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Home My WebLink AboutMiscellaneous - 18 HERRICK ROAD 4/30/2018Date ..� ..... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ........ / ... /z..>. ... h ... ............ has permission to perform ....... ......................... plumbin;gl the gs e buildinof.... at ... e( .1 4........:. Fee.33!?/).. Lic. No. .9 Check# 1Uqo;� .......... ........ ANort Andover, Mass. ................................... JPLUMiB�ING� I�S�PECTOR MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY MA DATE PERMIT # JOSSITE ADDRESS a OWNER'S NAME r / P OWNER ADDRESS TEL —rf AX ft TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CLEARLY _ NEW: _ RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES _ N0— 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 GASIOiIJSAND SYSTEM DEDICATED GREASE SYSTEM a l DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER , DRINKING FOUNTAIN FOOD DISPOSER FLOOR t AREA DRAIN INTERCEPTOR INTERIOR KITCHEN SINK LAVATORY ROOF DRAIN -- SHOWER STALL SERVICE / MOP SINK TOILET Y URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER ORION INSURANCE COVERAGE: I have a current liabilityinsurance policy or its substantial equivalent which meets the requirements of MGL Ch. 442. YES 120"N'O IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY BOND OWNER'S.INSURANCE WAIVER: I am aware that the licensee doeson t have the insurance coverage required by Chapter 142 of the Massachusetb 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 true and accur to the best of my Wnowledge and that all plumbing work and installations performed under the permit issued for this application ben will lance ITertinant provisI f the Massachusetts State Wing Code and Cha ter 142 of the General Laws. PLUMBER'S NAME LICENSE # NATURE MPriv., JPz CORPORATION O=PARTNERSHIP,_# LLC _# COMPANY NAM r ADDRESS � CITY`(IJ f 4 Ll hd_hm STATE ZIP f _ TEL.L u FAX CELL EMAI S(,{ t� K PLUMBERS FITTERS ISSUES THE FOLLOWING LICENSE LICENSED AS A MASTER PLUMBER ROBERT A SAMMATARO 8 DUNRAVEN RD WINDHAM NH 03087-1263 9333 05/01/16 226084 C COMMONWEALTH OF -MASSA HUSETTS BOARD OF PLUMBERS AND GASFITTERS ISSUES THE FOLLOWING LICENSE REGISTERED AS A PLUMBING CORP ROBERT A SAMMATARO r ROBERT A SAMMATARO P6H., INC 8 DUNRAVEN RD WINDHAM NH 03087-1263 3373 05/01/16 221168 a , PTA a The Commonwealth of Massachusetts 02 Department of Industrial Accidents Office ofInvestigations.d 1 Congress Street, Suite 100 Boston, MA 02114-2017 www mass govIdla- Workers' Compensation Insurance" Affidavit: Builders/Contractors/Electricians/Plubers Name (Business/Organization/Individuat): G.# Ci /State/Zi : a QWL Phone Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4.•v[] I am a general contractor and I Type of project (required): employees (full and/or part-time).* have hired the sub -contractors 6. ❑ New construction 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. ` 7, 0 Remodeling ship and have no employees These sub -contractors have g• Demolition working for mein any capacity. employees and have workers' [No workers' comp. insurance mp. insurance. 9 ❑Building addition required.] 5. LWe are a corporation and its 10.0 Electrical repairs or additions 3.0 lama , ama, homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL insurance required.] + c. 152, § 1(4), and we have no 12.0 Roof repairs employees. [No workers' 13.0 Other comp. insurance reouired.l 'Atry applicant that checks box # i must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. =Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers, comp, policy number. lam an employer Mat is provtaing workers, compensation insurance for my employees. Below is the pokey 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 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. 100"?. Date...ka .7,<�.`.�.... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ��BAc►,usst� This certifies that .................:.: ...................................................................................... ........... has permission to perform �` �, 7� P f� /� .................... plumbin in the buildings of. �' �° / Tf�t°� rP r e �C r at....�.............................................7 .......... �................., North Andover, Mass. Fee ...................... Lic. No. 31....112 --....... PLUMBING INSPECTOR Check # 1 RO P TYPE OR PRINT CLEARLY MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY MA DATE /U -2 / PERMIT # / JOBSITE ADDRESS OWNER'S NAME[/y/ Cho 6�S` OWNER ADDRESS TEL _- 7 MFAX F— OCCUPANCY TYPE COMMERCIAL Q EDUCATIONAL 0 NEW: 0 RENOVATION: 0 REPLACEMENT: Q FIXTURES Z FLOOR--+ BSM 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 f� SHOWER STALL SERVICE / MOP SINK TOILET URINAL CONNECTION WATER HEATER ALL TYPES ', WATER O`1`HER RESIDENTIAL &�'— PLANS SUBMITTED: YES EO NO Ell 10 1 11 1 12 1 13 1 14 INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES IF YOU CHECKED YES, PLEASE INDICATE THE T OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY D BOND Q 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 101 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 and that all plumbing work and installations performed under the permit issued for this application will be in co nce Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME _ J LICENSE # with all o o z W a w w LL 0' Date ....... /.b./ �A./ ....... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that .......we:.../.., . I(// .......................................................... has permission for gas installation in the bui dings f at ........ ........................................................................................ North Andover, Mass. Fee....................... Lic. No....... ... 