HomeMy WebLinkAboutMiscellaneous - 175 CORTLAND DRIVE 4/30/2018January 6, 2018
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FORM OF NOTICE OF CASUALTY LOSS TO BUILDING
UNDER MASS. GEN. LAWS, CH. 139, SEC. 3B
Building Commissioner, or Inspector of Buildings
c/o City or Town Hall
1600 Osgood Street
North Andover, MA 01845
Board of Health or Board of Selectmen
c/o City or Town Hall
1600 Osgood Street
North Andover, MA 01845
Fire Department or Arson Squad
c/o City or Town Hall
1600 Osgood Street
North Andover, MA 01845
RE: Our File No.: P1833955
Insured: ETTA SHAPIRO
STANLEY SHAPIRO
Address: 175 CORTLAND DRIVE, NORTH ANDOVER, MA
Policy No.: H1590308A
Loss Date: 01/03/2018
Loss Type: Building or Other Structure Damage
A claim has been made involving loss, damage or destruction of the above captioned property,
which may either exceed $1,000.00 or cause Mass. Gen. Laws, Ch. 143, Sec. 6 to be
applicable. If any notice under Mass. Gen. Laws, Ch. 139, Sec. 3B is appropriate, please direct
it to my attention and include a reference to the captioned insured, location, policy number, loss
date and claim or file number.
If no reply is received from your office within ten days, we will assume you have no liens of any
type against this property, and the claim will be paid in our customary manner.
Sincerely,
Dawn L. Parmeggiani
Property Claims Examiner
1-800-688-1825 x1119
NORFOLK & DEDHAM MUTUAL FIRE INSURANCE CO. 222 Ames Street, P.O. Box 9109, Dedham, MA 02027-9109
DORCHESTER MUTUAL INSURANCE CO. Telephone: (800) 688-1825
FITCHBURG MUTUAL INSURANCE CO. ® Fax: (781) 329-1818
� No'►rN
CERTIFICATE OF USE & OCCUPANCY
TOWN OF NORTH ANDOVER
Building Permit Number 1709/1/20091 Date: February 26, 2010
THIS CERTIFIES THAT
THE BUILDING LOCATED ON 175 Cortland Drive
MAY BE OCCUPIED AS Single Family Dwelling IN
ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING
CODE AND SUCH OTHER REGULATIONS AS MAY APPLY.
Certificate Issued to: Meetinghouse Commons LLC
115 Carterfield Rd
North Andover MA 01845
Building Inspector
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APPLICATION FOR CERTIFICATE OF OCCUPANCY/INSPECTION
Building Permit # f 70
ADDRESS/LOCATION OF PROPERTY: i35
Map /0K Parcel Lot Number S,
SUBDIVISION
DATE REQUESTED FILED/READY FOR INSPECTION
CLOSING DATE ON PROPERTY: BIZ G ( 10
ALL WORK AND SIGN -OFFS MUST BE COMPLETED WITHIN THIS TIME FRAME. A RE-
INSPECTION FEE OF TWENTY DOLLARS $20.00) WILL BE CHARGED IF THE STRUCTURE
r DOES NOT MEET ALL APPLICABLE CODES.
Permit Issuedto: ULC
Address SG,4,er Y- 2 m/f
SIGNED
ROUTIN
F*7a// 7//�
CONSERVATION v
PLANNING Nik•040t D
DPW - WATER METER
SEWER/WATER CONNECTION
NOTE
DPW MUST INDICATE THAT THE WATER METER HAS BEEN INSTALLED PRIOR TO
SUBMITTAL OF THE OCCUPANCY/INSPECTION REQUEST
DPW
Signature
File: Application for OC form revised Jan 2007
Date ... ......0 .P..............
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
4 4L
This certifies that It .... ........ 6&CZ4�
. J ..... In ............ I .......................................
has permission to perform ...... 2 �� ....................................................
wiring in the buil of ............................
• at2�. . ..... ..... North Andover, Mass.
Fee..-jYZ .......... Lic.
ELECTRICAL INSPECTOR (Of
Check # �&?
8997
Il
Commonwealth of Massachusetts
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
Permit No.
Occupancy and Fee Checked
.ev. 1/071 Qeave blank)
APPLICATION FOR PERMIT TO PERFORM ELECT 1
All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMTELECTRICAL pp WORK
(PLEASE PRINT WINK OR TYPE ALL INFORMATION) Date:
City or Town of: NORTH ANDOVER a
By this application the undersigned gives notice of his or h To .the Inspector of Wires
tentiou t erform the electrical work described below.
