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HomeMy WebLinkAboutMiscellaneous - 172 CHESTNUT STREET 4/30/2018 (5)Date .v§.V-1.1.1.5 .......... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING "tiis certifies that J PwV-0 S -7 ILQ- . . ....................... .......... I. ..... . ... �L..............'w� has permission to perform .... k 6 ... . ...... ... ', plumbing in the buildings of ................... IL at.... ... I L ... . ............... 1-/ . .............................. North Andover, Mass. Fee'�-.>qn Lic. No. .1 P`kA ........................ ........................................................ PLUMBING INSPECTOR Check # )Y2- L\— " MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK Ulf,CITY I NORTH ANDOVER MA DATE 10-7-15 JPERMIT# JOBSITE ADDRESS 1172 CHESNUT ST UNIT 12 OWNER'S NAMEJ JEFF MACGILL POWNER ADDRESS 1209 NORTH END BLVD SALISBURY MA TELI 617-719-6008 FAX TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL0 PRINT CLEARLY NEW: 0 RENOVATION: 0 REPLACEMENT: 0 PLANS SUBMITTED: YES Q N00 FIXTURES Z 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 GAS/OIL/SAND 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 r 1 WATER PIPING EITHER — - 7 =F71 INSURANCE COVERAGE: I have a current liabili insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES 0 NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Q OTHER TYPE OF INDEMNITY 0 BOND 0 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 El 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 Pert"Hent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �` PLUMBER'S NAME I JAMES BURKE LICENSE # 10469 SIGNATURE MQ JPQ CORPORATION O# 2727C PARTNERSHIP©# LLC©#E� COMPANY NAME I BURKE & SONS PLG & HTG INC ADDRESS I PO BOX 102 nen CITY GROVELANDSTATE MA ZIP 01834 TEL 978-374-7837 FAX 978-373-6615 CELL 978-360-4453 EMAIL 'im@burkeandsonsplumbin .com Date....... �. TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION Thiscertifies that .................................................................................................. has permission for a installation . �' �'. �n `..� in the buildin s of ............. G ..°�'. �'....... at ..... h.Z.. -.:v`.....S..^ `'#"..... . ^..`........ ` -....... North Andover, Mass. Fee.............. Lic. No.................................................................. G GAS INSPECTOR Check # �",� in MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY I NORTH ANDOVER I MA DATE 10-7-15 PERMIT # JOBSITE ADDRESS 1172 CHESNUT ST UNIT 12 OWNER'S NAME JEFF MACGILL GOWNER ADDRESS 1209 NORTH END BLVD SALISBURY MA TE 617-719-008 IFAXI TYPE OR � OCCUPANCY TYPE COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIALF1 PRINT CLEARLY NEW:O RENOVATION: [I REPLACEMENT: ❑ PLANS SUBMITTED: YES❑ NOQ APPLIANCES -1 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 El FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST 1 UNIT HEATER UNVENTED ROOM HEATER WATER HEATER i 1 OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES Q NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY F71 OTHER TYPE 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 com ' nce with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME I JAMES BURKE I LICENSE # 10469 SIGNATURE MP 0 MGF ❑ JP ❑ JGF ® LPGI ❑ CORPORATION n# 2727C PARTNERSHIP ®#0 LLC ®# COMPANY NAME: BURKE & SONS PLG & HTG INC ADDRESS I PO BOX 102 CITY GROVELAND STATE MA ZIP 01834 TEL 978-374-7837 FAX 978-373-6615 CELL 978-360-4453 JEMAILFjim@burkeandsonsplumbing.com ��t The Commonwealth of Massachusetts Department oflndustrialAccidents d 1 Congress Street, Suite 100 t Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Name (Business/Organization/Individual): Address: V City/State/Zip:, Phone #: / Are you an employer? Check the appropriate box: Type of project (required): 1. Wam a employer with 1 --employees (full and/or part-time). * %. F1 New construction 2. ❑ I am a sole proprietor or partnership and have no employees working for me in 8. ❑ Remodeling any capacity. [No workers' comp. insurance required.] 9. ❑ Demolition 3..❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 10 ❑ Building addition 4.❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole 11. ❑ Electrical repairs or additions proprietors with no employees. 12. [Rflumbing repairs or additions 5. I am a general contractor and I have hired the sub -contractors listed on the attached sheet. ❑ � - 13. Roof repairs These sub -contractors have employees and have workers' comp. insurance.$ 6. Q We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Q Other oyees. [No workers' comp. insurance required.] 