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HomeMy WebLinkAboutMiscellaneous - 171 PLEASANT STREET 4/30/2018%L_ This certifies that Date TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION �PMWA,,A...U VIA �'J, , has permission for gas .nstallation ..... . in the buildings of. . ........................ . i.a S... ,North Andover, Mass. Fee' P. Lic. N024.n-,> . M � ................... ... GASINSPECTOR Check # 13 Q 8698 -'\ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK - GOWNER TYPE OR PRINT CLEARLY CITY `NORTH ANDOVER MA DATE y S1� PERMIT # d "'� JOBSITE ADDRESS /-7-? /0Z�fJS9Aq— .ST OWNER'S NAME Y yet ADDRESS e- TEL FAX OCCUPANCY TYPE COMMERCIAL ❑ EDUCATIONAL [] RESIDENTIAL NEW: RENOVATION: REPLACEMENT: F PLANS SUBMITTED: YES F—, NO APPLIANCES Z FLOORS— BSM 1 2 3 4 5 6 7 8 1 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER 1 OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch.142 YES NO 71 1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [X-] OTHER TYPE INDEMNITY E] BONDI:] 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 I 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 compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws.--`G��— PLUMBER-GASFITTER NAME LICENSE # 24833 SIGNATURE MP, MGF E7 JPJGF LPGI CORPORATION [ j# PARTNERSHIP E-]# LLC E# COMPANY NAME:T.HALLORAN PLUMBING ADDRESS 826 DALE ST. CITY NORTH ANDOVER STATE MA ZIP 01843 TEL 978-685-9504 FAX CELL EMAIL lU V 7-->`D 11 e -,I Lj .,I IIY\C4, ( •J 1 e. The Commonwealth of Massachusetts WN Department oflndustrial Accidents (74 Office of Investigations �., 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information PIease Print Legibly Name (Business/Organization/Individual): AwZza r j/I Address:'2e, Phone #: Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. [:] I am a general contractor and 1 employees (full and/or part-time).* have hired the sub -contractors 2.10 I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] These sub -contractors have employees and have workers' comp. insurance.T 5. F� We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance reciuired.l Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. E] Building addition 10.❑ Electrical repairs or additions 11.0 Plumbing repairs or additions 12. F-1 Roof repairs 13. ❑ Other *Any applicant that checks box 41 must also fill out the section below showing their workers' compensation policy information. r 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 state whether or not those entities have employees. If the sub -contractors have employees, they must provide their xvorkers' comp. policy number. I attz an employer that is providing workers' compensation insurance for nzy employees. Below is the policy and job site information. Insurance Company Nam Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: 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 up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of pez juzy that the information provided above is true and correct. Phone #: >7JV_" Official use only. Do not write in this area, to be completed by city or town official City or Town: Issuing Authority (circle one): 1. Board of Health 2. Building Department 6. Other Contact Person: Permit/License 4 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector Phone #: J 1 f 0 1:49 Date . � ....... . toTOWN OF NORTH ANDOVER PERMIT FOR PLUMBING r 'This certifies that ............. ....��i/M. ............ . r -�ias permission to perform ... ��` . �!' :.. �............. . plumbing in the bu�ecksj.*9. dings of ...................... �at .. �......c.. ,North Andover, Mass. Fee ....... Lic. No�iO3 . . � ................ ... PLUMBING INSPECTOR Check #) 311 SII f IIS V L "-)I VrILt-,L MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK Na I CITY NORTH ANDOVER MA DATE l� PERMIT # C ` 1 w JOBSITE ADDRESS IV ®�� S•r '� 5 /OWNER'S NAME Ja'f, Cc Z^L'6,6"Z1S OWNER ADDRESS 9-6 /v? TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL '. _ EDUCATIONAL . RESIDENTIAL K PRINT CLEARLY NEW..-.--- RENOVATIOW .-_ REPLACEMENT:` PLANS SUBMITTED: YES NOS FIXTURES 1 FLOOR— eSM 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 DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/ AREA DRAIN INTERCEPTOR INTERIOR KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES 1 W TER PIPING OTHER INSURANCE COVERAGE: 1 have a current liabilityinsurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YESNO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW 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 Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER :_ _..; AGENT SIGNATURE OF OWNER OR AGENT I 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 compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME THOMAS HALLORAN LICENSE # 24833 SIGNATURE MP.. JP k CORPORATION ' # PARTNERSHIP _ # LLC COMPANY NAME HALLORAN PLUMBING ADDRESS 826 DALE ST. CITY NORTH ANDOVER STATE MA ZIP 01845 TEL 978-685-9504 FAX CELL EMAIL d— „„ SII f IIS V L "-)I VrILt-,L The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations 600 Washington Street f .,, ' Boston, MA 02111 ife . ..