HomeMy WebLinkAboutMiscellaneous - 18 ALCOTT WAY 4/30/2018N
r
Date ... .3��'.r ......
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
�
�e����
This certifies that ..............................}...................... ............................................................
......
has permission to perform ... ! .. -?! .....�.j.``.��:,........................................
wiring in the building of.....................' -60
�................................................
at.......
....:./r.� VVI .................................. .North Andover, Mass.
............ !I ....................;
Fee...:'............ Lic. Nom--r�...��J
....................................................................................
ELF.CTRTCAL INSPECTOR
�
Check2
:#
t 3 2 2��1
� do
' O
Commonwealth of Massachusetts fficial Use Only
��77b
o Department of Fire Services Permit No. '
BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07Occupancy andeav e lank)Checked
(leave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 C 12.00
(PLEASE PRINT INEX OR TTPE ALL INEORMATI0A9 Date: 10MI�
City or Town of: NORTH ANDOVER To the Inspector of Wires:
By this application the undersigned gives n tice o his or her intention to perform the electrical work described below.
Location (Street & Number ice
V Ll"
Owner or Tenant
Owner's Address
Telephone No.
Is this permit in conjunction with a build *ng permit? Yes 0) No ❑ (Check Appropriate Box)
Purpose of Building (yes Qr Utility Authorization No.
- Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters _
New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters _
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
r4 01 01JJC e^Jtfi, aN
Completion of the following table may be walvea by the Ins ector of Wires.
No. of Recessed Luminaires / �,
lC/
No. of Ceil: Susp. (Paddle) Fans
No. of Total
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool Above ElIn- Elo.
rnd, rnd.
o mergency Lighting
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
I No. of Zones
No. of Switches
No. of Gas Burners
No. of Detection and
Initiatin Devices
No. of Ranges
g
No. of Air Cond. Total
Tons
No. of Alerting Devices
No. of Waste Disposers
p
Heat Pum
Totals
Number
" ' ' '-
Tons
KW
" '
No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers
S ace/Area Heating KW
p g
Local ❑ Municipal ❑ Other
Connection
No. of Dryers
Heating Appliances KW
SecuritNo. o Devices or Equivalent
No. of Water KW
Heaters
No. of No. of
Signs Ballasts
Data Wiring:
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wiring:
No. of Devices or Equivalent
OTHER:
Attach additional detail if desired, or as required by the Inspector of Wtres.
Estimated Value of EI ctrical Work: (When required by municipal policy.)
Work to Start: 3 109q 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 YP BOND ❑ OTHER ❑ (Specify:)
I certify, under the pains and penalties of perjury, tit at the information on this application is true and complete.
FIRM NAME: LIC. NO.:
Licensee: - lei Q (!& Signature LTC. NO.: 12716-6
a hcabl tern" a t" ' t e li nse nzrm line. Bus. Tel. No.:, 03-35fo- 71. /
Address: lei r 461y���� Alt. Tel. No.: Z
*Per M.G.L c. 147, s.'57-61, security work requires Departhient 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 PEhMIT FEE: $
Signature _ Telephone No.
❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the
permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed
on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an
electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the
notification of completion of the work as required in M.G.L. c. 143, § 3L.
Permits shall.be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he
or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written
application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written
request of either the owner or the installing entity stated on the permit application.
❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of
the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this
purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With
limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was
"in effect or existence" during the qualifying period beginning on August 15, 2008 and extending through August 15, 2012.
❑ Rule 8—Permit/Date Closed: *** Note: Reapply for new permit ❑
❑ Permit Extension Act — Permit/Date Closed:
Trench Inspection
Pass 0
Failed 0
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
SERVICE INSPECTION:
Pass 0
Failed
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
PARTIAL ROUG SPECTION:
Pass
Failed
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
ROUGH INSPECTION:
Pass 0
Failed 0
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
FINAL INSPE ON:
Pass 0
Failed
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date: Jr�'
DEB WEINHOLD ... TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com
The Commonwealth of Massachusetts
Department of Industrial Accidents
X Congress Street, Suite 100
Boston, MA 021142017
www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PEMOTTING AUTHORITY.
Name (Business/Organization/Individual):
Address: 1 1 � jA05L�_ kms'
City/State/Zip
Are yon an employer? Check the appropriate box:
1.Q I am a employer with employees (full and/or part-time).*
2'P I am a sole proprietor or partnership 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.] t
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
proprietors with no employees.
5. ❑ 1 am a general contractor and I have hired the sub -contractors listed on the attached sheet.
