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Home My WebLink AboutMiscellaneous - 1631 SALEM STREET 4/30/2018 / 1631 SALEM STREET J 210/106.8-0081-0000.0 Date �1 .`:.'. ".O?T:�� TOWN OF NORT ANDOVER PERMIT FOR PLUMBING SS,'fir +O+, us us This certifies that�r�--. . . . :-� . . . . . . . . . . . .f: ��-2�' has permission to perform . . -� f,h.��!. . . . . . . . . . . . .�' plumbing in the buildings of . . . . . .(: . - at . ... .. . . .`.. . . . . . . . . .. North Andover, Mass. Fe . .Lie. No..�_ 5.`� / . . . . . . PLUINSPECTOR . . . . . . Check # 8263 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS +` mcation DateBuildin LoL ONAm Pe ount 0 ca--0 Type of Occupancyz ) Id New Renovation Replacement Plans Submitted Yes ❑ No ❑ FIXTURES xCr U W 1 Lo 0 F, a F ►a � A A � w a w A a x H A - x w MMVENr M HOM zl`n Hit �t Hncat alHHMt s>�x Hit M FLOCI t - 7MH00R gm Herat (Print or type) / I I Jrs7b�`d/ r i li�G�rid Check one: Certificate Installing Company Name Corp. ❑ Address d Partner. ®�Business Telephone Firm/Co. Name of Licensed Plumber: i Insurance Coverage: Indicate the type of in urmce..coverage by checking the appropriate box: Liability insurance policy n �.--""' 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 I Signature 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 Permit Issued for this application will be in compliance with all pertinent provisions of the Massac tts ?ate P tubing C .and Chapter 142 of the General Laws. By: ignp re o kens um Title ype of Plumbing License f�� City/Town icense um er Master Journeyman ❑ APPROVED(OFFICE USE ONLY The Commarl wealth of Mmachusetty k1 i Department of Industrial Accidents Office of Investigations IN ;' 600 07irshin;torr Street Boston, MA 02111 www nasus gov/dia . Workers' Compensation 1=4rance Affidavit: Builders/Contractors/Electricians/plumbers Aripficant Information Please Print Legibly Name (Businessiorganim ion/Individual): ' v� c Address: City/State/Zip:__�e tQ _ Phone ZID w EAEyou an employer?Cheek the appropriatebox: 1 am a employer with 4. ❑ 1 am a general contractor and TF7 = Project(required): employees(full andlorOart-time).* havo hired the sub-contractors onstrucction I am.a.sole proprietor or partner- listed on the attached sheet 3 deling hip and have no employees These sul�-contractors have .working for me in lition airy capacity. workers comp.insurance.[No workers'comp. insurance 5. ❑ Weare a corporation and itsaddition rt:gttired.J officers have exercised their cal repairs or additions I am a homeowner doing all work right of exemption per MGLinmyself.[No•workers'comp, q 152, §1(4),and we have nog repairs or additions insurance required.]t em io ees. 12•❑ Roof repairs P Y ['No workers' COMP. hisurancerequired..J 13•❑.Other 'Any applicant fhat-hacks bo>'#t must also fila out the section below showing their workers'compensation policy information t Homeowners who submit this affidavit indimtin lh are doingall ;Coutract w that check this box must amalmd an t-�sheat showing. �d then him outside contractors must submit a new affidavit indicating such. ++Eg•the normo of the sub-cmnotors and their work='corn- polim•irtormation. I am an emplaper Cho hprgv Mg:workers'comPerrsation "aurmce or information f ' Ply Below is thePO&7 and job site . Insurance Company Name: Policy#or Self-ins.Lie.P Expiration Date: Job Site Address: . CitylState/Zip: Attach a copy of the workers' eompeusation policy tfeciaratiou page(showing the policy number and expiration da*e Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penahies 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 ORp£R and a fine ' of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office a Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties afPerjury that the in.1F ormagon p vro ' ,,,�___.•_.—... � uled above is true and rowed Phone#: 7 S d a Offickd use o&lP. Do not write in tftis area,to be camplered by citj,or town ofcia( City or Town: Permit/License# Issuing Authority(circle one): + 1. Board of Health 2-.Sanding Department 3.City/Towa Clerk 4.Electrical Inspector S.Plumbing inspector 6.Othei Contact Person: � "'" Phone#: Information a. nd Instructions. � } Massachusetts General Laws chapter 152 requires all emp 3oyers to provide workers' compensation for their employees. K 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,assadiation,corporation or other legal entity,or any two or mom of the'fbmping engaged in a joint enterprise,and includirig the legal representatives of a deceased employer,or the receiver ort mstee of an individual,partnership,association or other legal eritity,employing employees. 'Howeverthe owner-of a dwelling house having not more than three apa -tments 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 shat not bemuse of sucb 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 bulidings in the commonwealth for any applicant who has oot produced acceptable evidence.of compliance with the insurance coverage required." Additionally, MOL chapter 152,§25C(7)states"Neither t3he commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliant:with the insurance requirements of this chapter have been presented to the coxrruacting 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).mind phone nwriber(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 requireditu carry workers'ca rn sation 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 Departrnent at the number listed below. Self=Vred o"arrgani-should-..— fin r self-insuaance-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 yore 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/licanse number which%%-iII be used as a.reference number. In addition,an appikant that must submit multiple permit/license applications in any given yeg,need only submit one affidavit indicating current policy'infonnation(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy oftthe 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 atfidavit 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 bum leaves etc.)said pers6n 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 Boston, MA 02111 TeL fr 617-727-4900 ext 406 or 1-977-MASSAFE Fax 4 617-727-7749 FL wised 5-26-05 www-mass.Dov/dia TOWN OF NORTH ANDOVER OCT 2 5 2001 SYSTEM PUMPING RECORD DATE: 10 SYSTEM OWNER &ADDRESS SYSTEM LOCATION (example: left front of house) O5� Gat I � DATE OF PUMPING: 1-0-3-0( QUANTITY PUMPED GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER (EXPLAIN) i SYSTEM PUMPED BY: �, COMMENTS: CONTENTS TRANSFERRED TO: