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HomeMy WebLinkAboutMiscellaneous - 186 ROSEMONT DRIVE 4/30/2018N_ O C" 00 O W cn om $ o z C) --I C) v o � , o m 7 62 U Date .. q . q / I ... , / .f� f NORTH o= TOWN OF NORTH ANDOVER • PERMIT FOR GAS INSTALLATION .sem This certifies that ... M A.6! .i) C O , , has permission for gas installation .... v ... .... . in the buildings of .....hucItI�!t- ..- ...................... at .... 16-(.0 ... j QO-WIV.K! a L.... . , North Andoverrj Mass. Fee. '5.�50 Lic. No.la : 57.0? ... ..,/ . GAS INSPECTOR Check # _ FIXTURES W UJY MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING umCity/Town-&,q-H-,- Ajq e� MA. Datejolino Permit# I Building Location: /d6/ Owners Name: j//ft,1A /UUtJa-/`, Ne Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential New: ❑ Alteration: ❑ Renovation: [Replacement: ❑ Plans Submitted: Yes ❑ No FIXTURES W UJY C6 IX 0 2 = W m = O W (7 W .1 U } U) Q' Fy- Z W O O IX H z 1— w rn Q W m 0 a H o O w X W ~ LILI W w z g W O aUJ W W L) W Q W z (7 w '� H J I— O u) = z J 0 LL N = Z W w ~ W W z o r lX o W N 0 a 0_= a m g W O z 'O a 0 IX�>>> W H 3 0 0 SUB BSMT. BASEMENT 1 FLOOR 2 FLOOR 3 FLOOR 4 FLOOR WN FLOOR 6 FLOOR 7 FLOOR 81HFLOOR Check One Only Certificate # Installing Company Name:�yA6-- V/�=(CU �=v7`1`c r Ly -corporation G' r L Address: 31 4NC, -* �/ City/Town:/�mot': (e- State: ❑ Partnership Business Tel: �� 9� ' 83G- z 19 3 Fax: /r 97fr '3a Y — /J --w y ❑Firm/Company Name of Licensed Plumber/Gas Fitter: rC INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes No ❑ If you have checked Yes, please indic a pe of coverage by checking the appropriate box below. A liability insurance policy 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 ❑ Sianature of Owner or Owner's Aaent By checking this box ❑; 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 Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. of License: By_ Title y— Title of Licensed Plumber/Gas Fitter Cityrrown ❑Journeyman License Number: APPROVED (OFFICE USE ONLY) ❑ LP Installer ,A I APR -05-11 09:17AM FROM -E-A STEVENS CO 1781-397-7672 T-145 P•001/001 F-639 VA lr - - -I �o CERTIFICATE OF LIABILITY INSURANCE 1 3/24/2011 rH� GHTS UPON THE CERTIFICTE HOLDER. THS RTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND OR ALTER CONFFIRS No TIWE COVERAGE AFFORDEDABY THE POLIC EIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER($), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER - t be IMPORTANT, If the ensCertificate the older i an ADin policies Am INSURED, SURED the an endorsement. m A statement ondthis -certificate Rdoes not conferOrights it the the terms and c —+;fle-ate holder in lieu of such endorsement(;)- I r1nNTCCT11 PROOLICER Ep, Stevens Company, Inc. 389 Main St. P. 0. Box 188 maiden MA 02148 INSURED MAGNIFICO BROTHERS PLUMBING HEATING & GAS 3�1 FOREST STREET Steve Gl _ (781) 322-2324 =VAX (761)397 