Location (Street &Number) _ -
Owner or Tenant / `
Owner's Address ,_J _ I _ _ Telephone No.
Is this permit in conjunction with a building permit. ?
Purpose of Building Yes ❑ NO ❑ (Check Appropriate Boa)
Utility Authorization Nn. / 1
Existing Service Amps °7 ✓l'
/ _Volts
Overhead33
❑ Undgrd ❑ No. of Meters
New Servicep�
APs / Volts
Overhead ❑ Undgrd No. of Meters
Number of Feeders and. Ampacity V
ZO
%
Location and Nature of Proposed Electrical Work:
W
No. of Recessed Luminaires
c om ietion o the ollowin table n!9 he waived b the Inspector of Wires.
No. of Ceil.-Sus No. of
p. (Paddle} Fans
No. of Luminaire Outlets
No. of Hot Tubs
Transformers Total .
V17
No, of Luminaires
Swimming Pool Above ❑ In-
Generators KVA
o, o
No. of Receptacle Outlets
d' rnd•
tg g
❑ Batte Units
ynits
No. of Oil Burners
No. of Switches
FIRE ALARMS No. of Zones
No. of Gas Burners
No..of Detection and
No. of Ranges
No. of Air Cond, Total
Wtiatin Devices
No. of Waste Disposers
Tons
Heat Pump Number ons KW
No. of Alerting Devices
No. of Dishwashers
Totals: ` __.__. __ _ .... No, of Self -Contained
-� Detection/AlertingDevices
Space/Area Heating KW
Local ❑ Municipal
❑ Other
No. of Dryers
HeatingA PPvances KW
Connection
Security Systems:*
o. of Water
Heaters'
No, of No. of
No. of Devices or E nivalent
Si s Ballasts
Data Wiring:
No. Hydromassage Bathtubs
.
No. of Motors Total HP
No. of Devices or E uivalent
Telecommunications Wiring;
OTHER:
No. of Devices or Ennivaipnt
Estimated Value of Electrical Work:Attach additional detail if desired, or as required by the Inspector of Wires.
( ,�
Work to Start (When required by municipal policy.)
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 cov rage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE I$OND ❑ OTHER
I certify, under the outs and enarlt:es o ❑ (Specify.)
P f perjury, that the information on this ap lication is true and complete.
FIRM NAME: '
etl ,� � I
Licensee: LIC. NO.: ,2,
I a licable, enter, exempt " in the license number line.) Signature
(f pp — LIC. NO.:
Address: i Bus. TeL No.:Z1MF_'T_
��'
*Per M.G.L c. 147, s. 57-61, security work re aures D 1 Alt. Tel. No.:
All
OWNER'S INSURANCE W q eP�nent of public Safety "S" License. Lic. No.
AIVER: I am aware that the Licensee does not have the liability insurance coverage normally
required g 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: $�yz.
J
The Common wealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 JMzyhington Street
Boston, MA 02111
www mums govId, a .
Workers' Compensation Insiumnce Affidavit: Builders/Contractors/Electricians/plumbers
alicant Information .
Naini (BusinesslOrgwization/Individual):
Address: NOW
�
Are you an employer? Cheek.the appropriate box:
1. c5el-
am a employer with — _12::�
4. ❑ 1 am a general contractor and I
employees (full and/or part-time).*
2. n I am.a:sole proprietor or
have bred the sub -contractors
listed
partner-
ship and have no employees
on the attached sheet t
These sub -contractors have
working for me in any capacity.
[No workers' comp. insurance
workers' comp. insurance.
S. ❑ We are a corporation and its
3. ❑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 re "iced.
0
Type of Project (required):
6. [] New construction
7. ❑ Remodeling
8. Q Demolition
9. [] Building addition
10. Q .Electrical repairs or additions
11.[] Plumbing repairs or additions
12.❑ Roof repairs
q i 13•[].Other
`Any applicant that checks bob# l must also fill out the ""tion below showing their workers' compensation policy mfonnahon.
t homeowners who submit this affidavit indicating they ars doing all work and then hire outside con
;Carttractors that check this box mustattaehed an additional sheet showitrg the amne of fhcsub-cono�� submit a new affidavit indicating such.
tractors and their Work=' camp. policy in&Mis con.
1 am an employer that is pr1?Vi&Mg:workers' compensation t'nsuranee or e
information. f my n Paye: Below is the policy and job site
; 1 i - I i
Insurance Company
Policy # or Self -ins. Lic.