{{Tl t4: www.mass.gov/dia Workers' Compensation insurance Affidavit: BuildersfContractors/Electricians/Plumbers Applicant Information Please Print Legibly Na1ne (Business/Organization/Individual): �/Q�L�%r�ig� e,LL/m Address: At, Ci /State/Zi ty p: Wa �i �'�I©%��� Phone #: Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 6. ❑ New construction 2X I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub -contractors have 8. ❑Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers' comp. insurance comp. insurance. $ required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12. ❑ Roof repairs insurance required.] t c. 152, § 1(4), and we have no 13. ❑ Other employees. [No workers' comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t 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 thesub-contractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. Iain an employer that is providing workers' compensation insurance for m y employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: 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 up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. 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 6. Other Contact Person: 4. Electrical Inspector 5. Plumbing Inspector Phone #' .r Date .• I TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION I �- This certifies that..... .. has permission for ga(ymstallation .�(�� ) . ...................................... . . in the buildings of . ` Qe ............................. Q ..... North Andover, Mass. Fee��!.. Lic. No.? GASINSPECTOR Check # I I 8436 _/Y' v\j V MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY NORTH ANDOVER MA DATE 11�1(v�l Z PERMIT # JOBSITE ADDRESS 171 /34SAy% Sfi OWNER'S NAME joc'e (!��Jf6=�fcs GOWNER ADDRESS S'�gse� -� TEL FAX TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL[] EDUCATIONAL E RESIDENTIAL] CLEARLY NEW: El RENOVATION: Q REPLACEMENT: PLANS SUBMITTED: YES E-] NO F APPLIANCES 7 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 DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER 1 OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES NO j I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 5?1 OTHER TYPE INDEMNITYE] BOND f 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 - AGENT SIGNATURE OF OWNER OR AGENT I 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 compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. .71-- fir, �,s� , , PLUMBER-GASFITTER NAME THOMAS HALLORAN LICENSE # 02 v g.33 SIGNATURE MP MGF JP JGF LPGI CORPORATION(j j# PARTNERSHIP 0# LLC F'# COMPANY NAME:HALLORAN PLUMBING ADDRESS 826 DALE ST. CITY NORTH ANDOVER STATE MA ZIP 01845 TEL FAX 978-208-0840 CELL EMAIL Z� fx /. 2 _/Y' v\j V w O z z O U LU CL N z_ Q z o z } y J A El z CD F. LU w cn O w O w CL at z U = F- L w Q LL - LU :> O O. w d W [G O w z w Q ca J O z CL J W Q [n U J a a �s x w cn LU F- O z z O U LU CL Cn z 0 z m J CL 2 CD O Cr 9 The Commonwealth ofMassachusetts Department of Industrial Accidents Office ofInvestigations ..600 Washington Street Boston, AM 02111 www in ass gov/dia pWorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Aplicant Information Please Print Legibly Name (Business/Organization/Individual): - - Address: Gly/State/Zip: Are you an employer? Check the appropriate box: I. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).*' 2. 12fI am a sole have hired the sub -contractors listed proprietor or partner- on the attached sheet. # ship and have no employees These sub --:contractors have working for me in any capacity. [No workers' comp. insurance workers' comp. insurance. 5. ❑ We are a corporation and its required.] 3. El. I am a homeowner doing officers have exercised their all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] *AnY a_ vL=cant th at checks bo=. #1 must also fill out the section below s:hhom e - Type of project (required): 6. ❑ New construction 7. E] Remodeling 8. [] Demolition 9. [:]Building addition 10, El Electrical repairs or additions .11.❑ Plumbing repairs or additions 12.0 Roof repairs 13.❑ Other T HX. omeownerswho 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 'heir workers' wmp. policy information. I o an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #. Expiration Date: Job Site Address: 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 up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby certify under the pains and penalties of perjury that the information provided above is true and correct Sienature: Phone #: Official use only. Do not write in this area, to be completed by city or town offzciaL City or Town: Permit/License Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town CIerk 6. Other 4. Electrical Inspector 5. Plumbing inspector Contact Person: Phone #: 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,' 925C(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 certificates) 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 anLLC or LLP does have employees, a policy is required. Be.advised that this affidavit maybe 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 re+t�'sTa�? � the t Gtr t<ivJa tli t th FV %sGEtiiY� i'y � for the p r�ator license i$ being requested, not the Depar�Ynf 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 homeowner 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 woi ld'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 Massaebusetts Department of Industrial Accidents Office of Iarestibations 60:0 Washing -ton Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-8.77-M. ASSAEE Fax # 6.17-727-7749 - N° 9671 Date. >> I �I TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING SSACMUS� This certifies that.. ..... [ . ��............. . has permission to perform . �'`-f P!lD G� plumbing in the buildings ,of }. JQ. �!�...................... at ..... �. { ....� -P%"7l��-�7 . l�' .. ..... , N rth Andover, Mass. Feev . ... Lic. Noz'TB-3. ! . ..... PLUMBI G INSPECTOR Check # I Z F WHITE: Applicant CANARY: Building Dept. PINK: Treasurer MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK '- - CITY NORTH ANDOVER MA DATE PERMIT # JOBSITE ADDRESS /'7% fle4g4,V <,D7 OWNER'S NAME -OyCe POWNER ADDRESS 9A In -Y-- TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL] EDUCATIONAL �' RESIDENTIAL wX� PRINT CLEARLY NEW: Ej RENOVATION: [ REPLACEMENT: PLANS SUBMITTED: YESD NO�� FIXTURES Z FLOOR— BSM 1 2 3 1 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OILISAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR / AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE I MOP SINK TOILET URINAL WASHING MACHINE CONNECTION , WATER HEATER ALL TYPES 1 WATER PIPING OTHER INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES 7Z. NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY E] BOND' 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 L � AGENT fi SIGNATURE OF OWNER OR AGENT I 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 compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. -;7/, PLUMBER'S NAME NAME THOMAS HALLORAN LICENSE # 24833 SIGNATURE MPD- JP2 CORPORATION(I# PARTNERSHIP# LLC E]# COMPANY NAME HALLORAN PLUMBING ADDRESS 826 DALE ST. J �v �� CITYSTATE ZIP TEL 1t NORTH ANDOVER MA 01845 978-685-9504 FAX CELL EMAIL v 1512 03:07p THOMAS HALLORAN 978-685-9504 p.1 _--.CO�Vi----EALTFi OF ;1f1ASSRCi-iUSETTS :.. -. . ' GASF T oNw RS LICENSED ASA JOURNEYMAN PLUMBER i ISSUES THE ABOV E LICENSE TO. THOMAS 14 HALLORAN 826 DALE ST .NORTH ANDOVER MA 01845-1422 24833 05/01/14 142701 e r r Fot•a, Then Detach Along All Ped Orations 'e. Date.. ...... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that .................................... has permission for gas installation �. A4/ex- in the buildings of . ........................... at ... /.7/--.../`.7v ....... North dover, Mass. -Ag Feeg.' P .. Lic. No s.3 i;4T. GAS INSPECTOR Check # I/P 8232 gL\ MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) K)OZH AtJjD 111,c Mass. Date. 07/�2AD12, Permit # O AI�� Building LocationIII — 17.3 PLFASAWT ST. Owner's Name JDYU CE iew S W( -TH AN[�(LI; 2� Q Type of Occupancy Z Eft ki, 9 L.4 0 New ❑ Renovation ❑ Replacement ❑ Plans Submitted: Yes❑ No ❑ Installing Company Name COLUMBIA 6AS GI' MA5SACHLL5ETTS Check one: Certificate # Address 55 MARSTON STREET SCJ Corporation 1862 LAWRENCE, MA 01841-2312- ❑ Partnership Business Telephone 9 7 8- 691- 6406 ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter Francis X. Corkery INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes K No ❑ If you have checked, please Indicate the type coverage by checking the appropriate box. A liability Insurance policy D< 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: Signature of Owner or Owner's Agent . Owner❑ Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in aboup pplication are true and accur,4te to the best of my knowledge and that all plumbing work and installations performed