7612 sgall®eastevensins-Com PRODU(5E-R 00003587 — p_U5T4MF&ID-e- - INSURER($) AFFORDING COVERAGE , NAIL 2 INsuRERA-.Hartford Fire_ Yniaurance Company 19582 INSURea8:Safet�r Ins 9454 INSURERC:Twin City Fire 29459 INSURER D : INSURER E;- _ MIDDLETON 13A 01949 1 INSURERI=: COVERAGES CERTIFICATE NUMSER:11-12 MASTER REVISION NUMBER: 00 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PER TH ECT CERTIFICATE MAY BESISSUEID OR MAY PERTAIN, ODOCUMENTF ANY CONTRACT OR 07HER ANY PERTA N, THE INSURANCECE AFFORDED BY T E POL CIES D SCRI EOHEREIN IS SI UB ECTPTO ALO THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED OU POLICY E BY PAID AI PCLI Y E PS LIMITS N- TYPE OF INSURANCE POLICY NUMBER MMIDDNYYY I MMADo�YYrY 1,000,000 EACH OCCURRENCE S GENERAL LIABILITY 'DArTOORR NTED 300,000 PRFMIS[$ E occuj ncd _ $ yA X COMMERCIAL GENERAL LIABILITY � CLAIMS -MADE a OCCUR OBS13AU05370 /24/2011 3/24/2012 nyongPQrsOn) $ 10,000 $ 1,000,OOC — _MEDEXP.A( pERSONALBADVINJURY -- GENERAL AGGREGATE $ 2,000,00( PRODUCTS-COMPlOPAG13 $ 2,000,00( S GEN•L AGGREGATE LIMIT APPLIES PER, X POLICY (� PRO- LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Eo accldem S — BODILY INJURY (Far pe(son) S $ ANY AUTO ALL OWNED AUTOS SCHEOULED AUTOS 5053635 /24/2011 /24/2012 - BODILY INJURY (Per accident) - PROPERTY DAMAGE (Per ecciaont) _ $ - $ i HIRED AUTOS S _ NON -OWNED AUTOS X UMBRELLA UAB OCCUR EACH OCCURRENCE S 11000,00 AGGREGATE 1, 000, 00 $ — `r EXCESS LIAR CLAIMS -MADE DEDUCTIBLE 13/24/2011 /24/2012 A X RETENTION S 10 000 11SBAUQ5370 WC STATU- OTH- C WORKER$ COMPENSATION 1'ABYL)Mli ER AND EMPLOYERS' LIABILITY Y I N E L. EACIi ACCIDENT _ ANY FROPRIETORIPARTNORlEXECUTIVE ❑ NSA 3/24/2011 3/24/2012 OFFICERIMEMB6R EXCLUDED? OSWFCRJ9050 E L. DISEASE - EA EMPLOYEI (Mandatory In NH) It yes, 0e8onbe under E.L. DISEASE -POLICY LIMIT DESCRIPTION OF OPERATIONS oeloW DESCRIPTION OF OPERATIONS ! LOCATIONS I VEHICLES (Attach ACORD 701, Addltlonat Remarks schedule, If more Space Is regt,lred) (978)688-9542 Town of Andover Attn: James Drozi 36 Barlet Street Andover, MA 01810 ACORD 25 (2008/09) INS025 (200409) N $ 500,00 500,00 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACGQRDANCI- WITH THE POLICY PROVISIONS, AUTHORIZED -REP S NTATtVE.'. FrancyM. Cri o�� bJr�?�c�C f. ©1988-2009 ACORD CORPORA ON: All rights reserve The ACORD name and logo are registered marks of ACORD APR -05-11 09:18AM FROM-E.A STEVENS CO 1781-397-7672 T-146 P.001/001 F-640 DATE (MMIUUIY Y Y Y I "RE CERTIFICATE OF LIABILITY INSURANCE 3/24/2011 HIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER($), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT, If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed, if SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT PRODUCER NAME: 5tevA Glll PHONE (781)322-2324 �IAC_No):1791139Y•7672 EA Stevens Company, Inc. -(Ad-No.E)cq:. —. E-MAIL g ill@eastevensins.com 389 Main