These sub -contractors bade employees and have workers' comp. insurance.;
6. Q 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 required.]
Type of project (required):
7. ❑ New construction
8. 0 Remodeling
9. ❑ Demolition
10 ❑ Building addition
11.0 Electrical repairs or additions
12. FJ Plumbing repairs or additions
13. Q Roof repairs
14.0 Other
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
t Homeowners who submit #his 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-coritractors have employees they must provide their workers' comp. policy number.
I ant 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. Lie. #:
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 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 undeAe pains and penalties ofperjury that the information provided above is truet and correct.
Phone #: L)3 37 �D" �% ( Z
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 #:
G
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their opnployees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of le,
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 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-iia'sured 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. 4 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax 9 617-727-7749
Revised 02-23-15 www.mass.gov/dia
.COMMONWEALTH OF MASSACHUSETTS.
0
11 X08
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING f.
�BS�cHO
This certifies that x,11` `"'�"�
has permission to perform ...6.11 Z� .. i�� o IVB
plumbing in the buildings of (.: e. �c o,r r,� ........
at ......./�....... 1,4 c l ......................... North Andover, Muss.
Fee�Lic. No. �h..� �Y
(H ......... ....... ..........
_ PLUMBING INSPECTOR
Check# 1/3 � 51
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK.
CIN MA DATE j PERMIT # b
-
JOBSITE ADDRESS f A/C,;of—� OWNER'S NAME 0 e 0ny%d __ r,_ 71
POWNER
ADDRESS TEL FAX
TYPE OR
OCCUPANCY TYPE COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL
PRINT
CLEARLY
NEW: [J RENOVATION: ® REPLACEMENT: ® PLANS SUBMITTED: YES ❑ NO❑
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/OlUSAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM i
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN r-
FOOD DISPOSER
FLOOR / AREA DRAIN
INTERCEPTOR (INTERIOR)
KITCHEN SINK
LAVATORY
ROOF DRAIN
SHOWER STALL f
SERVICE/ MOP SINK
TOILET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER
INSURANCE COVERAGE.
I have a current liability insuraince policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YESIff NO Lj
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY )a 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 compli ce with all Pertinent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME I STEPHEN C. KIRKLANDLICENSE # 9431 SIGNATURE
MPN JP® CORPORATION ❑# 1883C . PARTNERSHIP ❑# LLC❑#
COMPANY NAME I KIRKLAND and SHAW, INC. ADDRESS 1 5 ADAMS STREET
CITY _BURLINGTON —� STATE MA ZIP 101803 —� TEL 781-272-2670 —�
FAX 781 272 7444 CELL 617-590-2035 EMAIL KIRKLANDANDSHAW RCN,COM
C
x
b
r
C
z
n
z
b
r�
n
H
O
z
z
0
m x
m ra
w �
v
r
n �
z O
a Cl)
m
z < O
m
O
3 -4 121
0
H X �
r�
� � o
El
❑0
R
41 z
� a
rA
H
z
z
0
H
rA
rAO
20 SUNtRI ST" AVE: <<,:
0188;-
The Commonwealth of Massa.chusetts
Department oflndustrialAceidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
t
www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERNHTTING AUTHORITY.
Applicant Information // // Please Print Le0bly
Name (Business/Organization/Individual): bt 1 • �T411
Address:_S A(gh_,�r - 13
City/State/Zip:
Are you an employer? Check the appropriate box:
Phone #: 7 fr-27Z�6j.�
I.911 am.a employer with loyees (full and/or part-time).*
2. ❑ I am a sole proprietor or partnership and have no employees working for me in
any capacity. [No workers' comp. insurance required.]
3. F] I am a homeowner doing all work myself [No workers' compAnsurance required.] t
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
proprietors with no employees.
5. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet.
These sub -contractors have employees and have workers' comp, insurance.t
6.F1 We are a corporation and its officers have exercised their right of'exemption per MGL G.
152, § 1(4), and we have ri. employees. [No workers' comp. insurance required.]
Type of project (required):
7. [f New construction
8. l'aemodelitig
9. ❑ Demolition
10 E] Building addition
11.❑ Electrical repairs or additions
12. Plumbing repairs or additions
13. Roof repairs
14. Other
*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.
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 subcorilraciors have employees, they must provide their workers' comp. policy number.
Iain an employer that is providing workers -compensation insurance for my employees. Below is the policy and Job site
information.
Insurance Company
Policy # or Self -ins. Lie. #:
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 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 under the pains and penalties of perjury that the information provided above is true and correct.
Sienature: Date: 3 -24-f '
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 coimnonwealth 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 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 bum 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
03/28/2016 09:46 7812727444 KIRK&SHAW PAGE 02
The Commonwealth ofMassachusgM
Department of IndashlQrl Accident'
I Congress Street, Suite 100
Bostwn, MA 02114-2017
ww►Km Lmgov/diia
Workers' Compensation Insurance Affidavit; Builders/CogtractomiElectricieng/Plumbers.