.lob Site
Expiration Date:__22-�_J // 0 _ -
, City/State/zip
py /fes �fdt/Cl "V
Attach a coof the workers' compensation policy declamation page (showing the policy ber and expiration date
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the irttponuDumm erOf criminal penalties of a
fine up to $1.5D0,OD 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 t e ns and penalties of perjury that the information provided above is true and correct
���i` e
Official use only. Do not write in
area, to he completed by city or town official
7,/a
City or Town:
Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Cierk 4. Electrical Inspector 5. Pihr,nF,.....
6. Other
Contact Person:
Phone #:
Information a nd Instructions
Massachusetts General Laws chapter 152 requires all emp 3 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'foreping 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 shaU not because of such employment be deemed to be an employer."
MGL chapter 152, 525C(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 ito construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence.of compliance with the insurance ''coverage required."
Additionally, MOL chapter 152, §25C(7) states "Neither t3he commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of 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) acrd 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 require& 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, pleasccall the Department at the nurmber. listed below. Self-insured companies should enter their
self-insurancelieense 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 A -ill 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 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 investibations
600 Washington Street
Boston, IIIA 02111
Tel. # 617-727-4900 ext 406 or 1-8.77-MASSAFE
Fax # 617-727-7744
Revised 5-26-05 www.mass.gov/dia
Date.. /.�% ....
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that
has permission for gas installation ..1-�l? w.... Aq? /.:e .........
in the buildings of ..7%ate... .................
at ?.- .... Q�? �! T % �............ . North Andover, Mass.
Fee (.0 ..c,?. Lic. No../5./5.7 . ...... ..........
'GAS INSPECTOR
Check # //G
666
MASSACHUSEM UNW0RMAPP11C,A'P0NF0RPW TI'T0 Dp
(Tune or print) DOW
NORTH ANDOVER, MASSACHUSETTS
Building Logations
Owner's Name
Newg�'
Renovation
Replacement ❑
I
9U B -BASEM ENT
3ASEM ENT
ST. F L 0 0 R
ND. FLOOR
RD. FLOOR
TH. FLOOR
TH. FLOOR
TH. FLOOR
TH. FLOOR.
TH. FL0.0R.
(Print or type) I
Name__
A
Date 0
Permit # ..
Amount $
Plans Submitted
Name of.Licensed Plumber'or Gas Fitter
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Name of.Licensed Plumber'or Gas Fitter
LIE
Check one: Certificate Installing Company
O Corp. .
E] Partner.
E]Finwco.
INSURANCE COVERAGE
I have a current liability insurance' policy or it's substantial equivalent Check one,
If you have checked es please in ' e the type coverage by checkiin Yes
Liability insurance policy g the appropriate b Nor
Other type of indemnity ox
Owner's Insurance Waiver. I am a Bond 0
ware that the licensee does n� oto h� the Insurance cov
Mass. General Laws, and that my signature on this Permit application waives this requirement,
mage required by Chapter 142 of the
Signature of Owner or Owner's Agent Check one:
t herewner
by certify that all of the details and information 1 have submitted (or eoered) in 0 aAgect 13
best li nc knowledge and that all plumbing work and installations performed under Permit Issued for
compliance with all pertinent provisions of the Massachusetts State G p are true and accurate to the
Gas Co a an Ch this application will be in
�� the General Laws.
Title Sig&jure of Licensed Plumber Or Gas Fitter
1:3 Plumber
City/7own; r1,�/ —,
Fitter L,cenSe Number
Master
APPROVED (OFFICE USE ONLY) �
Journeyman
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Check one: Certificate Installing Company
O Corp. .
E] Partner.
E]Finwco.
INSURANCE COVERAGE
I have a current liability insurance' policy or it's substantial equivalent Check one,
If you have checked es please in ' e the type coverage by checkiin Yes
Liability insurance policy g the appropriate b Nor
Other type of indemnity ox
Owner's Insurance Waiver. I am a Bond 0
ware that the licensee does n� oto h� the Insurance cov
Mass. General Laws, and that my signature on this Permit application waives this requirement,
mage required by Chapter 142 of the
Signature of Owner or Owner's Agent Check one:
t herewner
by certify that all of the details and information 1 have submitted (or eoered) in 0 aAgect 13
best li nc knowledge and that all plumbing work and installations performed under Permit Issued for
compliance with all pertinent provisions of the Massachusetts State G p are true and accurate to the
Gas Co a an Ch this application will be in
�� the General Laws.