3 ... ............. .................... .............................................. I GAS INSPECTOR Check # GENERATOR GRILLE INFRARED HEATER J. LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/ SPACE HEATER ROOFTOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER L z ! WATER HEATER OTIC.......... . ... ..... .... ... . ..... INSURANCE COVERAGE 1 have a current liabilit insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF CrBY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY [] BOND 01 OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application Will be in compli pce with all Pertinen;LprVvisio f the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. t--" PLUM BER-GASFITTER NAME LICENSE# SIGNATURE IMP Ej MGF EjI JP 02"J*GF LPGI DJ CORPORATION PARTNERSHIP [j#= LLC []#= COMPANY NAME: 1ADDRESS CITY Lw_ A STATEMZIP TEL FAXI 11 CELL I,----- EMAIL= -V v 114A F MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK uCITY ly TYPE OR PMT CLEARLY FVr MA DATE 181 - 7- PERMIT # 96 Z6) JOBSITE ADDRESS =_J_OWNER'S NAME OWNER ADDRESS =_Jl TELM 9AX[_ OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL NEW: El RENOVATION: El REPLACEMENT: [Er PLANS SUBMITTED: YES 0 NO F_J APPLIANCES I FLOORS- BSM' 1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER E:j E:J BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER . . . . . . . . . . . . . . . . . . DRYER FIREPLACE FRYOLATOR FURNACE 4 L_j I Ji GENERATOR GRILLE INFRARED HEATER J. LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/ SPACE HEATER ROOFTOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER L z ! WATER HEATER OTIC.......... . ... ..... .... ... . ..... INSURANCE COVERAGE 1 have a current liabilit insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF CrBY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY [] BOND 01 OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application Will be in compli pce with all Pertinen;LprVvisio f the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. t--" PLUM BER-GASFITTER NAME LICENSE# SIGNATURE IMP Ej MGF EjI JP 02"J*GF LPGI DJ CORPORATION PARTNERSHIP [j#= LLC []#= COMPANY NAME: 1ADDRESS CITY Lw_ A STATEMZIP TEL FAXI 11 CELL I,----- EMAIL= -V v 114A F V1 O z 0 H U W a w R' a z W !�- H W O W O W = � c a w a a O w w w w co o a a a U J F a a a cn LLI s w � w Un W H °z 0 H U a VD C7 O a M The Commonwealth of Massachusetts , - Depal-iment offfidustrial Accid&-ts Office of Investigations 600 Washington Street .Boston, MA 02111 www.mass.gov1d1a Workers' Compensation Xnsurance Affidavit: Bui tiers/Cont°actor/Blectr icians/Plikubex � .A ppIleant Information Please Print Lee bly Name (Business/Organizationlindividuat): Address: Phone M q / o W2 /6 aZ Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I a employex with �• ❑ I am a general contractor and I 6. ❑ New construction m to ees full and/oxpart-time,).*have Modthe sub -contractors p y listed on the attached sheet. `!• El Remodeling 2. I am a sole proprietor or partner ship and`haveno.employees These sub -contractors have 8. ❑Demolition woxlang for me in any capacity. workers' comp. insurance, � 9. � Building addition [No workers' comp. insurance 5. El We are a corporation and its 10.0 Electrical repairs or additions required.] officers have exercised.their 3. El am a homeowner doing all work right of exemption per MGL 11.[] Plumbing repairs or additions myself. LEO workers' comp. c.152, §1(4), andwehaveno 12.❑ Roof repairs insurancere edi employees. [No workers' q�', a 13.❑ other comp. insurance required.] zAny applicant that checks box#I must also fill out the section below showing their workers' compensation policy information. f 'Homeowners who submit ibis affidavit indicatingthey sre doing all work and then hire outside contractors must submit a new affidavit indicating such. 1Contractors that check this box must attached as additional sheet shown' gthe name of the sub -contractors and their workers' comp. policy infomaation. X ain an employer that is providing workers' compensation insurance forfny employees Below is thepalicy anciJ0 site infomation. Insurance Company Name:. Policy # or Self im.Lic. ff: ExpixationDate: Job Site Address: City/State/Zip: Attach a copy of the workers' comp ensationpolicy declaration page (showing the policy number and expiration date). failure to secure coverage.as requkedunder Section 25A ofMGL o.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 i a 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 flus statement maybe forwarded to the Office of Investigations of the DIA. for insurance coverage verification. Ido hereby cert rider thepains n ojper ury rnas we an,Turrnicuun pru vcueu uuu a 4a c,u u,ecc w„ cu. bate! Phone #: 978-qt:3,2 16 ?-Z- official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License 0 Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbinglnspector 6. Other Contact Person; Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for the employees. ,. Pursuant to this statute, an employee is defined as express or implied, oral or written." "...every person tri the service of another under any contract ofhire, An employe, is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a j oint 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 o ccup ant of the dwelling house of another who employs persons to do maintenance, construction orrepair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be, deemed to be an employes." MGL chapter 152, §25C(6) also states that "every state or Heal 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 checlang the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone numbers) 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 cany workers, compensationinsurance. ffanLL C or LLP does have employees, apolicyisrequired. Be advised that this affidavit maybe submitted to the Department of Tudustrial 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 cutrent 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 b een Ofdxcially 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. Anew affidavit must be fillgd 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 orpermit to burn 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 ciuesgons, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Gain oxA�woalth ofyassa..chwotts - ATaXiMeAt oflndustxial ,A,ccidalits Offtee dhRm gAtiom ' 6bG Wak gto?a• S to t Basion, MA, 02111 Te1, # 617.7.27,4900 QA 406 ox x-8,77, SS Revised 5-26-05 `ay, 617-727-7749 wwc�xaas�,govfdia.