TO BE FUD WITH' THE PERMITTING AUTHORITY,
NaMe (Busincros Organization/Individual): .0- 1c,y�,Q
Address:
City/State/Zip: 13 6 b Phone #: TV 7:; 6-7 a
Are you ap employer? Check the ■ppropriate bou
I - ff I Ani a e17111010yer with—d-Q_wetnpioyees (full and/or penrdmo).•
2.[] 1 Am A sole proprietor or potaomhip and have no employees working for me in
any capacity. [Pio workers' comp, insurance required,]
3.❑ I Am s homeowner doing ell work myself. [No workers' comp. insurance regoimd.] I
4,❑ I am a hPmeower ad will be hiring contractors to conduct all work on my property. I will
ensure that all oontrecton either hove workers' compeantion Ipstrrencc or Aro sok
proprietors whh no employees.
9,0 1 am A general contractor and I have hired the sub-contructors listed on the attached shoot,
These sub -contractors have employees and have workers' comp. insumm,t
6.❑ We aro a eorporMtion and its offioors have exorcised their right of awmption per MOL c,
152, 11(4). end we have no ornployees. [N4 workers' comp, ingumnop required.)
Type of pro*t (required):
7. 0 New construction
8.Remodeling
9. 8 Demolition
10 [] Building addition
11 .0 910ctricd] repaits or additions
12. 'Plumbing mp&irs or additions
13.0 Roof repairs
14. ❑ Other _
*Any Applicant that ducks box # I rmst also fill out the section below 00wing choir woricrs' corepansatjon policy information.
t homeowners who submit this affidavit indieetino they aro doing all work and then hits outside contractors nW submit a new af6d►vit indicating such.
=Coxotrwtors that cback this box must attached am additional sh" showing the name of the nub-oonttretors and StW whether or rpt those entities have
- Mloyees. If the sub-conttaetors have tnnplojws, they must provide their workers' corn,', policy number.
smammmal—
I am an employer that is providing workers' compensation insurance for my eniployem Mow is the
lnformadom pol'rey and job site
Insurance Company Name: Pn tr Rel+�,v Ti ;X yrs Uwe- czr
Policy # or Self -ins. Lic. #: Gc�GA- j_ q `T �,� � Expiration Dee: d I —a i — a d t 7
Job Site Address: Z2 -At -C-07-201 10-y City/Statt:JZip:!Y_4®VE.� �9!,� Cit 89
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to seem coverage as required under MOL c, 152, §25A is a criminal vioMon punishable by a fine up to S 1,500,00
and/or one-year imprisonment, u well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.04 a
day against the violator. A copy of this statement may be forwarded to the Office of investigations of rho bIA for irastrragce
coverage verification.
I do hereby cert try under Me pains and penalties of perjury that the ii{forma�n provided above is true and eorrepG
_zr /(-
Phone#• IZ(- ate ;),(,-71P t
Of khd use only. Do not write in this area, to he completed by city or town ofjgchd
City or Town. Permit/Limon #
Issuing Authority (olrelo one):
1. Board of Health 2. Building Department 3. CltylTown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone 0:
03/28/2016 09:46 7812727444
KIRK&SHAW
KIRKLAND and SHAW, INC.
Plawknq and 3alinq Conlruclvn
¢ PHONES: (781) 272-2670 - (781) 862-1097
FAX: (781) 272-7444 4.
o www,kirklandandshaw.com ;•
PAGE 01
5 ADAMS STREET, BURLINGTON, MA 01803-4972
FAX TRANSAff7TAL SHEEN'
DATE:-Zf 16
t3c.k--,,Ai1V6 G/�S ,ySipC-z�u(Z --
FAX#:
FROM:�/�`s�/�—K—
NUMBER OF PAGES (including this page) 3—
Message:
If yoU received an incomplete or illegible transmission, please contact
at (781) 272-2670
3/�
Date...
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that ,o(C.....,......-....;r/.......e.......x......l.e........5........6..6 14I�
//
...............................
has permission for gas installation ... e_e_
in the buildingspf
at .... .......
z4k�!� ..... ��j � � ......................... . North Andover, Mass.
Fee... 67)... Lic. No. Z ..... 2
...... ........ 7... ...............................................