under the permit iss f r this application will n compliance with all Pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene S. (/ rTil T e of License: lelumber Signature of Licensed Plumber or Gas Gasfitter Master License Number 374 5 City/Town Journeyman APPROVED OFFICE SE ONLY ONO W61=00 so] .. ■EMENEENEEMENEENE=mon■ ■'Ross no■ ME 0 K-411"- 0. MEMSERESSEEMIKEENS IEEE Installing Company Name COLUMBIA 6AS GI' MA5SACHLL5ETTS Check one: Certificate # Address 55 MARSTON STREET SCJ Corporation 1862 LAWRENCE, MA 01841-2312- ❑ Partnership Business Telephone 9 7 8- 691- 6406 ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter Francis X. Corkery INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes K No ❑ If you have checked, please Indicate the type coverage by checking the appropriate box. A liability Insurance policy D< 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: Signature of Owner or Owner's Agent . Owner❑ Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in aboup pplication are true and accur,4te to the best of my knowledge and that all plumbing work and installations performed under the permit iss f r this application will n compliance with all Pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene S. (/ rTil T e of License: lelumber Signature of Licensed Plumber or Gas Gasfitter Master License Number 374 5 City/Town Journeyman APPROVED OFFICE SE ONLY T_ z D r z m -0.1 o z IN m s m co V O C) m m N N N 0 -4 O - 2 r '^ r O D m v rn m D w z O t -- n tv O V D s m m m L7 m O -+ r O TI r w n � n c � o z o r a V O C) m m N N N 0 -4 O - 2 4.1 e-. Date ..... . . ....... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .............. G..,6 ............................. has permission to perform ....... ).N§ .. e!qI.0--e .. ........................ wiring in the building ofo........ ................................................. at ...... North Andover, Mass. . ......... . Fee,IS0.--�... Lic. No. ......... ................ ELECTRICAL I-NIS:P:-E- R:r Check# 1 Z-5-4 3992 t Commonwealth of Massachusetts Official Use Only l l Department of Fire Services Permit No. X, ! �lz- BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 1/07] (leave blank A APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINTININK OR TYPE ALL WFORMATIOI9 Date: 9111-2-oo g City or Town of- NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) 171—.1-7,3P�t�S.a.✓f S Owner or Tenant �'Q �l A_ G i9 / ' s Telephone No. 9 7,f r'oPA!(oi 2 Owner's Address 7,3 Pl e'?5 4..l� S� Is this permit in conjunction with a building permit? Yes )/ No ❑ (Check Appropriate Box) Purpose of Building Existing Service Zoo Amps G,2.a /,2%0 Volts New Service Amps / Volts Number of Feeders and.Ampacity Location and Nature of Proposed Electrical Work: t �a fh lrre) in — Utility Authorization No. Overhead R7 Undgrd ❑ Overhead ❑ Undgrd ❑ Flit — No. of Meters No, of Meters c ei n« , uuuwunai aetau q aestrea, or as required by the Inspector of Wires. Estimated Value of Electrical Work: y 1, O d (When required by municipal policy.) Work to Start:,,/ Aj�o cI Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ®' BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: �a,,-� �, r.. ,G ill fir, LIC. NO.: !83 G Licensee: %Ata•'fZ A"-." .e— Signature � LIC. NO.: 3 F, (If applicable, enter "exempt " in the license number line.) Address: _o?/ 1 A g S; p�t,0, Av L . Sct/e r» At/11 O 30 7 T Bus. Tel. No.: 6 !_?2 f 06 Alt. Tel. No.: 4/ 4 3 c>' l,�h V-ld *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ x .1 Date ... /! ......... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ......................................... ........................................... has permission to perform .......... ... . .......... .................................... wiring in the building of ..................................................... at... .. ..... ........... ��I ............................... North Andover, S. ""Jan .................. Lic. ............ ... . . ....... 6X�IC�AL NSPE Check # A77-0- 93-29 Commonwealth of Massachusetts Official Use Only Department of Fire Services Penn" No. - 1W Occupancy and Fee Checked k BOARD OF FIRE PREVENTION REGULATIONS EXev.11073 (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: City or Town of: NORTH ANDOVER TO the Inspector of Wires: By this application the undersigned gives notice of his or her intention toperformthe electrical work described below. Location (Street & Number) Owner or Tenant Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes No D (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps - Volts Overhead❑Undgrd ❑ New Service Amps Volts Overhead Undgrd .1 Date'.... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .............. 4 f .................... has permission to perform ....... J .. ................. wiring in the building of ......... at...... ..........:?.T......... . North Andover, Mos. Fee'z�...O.��—... Lic. No..ff.3�/ ELECTRICAL NspE R Check # MAE No. of Meters No. of Meters ving table may be waived by rhe TtLvn,,rtnr nr W;— 4, if desired, or as required by the Inspector of Wires, imcipal policy.) Work to Start . , �, /_, Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE F-3 BOND D OTHER E] (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: Licensee: LIC. NO.: Signature LIC. NO.: (If applicable, enter "exempt in the license number line.) Address: Bus. TeL No.: . No. *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Alt. LicTel. No.: OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement I am the (check one) [] owner 0 owner's agent. Owner/Agent ❑ Signature -- Telephone No. PERMIT FEE. $ go.3 - 9,1�e No. of Total Transformers KVA Generators KVA -No. of Emergency Lighting Battery Units FIRE ALARMS INo. of Zones IN 0. .01 Detection and Initiating, Devices No. of Alerting Devices No. of Self ontained Detection/Alerting Devices 0 L cal E] Municipal E] Other Connection Security Systems: tems:No. of Devices or Equivalent No. Data Wiring: No. of Devices or Equivalent 'I eiecommunicatio—ns-g: No. of Devices or Equivalent 4, if desired, or as required by the Inspector of Wires, imcipal policy.) Work to Start . , �, /_, Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE F-3 BOND D OTHER E] (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: Licensee: LIC. NO.: Signature LIC. NO.: (If applicable, enter "exempt in the license number line.) Address: Bus. TeL No.: . No. *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Alt. LicTel. No.: OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement I am the (check one) [] owner 0 owner's agent. Owner/Agent ❑ Signature -- Telephone No. PERMIT FEE. $ go.3 - 9,1�e Date.........-. ::�R� ....... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ........... T)14"(l has permission to pecrform-5f/.M.6A./­`­- wiring in the building of ....... zift .......... a�. V y .. ........................... at ... /31*.7- ... 172 ... ... ...... ............. North Andover, Man. . ........ . Fee lk . . .... Lic. No..B? 3 6 / .............. ELECTRICAL INSPECMR Check # M r Commonwealth of Massachusetts Official Use Only Department of Fire Services PernutNo.2— BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 1/07] (leUVave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT W INK OR TYPE ALL INFORMATION) Date: City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) 7/ . / 73 Owner or Tenant 70 Telephone No. r P Owner's Address / 7/ — Is this permit in conjunction with a building permit? Yes Purpose of Building srde,.ree— Existing Service Amps /go / Z yo Volts New Service 200 Amps /22o /aya Volts Number of Feeders and Ampacity No ❑ (Check Appropriate Box) Utility Authorization No. 0,5— y p 9 Overhead Undgrd ❑ No. of Meters_ Overhead® Undgrd ❑ No. of Meters Location and Nature of Proposed Electrical Work: Se 4 , �f c Estimated Value of Electrical Work: 3 700 . d O vuescrea, or as required by the Inspector of Wires. (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under the pains andpenalties ofperjury, that the information on this application is true and complete. FIRM NAME:Lle ;0,36 LIC. NO.: Licensee: } f 1, �Co C��4 Signature /tlJ�. -- - LIC. NO.:._�6K.3,&10 (If applicable, enter "exempt " in the licensee number line.) Address: a s S �.� / ,rc S� ,,� 1 ►-s! p 7 4 Bus. Tel. No.: 40.3 56 7 4.2 (o V3 Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent Owner/Agent Signature Telephone No. PERMIT�FEE-- $ i ti r The Commonwealth of Massachusetts kj 1 Department of Industrial Accidents w� Office of Investigations 600 Washington Street liY BostonMA 02111 j www.nzass.gov1dia . Workers' Compensation Insurance Affidavit. Builders/Contractors/Eiectricians/Plumbers Name Business/Or *- 1 ( ganirafion/Individttat): Address:_ City/State/�ig 1 Phone #:. 6a 3 q7,9 0 (c Are you an employer? Check.the appropriate box: I . ❑ I am a employer with 4. ❑ I am a general contractor and I Type of project (required): employees (full and/or part-time).* 2. �'% have hired the sub -contractors 6. ❑ New construction 1 am a.sole proprietor or partner_ ° listed on the attached sheet. 1 7. ❑ Remodeling shipand hemployees have no em P Y These sub -contractors have 8. ❑ Demolition working for me .in any capacity, [No workers' comp, insurance workers' comp. insurance. 