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HomeMy WebLinkAboutMiscellaneous - 161 MAIN STREET 4/30/2018 161 MAIN STREET 210/030.0-00340000.0 Date....I-]..zd-1A................. TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION HU This certifies that .......... . .......... d......................................................... ....... ........ ..... . has permission for gas i4stallation ........br..!Ie:0�1..................................... in the buildings q at.......... ........................................c:n... ... ........... North Andover, Mass. Fee... Lic. No. ...... Mk...................................................... GAS INSPECTOR Check# 4q 001 0 7 Lr 1) p MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY I('Ull+ �I MA DATE L3 PERMIT# JOBSITE ADDRESS 0 ER' NAME GOWNER ADDRESS TEL FAX -� TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONALE] RESIDENTIAL PRINT CLEARLY NEW:E] RENOVATION:El REPLACEMENT: PLANS SUBMITTED: YES F---Jl NOE] APPLIANCES 7 FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVES DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATERS — LABORATORY COCKS L-- _.._ J -._ 1 -��I �- -11 �t—J - MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER T _ ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATERS OTHER �- INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ® BOND -1 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. C LY: OWNER Q A7z"91/ SIGNATURE OF OWNER OR AGENTr� 1 hereby certify that all of the details and information I have submitted or entered regarding this appli ation are true and acc ra a best o no dge and that all plumbing work and installations performed under the permit issued for this application will ' compliance w inenl pro ' n o_f Massachusetts State Plumbing Code and Chapter 142 of the General Laws. — PLUMBER-GASFITTER NA I T L_jh'_1 ','--�'�?`�LICENSE# 3G ( SIGNATURE MPMGF JP 0 JGF 0 LPGI 0 CORPORATION©# PARTNERSHIP # LLC[J#� N COMPANY NA b ADDRESS ? --- - - CITY _ _� STATE G4iJ ZIP ]TEL d' FAX CELL LaaF EMA D O - - - ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES a P The Commonwealth of Massachusetts Department ofIndustdal Accidents Office of Investigations IV 600 Washington Street Boston,MA 02111 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Address: G �6�- City/State/Zip: / Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.0iT am a employer with U 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet.? E]Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. F1 Building addition [No workers'comp.insurance 5. El We are a corporation and its required.] officers have exercised their 10.❑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,§1(4),and we have no 12.❑Roof repairs insurance required.]t employees. [No workers' comp.insurance required.] 13.❑Other 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. TContractors 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 workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. e, �-� Policy#or Self-ins.Lie.9: Expiration Date: Job Site Address: ( 60 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 ypAo425.0.00 a day against he violator. d *sed that a copy of this statement may be forwarded to the Office of vestigations o e DIA fo ur ce vera v rification. I zereby cert u der It ins an ti ofperjury that the information provide/d above is true and correct. Si atu Date: ( 2 U 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#: q 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 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 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 ofM-assachusetts Department of Industrial.Accidents Office of Investigations 6.00 Washington Street Boston,,MA 02111 TeX,#617-7274900 QXt 406 or 1-87` MASSA FE Revised 5-26-05 Bax#61.7-727-7749 ww.utass,gov1dia :COMMONWEALTH OF MASSACHUSETTS PLUMBERS AND GASFITTERS : LICENSED AS A MASTER PLUMB ISSUES THE ABOVE LICENSE TO: TIMOTHY' A GIARD i 60 SAUNDERS _ST - NO ANDOVER MA 0184 -2414 1l, 10301 05/01/14 183494 F` Date.� .''?.C�l.... .. OF o= TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION \r SACHUSESS� This certifies that . . . . . . . . . . . . . . . . . . . . . has permission for gas installation . . . . . . . . . . . . . . . . . . . . in the buildings of . . 15 5. .w° t-` at . .,�G�. .l�!�E?'/.�°. .`f . . . . . . . . . . . , 'North Andover, Mass. Fee. .). v -. . . Lic. No.5 ?3 ?. . . . . . . . ..I. . .tom'^ .,-% . . . . . . GAS INSPECTOR Check# h ? 5x.28 MASSACHUSETTS UNIFOMIT TO 00 GASFiTTiNG tPrint or Type] RM APPLICATION FOR,PERf6n s• oath l/ so a ti J 2� BuilJA)ding Location _ Owners tyleA Type of Ocxupancy Newo Renovation 0 Reptacenfent� Plans Submitt8d: yes o No 0 W (0 ' v zz ', U z —SU& SMT o . . BASEMENT 1ST FLOOR 2ND FLOOR ' 3RD FLOOR ; 4TH FLOOR 5TH FLOOR 6TH FLOOR 7TH FLOOR STH FLOOR 01aWng Company Name 601 ` Check one: Certificate e:tirells 0 Corporation r iness Telephone �U 0 Partnership erne of Licensed Plumber.or OW Fitter irMCo. NSURANCE COVERAGE: have a CUrni t!4blllty Insurance policy or its substantial equivalent, which meets the requirements of MGL Ch. 742. Yes tY No 0 f you have checked yes,please Indicate the type of coverage by checking the appropriate box 1liability insurance policy®/' Omer type of indemnity 0 Bond 0 )iVMI+INSURNACE WAIVER: 1 am aware that the licensee does not have the Insurance coverage required by C hapter 142.of the Mass.General taw:, and that my signature on s pe eplNlcation Waives this requirement: gnareo wner or wne s an Check one: Owner 0 Agent p meby certify that ag of the detepa and Information I have submitted for entered!In above a plication aro true and accurate to the best of "owledoe and that all plumbing work and Installations performed ender the permit r lila application7.be in p/rtlnentpmvlsiom of the MarS20Metts SWeCas Code and Chapter 7462 of then Lcompliance with Type of License: Sr ri Plumber j- Tick 0 t;asfither re o cense Plu or or Gas tier Civro"PPROV ��_ pester License Number-tOFFIC°E USE ONLY) p Journeyman �010��NMBIIIMA1i OLMr1{O liwy>H Y>lAl1A1i I ON107M0 i0 MOIi�01 i ! >'�IN07M1/i0>N41!ARy11 ONWRO14 00 OL AINUM 110A 0001AV36ddV low sit "0112349N1 Ma"Olm =N ads"I IVNI i1NO 398 IIWAD MA M0734 � - r