Title Sig&jure of Licensed Plumber Or Gas Fitter
1:3 Plumber
City/7own; r1,�/ —,
Fitter L,cenSe Number
Master
APPROVED (OFFICE USE ONLY) �
Journeyman
r 1 •
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Department of Industrial Accidents .
0
lf'tce Of Investigatim s
600 Washington Street
Boston, AM 02111
Workers$ Compensation Insurance wWrnasS.;oz)/d
A Iicant Information Affidavit: Builders/Contractors/Electricialls/piumbers
Name (Business/Or PlPrint Leaibit
gin izaii o nM di v i dual) ; e$se
Address:
City/State/Zig: _
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with 4 ❑ I
Phone #:
em io am a ceneml contractor and I
2. ❑li Y .s (full andlor art -tune).* have hired th
i am a sole proprietor or partner-
ship and have no employees
woric:ing for me in any capacity.
No workers' comp. insurance
required.]
3. ❑ I' am a homeowner doing a11 work
Myself [No. workers' comp.
insurance required.] t
e sub -contractors
Iisted CM the attached shut t
These Sub -contractors have
workers° comp. insurance..
❑ We are a corporation and its
officers have exercised. their
right of exemption per MGL
C. IS2, 1(4), and we have no
PloYees. (No workers'
C
TYpe of project (required-_
.6•. ❑ New construction
�. ❑
ken Odefing, .
8• ❑ DemoIition
9 ❑ Building addition
g1=tricai repairs or additions
I I.❑ Plumbing repairs or additions
12,[] Roof repairs
`Any appiint.that checks box # 1 .most also rill out the section below hoir2SLirance required ] 13.(] Other
+ iiomcownert who saLmit.khis &titdavit intiicatitt� wing th it work M' compensation ii .
1ConIIattots that chec}: this bos.mrict ikeey erg Guinn ai; cuo,k :tier Eng hi:~ o Po e3 rmormatioa.
attached an additional sheat showing uiside wnuutori rnusi au
the namo.of the ss:b c bmii a ncu affidavit indiaung a ch.
f ani an7_?
loyer that is rov a , „ ontractots and their worl' �nnatiuci�t�or aars �° cdtrab workers . orfper'S :rrsre
ranee for m3' entPLoyees Belo►r is the poficl'job site
Insurance Company Name:
Policy # or Self .ins. Lic. #:
Job 'Site Address:
Expiration Date:
Attach a copy of the workers' compensation policy declat�tion Q CIty/S�Zip:
.Failure to srcene cov,,,age as required under Section 25A of page (Showing the policy Dumber and expiration
fine up to X1,500.00 andlor one-year imprisonment as well MGL c. IS2 can lead tocrate}
Of up to .S2S0.00 a da rr ' the Position 'of criminal pemhies of a
as civil penalties in the form of a STOP WORT, O
Investigations of D A four insin-ancetcoveragedvered that
h on Dopy of this stat
ement may be forwarded to the RDER and a fine
Office of
"NY under the pauzc ani[ p =a1lim o j perjar�� that the ircforrnation p►ovided above 1s rine and correct
5isrtature:
Official use nalp. Dn not write in this area to be cornplet1zd.h ,
3 city or town oficiA(
City or Town:
Issuing Authority (circle Diel:
1. Board of f4=ltb 2. Building Department
6. Other
Contact Person:
Permitucense #
I Cify/ToVc,n Clerk 4. Electrical Inspector
Phone #:
S. Plambinuinspector
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an emphyyee is defined. as ".. every person in the service of another under any contract of hire,
express or implied; oral or written."
An enwlnyer is defined as "an individual, partnership, association, corpomtion or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and inc}ircii Ti- the legal representatives of a dsceased employer, m the
receiver or trustee of an individual, partnership, associaii on or other legal entity, employing employees. However the
owner of a dwelling house having not more than .three ap; zm ments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do M.int-nance, construction or repair work on such dweili g house
or on the grounds or building appurtenant thereto shall ncnt because of such employment be deemed to be an =pioyer."