152, §1(4), and we have no 141 `Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. f Homeowners who submif '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 state whether or not those entities have employees. If the sub -coni actors have employees,' they must provide their workers' comp. policy number. I am an employer Mat is providing workers' compensation insurance for my employees.' Below is the policy and job site information. Insurance Company Name: ffl" Policy # or Self -ins. Lie. #: b P Expiration Date: / Job Site Address: Ch `^ Z City/State/Zip: Aqjp\L-A MA Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify uWer the pains and penalties ofperjury that the information provided above is true and correct. 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 #• 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 cityor 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 Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia FgRYti "i E✓ 6 ' yDD xa �Ofi r r :L .r x d�NORTH AM OWR BMDING DEPARTMENT 1600 Osgood Street SAC}¢tis . North Andover Tel: 978-688-9E545 Fax: 978-5889542 BUSWESSFO" .,FOR TOWN'CLERK DATE: Laol- NAM ADDRESS: -12w ,o GMSTRIC : - .[ .L M OF )BU l3J-L ES BUM1d.L1.y G LAYOUT PROVIDED; I-u.1.'r.1. ; 1 ES r NO ..634. Y .i3.J_IJA-E- LE .! A Rl-7c-l.e. `l G 811AM Y: ZONMGBYLAWUSAGE: YES NO 1-7 BUSINESS FORMFORTOWN CLERK t 2AD Rome OccupAon (1989132) An accessov use conducted within a dwelling by a resident who resides in the dwelling as his principal address, which is clearly Recoadaq To the use. of the -building for living pluposes, Home occupations shall 'iiicIude,'bu`t iiot'limited to the following uses; personal services such as fine fished by an artist or instructor, but not occupation involved with motor vehicle repairs, beauty parlors, animal kennels, or the conduct of retail business, or the manufac%uia g agoods, which impacts flit residential. nature of tho neighborhood; 4. For use of a dwelling in any residential district or multi-f4mily district for a home occupation, the following conditions shall apply: a. Not more than a total of three (3) people may be eniployg4 in the: home occupation, one of whom shall be fiieowaor of the home occupation, anal residing in said divelling, b. The use is carried on stdott3r Within the principal building; c. `There shall be no exterior alterations, accessory buildings, or display which are not customary with residential buildings; . d. Nof more than twenty-five (25) percent of the existing gross floor area of Jhe di veliing unit . so used, not to exceed one thousand (1000) square feet, is devoted. to'such use. In connection.wiih such use, there, is to be kept no stock in -trade, commodities or products which occup�r space beyond these jimits; e. There will be no display ofgoods or wares visible from the, street; f The building or premises occupied shall not be rendered objectiomble or detrimental to the residential character of the neighborhood due to the exrtenor appearance, emission of odor, gas, smoke, dust, noise, distu aace, or in any other way become objectionable or detrimental to any residential use within. the neighborhood; g. Any such building shalt include no features of design not customary in bindings for resident I -ISO. 5 /A Date. 01HORTM TOWN OF,NO/TH ANDOVER % PERMIT FOR PLUMBING This certifies that ......... ............... has permission to perform .... .................... plumbing in the buildings of ...................... ........... North Andover, Mass. r. r Fee.'. Lic. No.. r ........ ....... PLUMBING INSPECTOR Check # f- L U 0- Check�i3),/ MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Location �-� t? ,V j / .e ,� Date � i 13lI) Permit #1 Amount - erU F/ S f l t: v .v 1 i New 0. Renovation M Replacement FiXTi DTc Plans Submitted Yes rl No G�'rint or type) Check one: Certificate Installing Company Name R A) /r ' S P1 S ❑ Corp. Address-2UILLL nRn 1 j% N Partner. Business Telephone S' [9 �Cj � 1 _ ) C1 Firm/Co. Name of Licensed Phimber: H c ti a y P Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy 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 Owmer Agent F1 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 previsions of the Wmssachusetts 4jte plumbing Code and Chapter 142 of the General Laws. By: _ Title City/Town APPROVED (OFFICE USE ONLY Type of Plumbing License 1 % (a yx) cense Numoer Master ❑ Journeyman j]!{ v r The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Uf 600 Kashington Street Boston, MA 02111 www mas&gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers rnnlirant Tnfnrmn44-- 1 1C Name (Business/Organization/Individual): Address: City/State/Zip: Phone #: Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ 1 am a general contractor and I employees (full and/or part-time).* 2A� I am a sole proprietor or have hired the sub -contractors listed on the partner- attached sheet I ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. [1 We are a corporation and its required.] 