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Miscellaneous - 167 DUNCAN DRIVE 4/30/2018 (2)
A /• f• • N° 9704 Date��l•� �2-- ,.oR'M o TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ,S., cm SEt This certifies that . . . . . . . . . . . . . . . . . . . . . has permission to perform . . . . . . . . . . . . . . . . . . . . . . . . . . plumbing in the uildings of . ?e/° . . . . . . . . . . . . . . . . . . . . . at. 16 7. North Andover, Mass. Fe;32..!`? .Lic. No.V 4VQ. . N4. . . . . . . . . . . . . . . . . . . . . . . . . . PLUMBING INSPECTOR Check # �a WHITE: Applicant CANARY: Building Dept. PINK:Treasurer MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY �_ _y I MA DATE � � f PERMIT# JOESITE ADDRESS ) _ e OWNER'S NAME L POWNER ADDRESS / 7 ,r ,� FAX TYPE OR OCCUPANCY TYPE COMMERCIAL Q EDUCATIONAL 0 RESIDENTIAL©� PRINT CLEARLY NEW: 01 RENOVATION:© REPLACEMENT: PLANS SUBMITTED: YES DI NOD 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 GASIOILISAND SYSTEM DEDICATED GREASE SYSTEM ( I .__.....__1 .._..___..( 1 1 � J —_.I DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN ( _._...._._1 _ _( .__._._.._I �( ) ----__._.1 P _._..__i __-..___( INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY i ROOF DRAIN _..-.._._I SHOWER STALL SERVICE/MOP SINK TOILET 1 _{ __._...1 I .___.J .__ l ._.__._1 URINAL -.J WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER EE i -------I - --,I INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES R-NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY D BOND 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 0 AGENT _( 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 complia a ith all Pertinent vision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAMELICENSE# i SIGNATURE b MP 0 JP CORPORATION Of# j PARTNERSHIP O# __-_ -_ -R LLC U� ,Q COMPANY NAME F ADDRESS / ' CSL �[ p 7 _ i CITY�' � „ d- - STATE ZIP TEL 03 _ FAX CELL EMAIL _..__......_. .... _.._. - ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ n FEE: $ PERMIT# PLAN REVIEW NOTES t r rJ "y r The Commonwealth OfMassachusetts Department of IndustrialAccidems Office of investigations 600 Washington Street Boston,MA 02111 ki www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers A licant Information Please Print L--,]Ll-- Name (Business/Organization/individual): Address: ,,/ Y,21-1 � Phone#:_Z p t 01o7 G Are you an employer?Check the appropriate box: 1.❑ I am a employer with 4. ❑ I am a general contractor and I Type of project(required): _ er�Ployees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2. I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees El Remodeling actors hav working forme in any capacity. workers' omprinsurance.e 8• E]Demolition [ workers' comp.insurance 5. ❑ We are a corporation and its 9. ❑Building addition required.] officers have exercised their 10-ElElectricalrepairs 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 insurance required.]t employees. [No workers' 12-El Roof repairs comp.insurance required.] 13•❑Other Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. 1 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 is providing workers'compensation insurance for my employees. Below is the policy and job site Wformation. Insurance Company Name: ?olicy#or Self-ins.Lic.#: Expiration Date: yob Site Address: attach a copy of the workers'compensation policy declaration page(showing the Policy number and expiration d ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal enalti ate). a ORDER ine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK p es of a if up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of d a fine nvestigations of the DIA for insurance coverage verification. do hereby certyyund the pains andpena ties ofperjurythat the information provided above is true and correct. i nature: hone#: 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 6.Other 4.Electrical Inspector 5.Plumbing Inspector Contact Person: Phone#: it Information and Instructions M ssachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pt 1suant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, e ress or implied,oral or written." Aemployer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more o 'the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the re �eiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the o ner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the di ielling house of another who employs persons to do maintenance,construction or repair work on such dwelling house olon the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." IGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or r newal of a license or permit to operate a business or to construct buildings in the commonwealth for any taplicant who has not produced acceptable evidence of compliance with the insurance coverage required." A ditionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall eAter into any contract for the performance of public work until acceptable evidence of compliance with the insurance rquirements of this chapter have been presented to the contracting authority." pplicants f P ease fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if n 6ssary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of ir surance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the embers or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have e I ployees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial ccidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should b 11 returned to the city or town that the application for the permit or license is being requested,not the Department of I 'dustrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' mpensation policy,please call the Department at the number listed below. Self-insured companies should enter their E-If-insurance license number on the appropriate line. 'lease or Town Officials f lease be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom f the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. l lease be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant Pat must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current olicy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or i wn)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the �pplicant 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. 'rhe 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. fhe 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. # 617-727-4900 ext 406 or 1-877-MASSAFE R ised 5-26-OS Fax# 617-727-7749 � www,mass.gov/dia y :r PLUMBERS AND ti1.mks FITTERS LICENSED AS A JOUkAEyMAN PLUMBER , iSSUES THE ABOVE LICENSE TO: THOMAS ,S FARHADIAN IN 415 MAIN ST HAMPSTEAD NH 03641-2073 19420 05!01/14 163615 �« - --� _«-