MGL chapter 152, §25C(6) also states that "every state a r local licensing agency shall withhold the issuance or
renewal of a fimmse or permit.to operate a business or- to construct buiidiugs in the commonwealth for -any
applicant who has not produced acceptable evidence of compiiance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither -the commonwealth nor any of its poiitical subdivisionsshall
enter into any contract for the perFomiaiim of public worl< until acceptable evidence of compliance with the insurance
requirements ofthis chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit comp Vetely, by checking the boxes that apply to yore situation: and, if
necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their c-ertificate(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 cary.workers' coTrrp-nation insurance. If an LLC or LLP does have ..
employees, a policy is required_ Be advisedd that this afEicl.avit may .be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavitshould
be returned to the city or town that the application for the penn.it or license is being requested, not the Department of
Industrial Accidents. Should you.have any questions re_a rdirg the late or. if you ar requirrd to obtain a workers'
..comp-risabon policy, please call the Department at the na: nbcr,list_-d belovr. Self-insured companies should enter their
self-insurance license nrmnb-r on the appropriate. Iirre.
City or Town Officiate
Please be sure that the afridavit .is complete and printed Iegibly. The Department has provided a space at the bottom
of the .affidavit foryou to fill out in the event the Office of Investigations has to contact you regarding the appiicant.
Please be sure to fill in the permitAiceause number which will be used as a reference number. In addition, an applicant
that must submit multiple permit/iiceresenpplications in arty given year, need only submit one affidavit indicating current
policy information (if necessary) and und.cr "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 chat a valid affidavit is- on file for fi two permits or Iicenses. A new affidavit must be filled out each
year. Where a home own -r or citizen is obtaining a licens—_ or pert not related to any business or commercial venture
(i.e. a dog license or permit to burnleaves 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 far, niiriber:
The Commonwtedth Df Massachusetts
Dopiart mens of Emdmtrial Accidents.
. QfIIee of Lavestim6ons
600 wasl�gton Street
Boston, MA (12111
Tel. # 617-727-4900 M= 406 or I-& 777-MIASSA;E
Revised 5-26=05 Fax 4 61 7-7"2.7-7749
vvvtFat'.m as ;. g ov/ dia
VDate ..°'/ .
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that ...... /....... ......... %�/........... .
has permission to perform ...,� � � ::. ? � s ...... .
plumbing in the buildings of ... `� ... l�.l c=v!! �i�
at.. .....(.wr(�'� , North -Andover, Mass.
Fe64 . W . Lic. No. /.t x.5.7 . ... .rl16�, .
PLUMBING INSPECTOR
Check #
8192
0
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
f C �
Building Location J(4, Owners Name f�11y (jj DatePermit #
Amount
T ne e of Occu a `
New Renovation ri Replacement ri Plans Submitted YesNo ❑
VYV,r TT TT) Tr
.R
f
0
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
f C �
Building Location J(4, Owners Name f�11y (jj DatePermit #
Amount
T ne e of Occu a `
New Renovation ri Replacement ri Plans Submitted YesNo ❑
VYV,r TT TT) Tr
(Print or type) Check one: Certificate
Installing Company Name
❑
(�_ •_ Corp.
Address /1 dur-
❑Partner.
Business Telephone f3 87— 17 q Firm/Co.
n
Name of Licensed Plumber:
Insurance Coverage: Indicate the e 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
rgnature Owner ❑ Agent r
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetttts�State-lilumbiRg Code an Cha,�t- 142 of the General Laws.
By:
Title
City/Town
APPROVED (OFFICE USE ONLY
Type of Plumbing License
icense 114 um er Master El/
Journeyman ❑
01-IT.RT"OFIN MMMMMMMMMM
4 'l"'I
mumnI��
MM
MM
„' Fammum
M
MM������a�����
MMM=
MM
e r' mmmmm
MMM
mmmmmm
WOMMMMMMM
MMOMMMM
M�
M
M�
(Print or type) Check one: Certificate
Installing Company Name
❑
(�_ •_ Corp.
Address /1 dur-
❑Partner.
Business Telephone f3 87— 17 q Firm/Co.
n
Name of Licensed Plumber:
Insurance Coverage: Indicate the e 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
rgnature Owner ❑ Agent r
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetttts�State-lilumbiRg Code an Cha,�t- 142 of the General Laws.
By:
Title
City/Town
APPROVED (OFFICE USE ONLY
Type of Plumbing License
icense 114 um er Master El/
Journeyman ❑
,`s \
The Commanwealtk of M=achusws
kj 1
Department of industrial Accidents
Office
II
of Investigations
°-�
600 fTrashinhgZ`on Street
Boston, MA 62111
Workers' Compensationinsurance Affidavit-Dg�de�Contractors/Eientricia
3icant Infarmation . ns/pinmbers
Name
Address:
City/5tate/Zip:
Phone A.