3. ❑ I am a homeowner doing all work officers have exercised their 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 project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions 11.13 Plumbing repairs or additions 12.0 Roof repairs 13. ❑ Other t u -W V u< ice secaon oe:an.u• Sno•, g their workere con p--sadon policy information. o'n o�;mom 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 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 Si afore: Date.: Phone #: 11 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 #: 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), 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 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 Commonwealth of Massachusetts Department of industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-72.7-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 5-26-05 urww.rnass..govfdia NORTp 3a .�V.oc � 9 ,SSA USf Date. 5 r i TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ... . e'f .'r . �...... i ..� .; .................. has permission to perform ..... C.. . L ........ . �............ . r plumbing in the buildings of ..................... at .. .t ............... North Andover, Mass. Fee ..Lic. No.. /......... PLUMBING INSPIf&OR Check # 13 ,? l ehec k. 013Z/ MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS FITTING (Type or print) NORTH ANDOVER, MASSACHUSETTS Date -S--/-7-/o Building Locations ' l C 1 S -rt/ J1 .S % v4.j 1 I 6 Permit # /� °e /9 /) Amount $ p Owner's Name NewrM Renovation ❑ Replacement ❑ Plans Submitted ❑ (Print or type) Check one: Certificate Installin Com an i�-1 N ,� I S P )- -S ❑ Co g P Y Name rp Address 3 Lt1 ) 1 /1/? 13 1-1 Partner. Business Telephone SOyj—Y,� ® Firm/Co. Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes 10 No ❑ If you have checked yes, please indicate the type coverage by checking the appropriate box. Liability insurance policy14 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 U Agent ...,.,,may „y way att v,�, ucLaii, auu "JIU1111auvn i nave suorrnrcea kor 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 Massachusetts State Gad Code and Chapter 142 of the General Laws. City/Town (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter ❑ Plumber I' T i� (� ❑ Gas Fitter icense Number ❑ Master Journeyman w c x w N- a 4 o W Q � a z o z a o O F z i~ �d H z x a w w u x x Q W F �" W U e0q Z O z O i O w � 3 U a U C > A o0. O SUB -BA SEM ENT BASEMENT 1ST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH. FLOOR 5TH. FLOOR 6TH. FLOOR 7 T H. F L O O R 8TH. •FLOOR (Print or type) Check one: Certificate Installin Com an i�-1 N ,� I S P )- -S ❑ Co g P Y Name rp Address 3 Lt1 ) 1 /1/? 13 1-1 Partner. Business Telephone SOyj—Y,� ® Firm/Co. Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes 10 No ❑ If you have checked yes, please indicate the type coverage by checking the appropriate box. Liability insurance policy14 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 U Agent ...,.,,may „y way att v,�, ucLaii, auu "JIU1111auvn i nave suorrnrcea kor 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 Massachusetts State Gad Code and Chapter 142 of the General Laws. City/Town (OFFICE USE ONLY) Signature of Licensed Plumber Or Gas Fitter ❑ Plumber I' T i� (� ❑ Gas Fitter icense Number ❑ Master Journeyman The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, AVIA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: Phone #: Are you an employer? Check the appropriate box.- oa:❑ 0I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* !. I am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet I ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. fim rance 5• [1 We are a corporation and its required.] ❑ I am a homeowner doing all work officers have exercised their 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 project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ❑ Electrical repairs or additions I I.❑ Plumbing repairs or additions 12.0 Roof repairs 13. ❑ Other t - — - r- •••••.••:.o cjw. -a 1uw: e.JC1 11U out Me seCCIM DeMM showing Thur %vorke5' comBo' m �sation polif0.^.IIat'+Qn. 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 isproviding workers' compensation insurance for my employees. Below, is thepolicy 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 Signature: Date.: Phone #: Official use only. Do not write in this area, to be completed by city or town offciaL 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 #: 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 bereturned to the city or town that the application for the p--r=*t or license is being requ-sled, 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 Commonwealth of Massachusetts Department of Industrial Accidents Office of kvestibai ens 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised. 5-26-05 Fax # 617-72.7-7749 vv w-mass-gov/dia