plumbing Inspector Contact Person: Phone it-. iniormanon and instructions Massachusetts General.Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,ane e A e „ A r y person in tit.,servic,,P of another under any contract ofhire, express or iemployee is d..mplied, fined as ....,v.,oral or written." kn employer is defined as"an individual,partnership,association, corporation or other legal entity,or any mtwo or ore of the foregoing engaged m a,lomt enterprise,and mcludirtQ the leigal r resentatives of.a deceased ep d employ„r,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 ag artments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maint.-nance,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 1Ocal licensing agency shall withhold the issuance or renewal of a ficense or permit.to operate it bnsiness or to construct buildingstn the commonweattb 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 worlf< 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 comPI-etely,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 cerrificate(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 affic$avit may.be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Aiso be sure to sign and mate the.affidavit. The.affidavitshouid be returned to the city or town that the application for the Penn-it or license is being requested,not the Deparfinent of Industrial Accidents. Should vou.ha.ve arty questions reg' ding the-iaw or if you are required to obtain a workers' .compensation policy;please call the Department at the na:rnbor:lisrwd below. Self insured companies should enter their self-insurance license number on the avaropr late line. City or Town Officials Please be sure that the affidavit.is complete and printed leQibhv. The.Department has provided a space at the bottom of the.affidavit foryou to rill but in the event the Office of-Investigations has to contact you regarding the appiicant. Please be sure to fill in the permitJiicense number which will be used as a reference number. In addition, an applicant that mist submit multiple petmi0icense applications in arty 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 starnped 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 Iic--uses. A new affidavit must be filled orrt each year. lhrhere a home owner or citizzn is obtaining a linens= or permit not related to any business or commercial venture (i.e. a dog license or permit to burnleaves 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, r please do not hesitate to give us a call. The Department's address,telephone and fax number. The ComrnOnweg;jth of Massachusetts I3cpartment of Lmdustrial Accidents. Office of Licvesfite at-ions 600 Washdngton Street Boston; MA G2111 Te1. # 617-727-4900 C=406 crr 1-877-MASSAFE Revised 5-26=05 Far,# 617-727-7749 u�jS7i.'.Iri 3SS.g o V�dIB