Are you an employer? Check -the appropriate bo=
1 • ❑ I am a employer
with
4. ❑ 1 am a general contractor and I
P1ayem (full and/or part-time). *
2. ❑ I am.a.so}e proprietor. or
have hired the stub-cotrtractors
listed
partner.
ship and have no employees
on the attached sheet, _
These sub -contractors have
working for me in any capacity.
[No worker;' comp, insurance
workers' comp. insurance.
5. ❑ We are a corporation and its
3. ❑required.]
I aln s homeowner doing all work
officers have exercised their
right of exemption per MOL
myself. [No•workcrs' camp.
insurance
� 152, § I (4), and we have no
required.] t
.employees. [No workers'
comp ins iced.
Type of P%!ed (required):
6. ❑ New construction .
T• ❑ Remodeling
8.Q Demolition
9. ❑ Building addition
10.❑ .Electrical repairs or additions
1 !.❑ Plumbing repairs or additions
12.❑ Roofrcpairs
urarice rrqu ] 13.❑.Other
'may eFpl "M that checks bob a t mutt also fi[l out the section below showing their workers' bompenswion poiuy mforms6on
t Homeowners who srbmit this affidavit indi"""g they ars tieing aq work and then hire outside con
SCai►ttactnts that check this box curer anaahed an additioasl sheet show's must submit a new afndavif rndicatisg ouch
nig• the nom of the sub-com mtom and their workers' crotn�
1 ar an enrpfoyer that u ro s r. poFi�. 4n&nmW0n.
p . Crg:workers compensation insurance for my employe=
Below is the a '
informafinn. p 54y and job site .
Insurance Company Name: '
Policy # or Self -ins. Lie. #:
Expiration Date:
Job Site Address:
Attach a copy of the workers' cotrepensatiou policy declaration page (showing the polis}, number and expiration d
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 of i
of tip to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to a fine
investigations of the DIA for insurance coverage verification. the Office of
I do hereby certify under the pains and penalties ofpeoru7 that the ormahon in m
f vcded above is arse and correct
WJeial use nniy. Do not write in this area, m he compihMed or town o r
- b3' �1' ffi aL
City or Town
Permit/License #
Issuing Authority (circle one):
I. Board of Health 2- i3uildiug Department 3. City/Town Clerk
6. Other 4. Electrical Inspector 5. Plumbing Inspector
Contact Person:
Phone #:
Information a. nd Instructions
Massachusetts General Laws chapter 152 requires all emp foyers 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, nsodiation, corporation or other legal entity, or any two ormore
of the'foregoing engaged in a joint enterprise, and includirig the legal representatives of a deceased employer, or the
receiver artnrstee•of an individual, partnership, associabotn or other legal entity, employing employees. 'Howeverthe
owner -of a dwelling house having not more than three apaartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work m such dwelling house
or on the grounds or building appurtenant thereto shat not because of such employment be deemed to be an employer."
MOL chapter 152, §25C(6) also states that "every state or local 6eensing agency shalt withhold the issuance or
renewal of a license or permit to operate a business or *o construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence.oC compliance with the insarance'coverage required"
Additionally, MGL chapter 152, §25C(7) states "Neither tine commonwealth nor any of its political subdivisions shall
enter imp 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 eompie✓tely, by checking the boxes that appiy.to your situation and, if
necessary, supply sub -contractors) name(s), address(es), mind phone nuQnber(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 requiredito carry workers' co=npensation insurance. If -an LLC or UP 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 Ese 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 regar-ding the law or if you are required to obtain a workers'
compensation policy, pleawcall the Department at the nurriber.listed below. Self=mcu.+ed c--,nppniec ahould ente*thes
self-insurance licame, number on the'appropriete 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/iicense number which vh-iII be used as a reference number. In addition, an applicant
that must submit multiple parmit/license applications in any given year, need only submit one affidavit indicating -current
poiicy'infonnation (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 fuiare 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 vmture
(i.e. a dog license or permftto bum leaves etc.) said pms&n is NOT required to complete this affidaviL
The Office of Investigptions would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a cell.
The Department's address, telephone and fax number.
The Commonwealth of Massachusetts
Department of L-ndusiriai Accidents
Office of limesttigations
600 Washington Sti=t
Boston, MA 42111
TeL # 617-727-4900 exit 406 or 1-977-MASSAFE
Revised 5-26-05 Fax # 617-727-7744
wwwmass.gov/dia r