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Home My WebLink AboutMiscellaneous - 183 WEYLAND CIRCLE 4/30/2018 (2)N O i w N � m z v n � i b m 6/30/2016 This is an e -permit. To learn more, scan this barcode or visit northandoverma.viewpointcloud.comNNrecords/20806 OF p10 A 70110, m 0 v 4 � �9SSAC H USES( TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that Robert A Sammataro has permission to perform replace dishwasher plumbing in the buildings of ZHENG, FANGQING at 183 WEYLAND CIRCLE, North Andover, Mass. Lic. No. 3373 Date: June 30, 2016 I VVf11 GR OTHER I have a current liabil insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES0 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY e 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 wilm this requirement. SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this applici and that all plumbing work and insitallations performed under the permit issued for this application will Massachusetts State PI ing Code and Cha ter 142 of the General Laws. PLUMBER'S NAME LICENSE # MP.L JP4 00 _ CORPORATION O=PARTNERSHIP_#LLC COMPANY NAM to 4 ADDRESS CITY' STATE ZIP 1), !�-6-77_ TEL n FAX CELL � „ I I EMAIh, QhDi� (nvn /'/1�c _ �e CHECK ONE ONLY: OWNER i AGENT and accunA to the best of my the (e2-qjl�0 62<�J 9-1 ^,4);L _ TYPE OR PRIN CLEMILY I • : � all • • r • r r • 961 -. . k, ILI 11,01111% rOi Ino r � r � - - ;iiil♦i�iii�-.� Ilkwar,�■�iiiiii��ii�i ''10 IN I RTelINA •rr DISPOSER ��i •e. C I_ �i�iil• iii KITCHEN SINK ��iii•lii��_ P.M.•' �iiiiii�`_ MORE "M iiii • ��iiiiiii_��_ 11-0 �_ _i_ii_ • • VVf11 GR OTHER I have a current liabil insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES0 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY e 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 wilm this requirement. SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this applici and that all plumbing work and insitallations performed under the permit issued for this application will Massachusetts State PI ing Code and Cha ter 142 of the General Laws. PLUMBER'S NAME LICENSE # MP.L JP4 00 _ CORPORATION O=PARTNERSHIP_#LLC COMPANY NAM to 4 ADDRESS CITY' STATE ZIP 1), !�-6-77_ TEL n FAX CELL � „ I I EMAIh, QhDi� (nvn /'/1�c _ �e CHECK ONE ONLY: OWNER i AGENT and accunA to the best of my the (e2-qjl�0 62<�J 9-1 ^,4);L The Commonwealth of MassachuSetb Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.massgov/dia IVorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/ftmbeiv TO BE FILED WITH THE PERMITTING AUTHORITY. Name (Bi Address: +* 7; FI n 14 h /? vA . R 1 Yo 11W Mo ne l),S' _K3 -5" Are you an employer? Check the appropriate box:,, Type of project (required): 1.0 I am a employer with employees (full and/or part-time).* 7. New construction 2.[]l am a sole proprietor or partnership and have no employees working for me in $, yodeling any capacity. (No workers' comp. insurance required.] 9. ❑Demolition 3.01 am a homeowner doing all work myself. [No workers' comp. insurance required.]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 11.0 Electrical repairs or additions proprietors with no employees. 12. [] Plumbing repairs or additions sr3l am a general contractor and I have hired the subcontractors listed on the attached sheet 13. ❑ Roof repairs sub -contractors have employees and have workers' comp. insurance? 14. ❑Other 6. 7152,811(4). e a corporation and its officers have exercised their right of exemption per MGL c. and we have no employees. (No workers' comp. insurance required.] *Any applicant that checks box # 1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contraetors 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. I am an employer that is providing workers' compensation insurance for my employees Below h 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 (mprisoroieftt3,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. 1 do is%VAMI� ofperjury that the Qftial use only. Do not write in this area, to be completed by city or town offikial City or Town: Permit/License # true and correct Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector 6. Other Contact Person: Phone #: n -MARAALRAIE A 1 Tu Ar u Y ndft A.wi ■■ •w PLUMBERS AMD GASFITTERS ISSUES THE FOLLOWING LICENSE LICENSED AS A JOURNEYMEN PLUMBER ROBERT A SAMMATARO 8 DUNRAVEN RD WINDHAM, NH 03087.1263 18214 05/01/2018 PLUMBERS AND GASFITTERS ISSUES THE FOLLOWING LICENSE LICENSED AS A MASTER PLUMBER ROBERT A SAMMATARO 8 DUNRAVEN RD WINDHAM, NH 03087-1263 9333 05/01/2018 COMMONWEALTH OF MASSACHUSETTS a•�� vi tilu1. [��a,:r�7 ��X9[�7 �►�n■kiTie7-� BOARD OF PLUMBERS AND GASFITTERS ISSUES THE FOLLOWING LICENSE REGISTERED AS A PLUMBING CORP ROBERT A SAMMATARO ROBERT A SAMMATARO P&H, INC 8 DUNRAVEN RD WINDHAM, NH 03087 3373 05/01/2018 34142-1