5. ❑ We are a corporation and its g, ❑ Building addition required-] 3. ❑ I am a homeowner doing officers have exercised their 10•0 Electrical repairs or additions all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No -workers' comp, c. 1.52, § 1(4), and we have no 12. Roof ❑ repairs insurance required.] t �l ][No employees. workers' 13.0.0ther comp. insurance required_] rr••-�^• ��.• -11 1�x M l muse luso nu out the section below showing their workers' compensation policy information. t 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 ant an employer that isproviding: workers' compensation insurance for my employees: information Below is the policy and job site Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: 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 up to $250.00 a day against the vioiator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cedify under the pains and penalties of perjury that the information provided above is true and correct I', Phone #: D 3 '/? % ;? 4D� 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 2.001 Contact Person: Phone #: 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-contractor(s) name(s), addresses) 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, notthe 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 munberlisted 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 NviIl 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 lnvestiptions 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, IIIA 02111 Tel. # 617-727-4900 ext 406 or 1-8.77-MASSAF'E Revised 5-26-05 Fax # 617-727-7749 vvww.mass.gov/dia Jul 16 09 01:27P Dave Gleason G03 772-6044 P.1 Gleason Architects P.O. Box 596, 152 Portsmouth Avenue Stratham, New Hampshire 03885 603 772-7370 Fax: 603 772-6044 Email: =leasonarchiiectstcomcast.net Web site: gleasonarchitectsnh.com July 16, 2009 Town of North Andover Brian Leathe, Building Inspector 1600 Osgood Street North Andover, Ma. 01845 RE: 171 —173 Pleasant Street Dear Mr. Leathe; On July 15`h I made a site visit to review the third floor to look at the area for the R-30 insulation. The code allows an area of a minimum of 3 feet above the insulation to the vent. The rafters will be fully insulated and have a 6 mil poly vapor barrier with will have control the moisture, if any, in the rafter. Since there is no soffit vent provided and since the rafter is fully insulated, this assembly should act like a wall. Any heat or moisture generated in this assembly will act in a vertical direction and move to the area over the collar ties to be vented out the ridge vent. The original construction was similar in that, there was no soffit vent and was fully insulated.; I believe this assembly using a full batt insulation and having a vapor barrier meets the intend of the code. Sincerely, AGleaso. No. 7243 EXETER DaveH #I, Gleason Architects P.O. Box 596,152 Portsmouth Avenue Stratham, New Hampshire 03885 603 772-7370 Fax: 603 772-6044 Email: gleasonarchitects@comcast.net Web site: gleasonarchitectsnh.com July 16, 2009 Town of North Andover Brian Leathe, Building Inspector 1600 Osgood Street North Andover, Ma. 01845 RE: 171-173 Pleasant Street Dear Mr. Leathe; I am writing regarding the work at 171-173 Pleasant Street. On July 15`h I made a site visit to review the framing on the third floor as described in the plans I submitted to you for a building permit. The work was done in accordance with the plans and appeared to meet the standards of good workmanship. Gleason Architects P.O. Box 596, 152 Portsmouth Avenue Stratham, New Hampshire 03885 603 772-7370 Fax: 603 772-6044 Email: P-leasonarchitects@comcast.net Web site: gleasonarchitectsnh.com July 16, 2009 Town of North Andover Brian Leathe, Building Inspector 1600 Osgood Street North Andover, Ma. 01845 RE: 171 —173 Pleasant Street Dear Mr. Leathe; On July 15"' I made a site visit to review the third floor to look at the area for the R-30 insulation. The code allows an area of a minimum of 3 feet above the insulation to the vent. The rafters will be fully insulated and have a 6 mil poly vapor barrier with will have control the moisture, if any, in the rafter. Since there is no soffit vent provided and since the rafter is fully insulated, this assembly should act like a wall. Any heat or moisture generated in this assembly will act in a vertical direction and move to the area over the collar ties to be vented out the ridge vent. The original construction was similar in that, there was no soffit vent and was fully insulated. I believe this assembly using a full batt insulation and having a vapor barrier meets the intend of the code. Sincerely, Date. .7.7 . ..? ? TOWN OF NORTH PERMIT FOR PL= This certifies that —7 ...........rte ...................... . has permission to perform ................... ,ings .................... plumbing in the build' of at ............. North Andover, Mass. -7 ..... Fee Lic. No .......... *i�; /I �,x ............ PLUYBI*N'O INSPECTOR Check At /,�W n .t MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSAC TTS d ^ //r Date Building Location 71' / r4�y / 6Owners Name Permit it Amount Type of Occupancy New Renovation Replacement Plans Submitted Yes No El FliYARES i -----..------------------ i (Print or type) � / /, % � Check one: Certificate ` InstallingCompanyNa �l ❑ Corp. Address 10& Partner. �( t Business Telephone — 21 Firm/Co. Name of Licensed Plumber: LC h Z Insurance Coverage: Indicate ^the ty of insurance coverage by checking the appropriate box: Liability insurance policy ' /X 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 Signature Owner ❑ Agent I hereby certify that all of the details and information I have submitted or entere bove application are true and accurate to the best of my knowledge and that all plumbing work a insta ions p �7eger ' 't Is r this application will be in compliance with all pertinent provisions of the Ma a s Sta of the General Laws. By: ig Lure o icen r Type of Plumbing License Title ' City/Town en un er Master �;-<— (OFFICE USE ONLY y U The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investi; ations 600 Mzshington Street Boston, M4 02111 www_mass.gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Eiectricians/Plambers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zig: Phone #: . Are you an employer? Check the appropriate box: 1. ❑ 1 am a employer with 4. ❑ I am a general contractor and I employees (fulland/or part-time).* 2. ❑ I am.a.sole proprietor or have bred the sub -contractors listed partner- on the attached sheet t ship and have no employees These sub -contractors have working for me in any capacity, [No workers' comp, insurance workers' comp. insurance. 5. ❑ We are a corporation and its required.) 3. ❑ 1 am a homeowner doing officershave exercised their all work right of exemption per MGL myself. [No•workers' comp, C. 152, § 1(4), and we have no insurance required.] t .employees. [No workers' COMP. insurance required_] Type of pre1ed (required): 6. ❑ New construction t ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions I l.❑ Plumbing repairs a additions 12.❑ Roof repairs I3.❑ Other tractors must submit a new affidavit indicating such H — I'll uuc me sc=DR *Mw showing their workers' compensation policy information omeownwho submit this affidavit indicating they are doing all work and then hire outside con =Contractors ers that check this box must atraabed an additional sheet showis Size name of the sub -contactors and their workers' comp. it famration. information. ant an employer that is providing: workers' compelldon insurance for M employees: Below is the policy and job site Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaratiou 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 up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DlA for insurance coverage verification. I do hereby certify under thepains andpenalties ofperjury that the information provided above is true and correct Ssrtature: Date: Phone #: ficial use only. Do not write in this area, to be wntplete_d by city or town ofciaL City or Town:Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Cierk 4. Electrical Inspector 5. Plumbing Inspector 6.Otber Contact Person: Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all emp I oyers 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 includir ag 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 apaa-tments 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 seat "every state or- local ficensing 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 require n=ts of this chapter have been preserrted 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). acid phone number(s) along with their certificates) 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 fo;.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 numberlisted below. Self-insured d cf mpanif+c c'_nniiin PntpT th W' self insurance-Iicense number on the*appropriate dine. 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 permittlicense number which vwill 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 inflormation (if necessary) and under "Job Site Address" the applicant should writs "all locations in {city or town)." A copy of tare 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 as 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 # 617-727-4900 Ext 406 or 1-8.77-MASSAFE Fax # 617-727-770 Revised 5-26-05 www.mass.gov/dia d