GAS INSPECTOR
Check #
0470
9
DRYER
FIREPLACE
FRYOLATOR
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM / SPACE HEATER
ROOFTOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
INSURANCE COVERAGE
have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL. Ch. 142 YES
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAG Y CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 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 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 Peri12? entision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. t' o A ��,
PLUM BER-GASFITTER NAME �,�C.��-4�,p�e� C`�w� � �LICENSE#1_I_35611SICMTURE
MP MGF 0 JP [3 JGF Q LPGI 0 CORPORATION Q# PARTNERSHIP 0#= LLC E]#
COMPANY NAME: ADDRESS�,►7_1_P
CITYj,n1 r STATE MKI ZIP ITEL
FAX -1 CELL : EMAIL
it
V
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY ..h10ri'I1c�o�l�(L MA DATE
_ PERMIT# `
JOBSITE ADDRESS ISR _ CA± �( �IOWNER'S
NAME
GOWNER
,%�I �,.
ADDRESS aV�
TEL FAX L�
TYPE OR
PST
OCCUPANCYTYPE COMMERCIAL EDUCATIONAL
RESIDENTIAL
CLEARLY
NEW: 90" RENOVATION: REPLACEMENT:
PLANS SUBMITTED: YES Q N0�]
APPLIANCES 7
FLOORS-- BSM 1 2 3 4 5 6
7 8 9 10 11 12 13 14
BOILER
I __�
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
ROOFTOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
INSURANCE COVERAGE
have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL. Ch. 142 YES
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAG Y CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 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 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 Peri12? entision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws. t' o A ��,
PLUM BER-GASFITTER NAME �,�C.��-4�,p�e� C`�w� � �LICENSE#1_I_35611SICMTURE
MP MGF 0 JP [3 JGF Q LPGI 0 CORPORATION Q# PARTNERSHIP 0#= LLC E]#
COMPANY NAME: ADDRESS�,►7_1_P
CITYj,n1 r STATE MKI ZIP ITEL
FAX -1 CELL : EMAIL
it
V
h
O
O
H
U
w �}.
m
ya o
O �+ El
}
W
F- W
OH a z
U w ft
rc a W 5
a
LU
O >
w w
w U a
o
a a
rA
J
H °-
a
Ln iii
z w
H
O
z
0
H
U
a
C7
Ch
-
7
•
The Commonwealth o fMassachusetts
Department of IndustrialAccidints
Office O fInvestigations
600 Washington Street
Boston, MA. 02111
www massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Annlicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address:-
city/state/z
ip:
Phone
Are you an employer? Check the appropriate bog: -
Typo of project (required):
1. ❑ I am a employer with
4. ❑ I am a general contractor and I
6. ❑ New construction
Waployees (full and/or part-time)
have hired the sub -contractors
listed the sheet. t
7• ❑ Remodeling
m a sole proprietor or partner-
ship and'have no employees
on attached
These sub -contractors have
8. ❑ Demolition
working for me in any capacity.
workers' comp. insurance.9,
(� Building addition
[No workers' comp. insurance
5. El We are a corporation and its
1011 Electrical repairs or additions
required.]
3. ❑ I am a homeowner, doing allwork
officers have exercised their
right of exemption per MGL
11. ❑ plumbing repairs or additions
myself. [No workers' comp.
c.152, § 1(4), and we have no
12. Q Roof repairs
insurance required.] i
employees. [No workers'
13. ❑ Other
comp. insurance xequired J
*Any applicant that checks box#1 must also fill out the section bel6w showing their workers' compensation policy information.
i Homeowners who submit this affidavit indicating they 8ie doing all work and then hire outside contractors must submit anew affidavit indicating such.
tContraetors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
p am an employer that is providing workers' competsation 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 requiredunder 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.
f do hereby certlgunder tiiepains andpenalties ofperjury that t1 information provided above is ue and correct.
n , r\ n 17 7f l _ , /
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):
I. Board of Health 2. Building Department 3. CitylTown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other -
Contact Person: Phone
Information and Inst ueflons
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 ofhire,-
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 numbers) along withtheir 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. )fan 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/lieense 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 (ifnecessary) and under "Job Site Address" the applicant should write "alllocations 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:
Tha CQmmonwealth of MassachvsPt€s
Depaxtwmt ofhndustxial A,celdavts
Qfte ofIAvestigalzona
60 Wasbiugtou. Slxc ea
B oston} MA 02111
TQL # 617-727-4900 est 406 or. 1-877;MASSAFE
Revised 5-26-05 Fax## 617-727-7749
txFcxntrmnc.n lrnrsfa;n
w
1
_
l
i
nl"
01 If4
N
w
V,
U).
z
N} w
m
C
w
M
a a•3
:
M .
w e
O
C7 O
o, V.
,: J
J
1
Q O
',:C J
w
N .::
azCD
m
o
= d a
m
a
•
m H
in <
�
Q
� � ■
VN W
=w z.
`
p
J = w;LL
W
V);
C
N
CL
J
Lin w
r o
Z
AA