Loading...
HomeMy WebLinkAboutMiscellaneous - 17 MILLPOND 4/30/2018 17 MILLPOND 210/095.A-0017-0000.0 l Date... ..................... &ORrs, 0 TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION 14U .This certifies that ..............AA-T+,0,ffPf--J�QuL3,,S Kea . .............. .................................................................. has permission for gas installation ............................... in the buildings of.. ..... ............................................................................................. ............. .......................................... .... North Andover, Mass. Lic. No. .................... ................... ..................................................................... GASINSPECTOR Check# k_p��P,2_ 2_Lj 9725 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK + CITY _ MA DATE[Djjj�i PERMIT# OWNER'S NAME JOBSITE ADDRESS��-1��1' � �� w�r� GOWNER ADDRESS aWIA TE FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ® RESIDENTIAL PRINT CLEARLY PLANS SUBMITTED: YES� NO - NEW10 RENOVATION:Cl REPLACEMENT: APPLIANCES Z FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE - DIRECT VENT HEATER _ w DRYER _ FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE - INFRARED HEATER LABORATORY COCKS MAKEUP AIRUNIT OVEN------------ ------------ POOL HEATER = --- ROOM/SPACE HEATER ROOF TOP UNIT TEST - UNIT HEATER - UNI!ENTED ROOM HEATER WATER HEATER r--� - OTHER ^INSURANCE COVERAGE of MGL.Ch.142 YES NO bilit i —� have a current liansurance policy or its substantial equivalent which meets the requirements IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ® BOND OWNER'S INSURANCE W VER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the 1�4s s nerall- . s,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER © AGENT SIGNATUR 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 st of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all vision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME -a LICENSE# c31 NATURE MP MGF !I JP JGF LPG] CORPORATION E1# PARTNERSHIP®#E=LLC #� —�-�-- � c ADDRESS C9_ COMPANY NAME:I 1�tZhll�s5 C' -- -- - -- CITY STATE O TEL 235-7- '-7 --7(d FAX E:: CELL EMAIL — <r. 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 1 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 bum 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 Conunonwealth of Mossach-Metts Department of Industrial.Accidents Office of Iavestfgatiom 600 Washingtonn,Street Boston,MA,02111 Tel,#617-727-4900 oxt 406 or 1-877rMASSAFB Fax#617-727-7749 Revised 5-26-OS I WWv.Mass,govNia : § � G MMb�WEAL"`i`H OFMX�SA�HUS�'� f t x WRC., .'. L(CENSERAS Tkz't It.RNE1'MAN .Ptt ilEi R FRAMX ITURROND0 ¢t 9,179 Date •_°,;.'+,oma TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING SACMUSE� This certifies that has permission to perform . . . . . . .ot&!5*Ee . . . . plumbing in the buildings of ... . . . . . . . . . . . . . . at. . . . . . . . . . . . . . . . . . . . . . . .. Nyor.tAndovpr, Mass. -7 . .Lic. No.. . . V Fee.9�. . . . . . ..&0 21� . . . . . PLUMBING INSPECTOR Check # i rNew: ASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING �,�/� MA. Date: /�/�'�// Permit#:�� ��N�� Owners Name: j)L1/rlp.✓y: Commercial❑ Educational❑ Industrial❑ Institutional❑ ResIdtion:❑ Renovation: �,/ R Lr'I eplacemeri ❑ Plans Submitted: Yes❑ FIXTURES DEDICATED cU H z SYSTEMS 2 L', O h w z cn LO z 4 A a U W o p Q tY K vl w ¢ h O a N N W w d Y Z O ¢ z rr O� m a Z y C7 v a ¢ F. ¢ O p �. D w w Z u ¢ a w U r- 0 r— U j Q 3 0a Z S w w w df O rW w Q Q ,j O H 0 O ¢ m m D LL 2 Y OK H p �n w q cn -SUB BSMT. q 3 BASEMENT 1ST FLOOR 2ND FLOOR 3RD FLOOR 4T"FLOOR ST"FLOOR 6T"FLOOR 7T"FLOOR 8T"FLOOR Instaliirt g Crii��x.�,rz'TvamE_ _ �►j3A �-Ty'G®NNO(/� Ci^ seOs�lV GE±iiYi+ si:G;+= r Address:& 16F�`11'l WWiiy/Town:. �� El Corporation �sQl fes/} State: Business Tel:���^ '��f^�� ❑Partnership Fax: Name of Licensed Plumber: s0/yfdl /CO /V OdZ El Firm/Company INSURANCE CuV=11i I have a current liability Insurance policy or its substantial equivalent which �/ meets If you have checked Yes,please indicate the-type of coverage by checkingthe a the requirements of MGL.Ch.942 Yes L� PJo❑ appropriate box below. A liability insurance policy Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER:1 am aware that the licensee does f Neve the insurance coverage required by Chapter 942 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. Check One Only �i nature of Owner or Owner's A Agent Owner ❑ Agent ❑ l hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and Knowledge and that all plumbing work and Installations performed under the permit!ssued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. accurate•ate to the.,�„of ry ✓ I Type of License: y :►e ❑Plumber Signature of Licensed Plumber Y/Town ❑ aster (PROVED(OFFICE USE ONLY) Ou eyman License Number: Z/3 /-Z- The Commonwealth ofMassachusetts Depai''tin oflndustrialAccidents Office of Investigationg 600 Washington Street. Boston,MA.02111 www.massgovMa Workers' Compensation Insurance Affidavit: Builders/Contractors)Electri.cians/Plumbers Applicant Information Please Print Lealblv Name(Business/Organization/fndividual): /1 O�jf'�J p�CO J✓NO� Address:_ .City/State/Zip_�j/LG�9t I�� �jdf ®��G.Z Phone Are you an employer?Check the appropriate box: _ I.❑Tam a employer with 4. ❑I am a general contractor and I Type of project(required): 2.�employees(full and/6 part-time).* have hired the sub-contractors 6. ❑New construction I am a sole proprietor or partner- listed on the attached sheget.t 7. 9emodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp,insurance. �No workers'comp.insurance 5. 9. ❑Building addition p ❑ We are a corporation and its required.] officers have exercised the' 10.❑Electrical repairs or additions it p 3.❑ I am a homeowner doing all work right of exemption per MCL 11.Q 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 anew 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 my employees Below is the policy and job site information. Insurance Company Name: ra y2v/� A"z Policy#or Self-ins.Lie.#: O 30/ p Ex iration Date:_. Job Site Address: / /TGG- 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 r 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. Do' that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. r do hereby certify under theains and en o .p P fperjury tlraf the information provided above is true and correct. ii nature: ® ry Date- 'hone ate'none#: Of•jccial use only. Do not write in tliis area,to be coinpletecd by cify or town official City or Town: Permit/License# Issuing Authority(circle one): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#• � Y b COMMONWEALTH OF MASSACHUSETTS : :' r' :PLUMBERS AND GASFI.TTERS LICENE � iXIAN P.LU"IUI;B.AV , R.O-BER=T A OCON.NOR r� 33 .0-4 D PJ*LERICA, ROAD BEDFORD `e. y: .MA 0173:0,--1220 } • • t x. # I r' 1 t Y ! Name on Policy: O'CONNOR PLUMBING & HEATING LL Policy Term: 09-07-11 to 09-07-12 Policy Coverage Policy Number MASTERPAC GA403016 . f srJs Travelers Claim Action Line (800)238-6225 Representatives available 24 hours a day, 7 days a week.