St. AD.DRE55: 9 _ PRODUCER 00003587 P. 0. Box 188 D+r' — Malden MA 02148 INSURER(S) AFFORDING COVERAGE NAIC N— INSURED INSURERA:FIart ford Fire Insurance Cob► an 19682 wsuRERB.SafatY ns 39454 bLxGXIFICO SROTRER9 PLUMBIAG HEATING & GAS INSURERC:Twin Cit Fire 29459 31. FOREST STREET INSURER D; - a INSURER E: - MIDDLETON MA 01949 INSURER F. COVERAGES CERTIFICATE NUMBER:11-12 MASTER REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BCEN REDUCED BY PAID CLAIMS_. •to h}l'IIIYr6aT -POLICY EFF_ _POLICY EXP_ I LIMITS LTR I TYPE VF INS VrcANcc ' 1,000,000 GENERAL LIABILITY EACH OCCURRENCE g DAMA GR N 300,000 X COMMERCIAL GENERAL LIABILITY PREMISES (F� occumsnCe S 3/2h/2011 /24/2912 MED EXP (An oneperFon S 10,000 A CLAIMS -MADE ❑X OCCUR OBSBAUQ5370 y ) - PERSONAL e. ADV INJURY S 110001000 GENERAL AGGREGATE S 2,000,000 - PRODUCTS - COMPIOPAGG S 2.000,000 GEN'L AGOREGATC LIMIY APPLIE5 PER - $ rAN PRO- LOC COMBINED SINGLE LIMIT a LIABILITY (Ea sccldom) _ O B001LY INJURY (Par person) 5 $EDAU'f05 5053635 /24/2011 /24/2012 BODILY INJURY(Por aoelae11t) I ED AUTOS PROPERTY DAMAGE 3 (Per acudanqTOS NED AUTOS I XJ UMeRELLALIAB EACH OCCURRENCE 5 1,000,000 OCCUR EXCESSLIAB CLAIMS -MADE AGGREGATE S 1,000,000 - S DEDUCTIBLE 9SBAU45370 /24/2011 3/24/2012 B A Ix RETENTION S 10,000 VVC STATU-OTN- C WORKERS COMPENSATION TORY LIMITS. AND EMPLOYERS'LIABILITYY I N E.LEACHACCIDENT S 500,000 ANY PROPRICTORIPARTNERIEXECUTIVE OFFICERIMEMBEREXCLUDED7 NIA OBWECRJ9050 3/24/x011 /x4/2012 ELDISEASE•EAEMPLgYE $ 500,000 (Mandatory In NH) If vos. aeeorm wnoor E.L DISEASE -POLICY LIMIT $ 500,000 DESCRIPTION OF OPERAYIONS I LOCATIONS I VEHICLES IARach ACORD 1 al, Additional Remarks Schedule, If more space 18 roqulrod) Location -Building#G Walker Rd, North Andover, Ma. 01845 I (978)688-9542 Town of North Andover Jamea Diozzi 1600 Osgood St Bldg#20 Sui.te##2 -36 North Andove-, MA 01845 CA SHOULD ANY OF THE ABOVE DESCRIBED POLICIES 6E CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 'ACCORDANCE'WITH-THE.P0L•IC-Y PROVISIONS uTHOR12EDR � Ti4TIVE- � - .• - - -_' --'. -.- .:.. rani M- Clifford', Js,' .CgCC7, CIC" ACORD 25 (2009109) ©1988-2009 ACORD CORPORATION. An rights reserves. INS025 pooeoe) The ACORD name and logo are registered marks of ACORD Date. .......... 754 E; TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION .......... This certifies that . . . Z. v7 �-e....... �/ has permission for gas installation ..... i -C . /n. ............. in the buildings of ... U -.r. ........................ at ... P ......-...4— ......... North Andover, Mass. Fee... U. Lic.`No.J....... ......... ) .... ... GAS INSPECTOR Check# )J(, )-e .S FIXTURES W MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING City/Town: L t I-� `Z)F/ L , MA. Date: Permit# Building Location: 1 �I� � ((J GU[ Owners Name: _ �0 Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residentia New: ❑ Alteration: ❑ Renovation: ❑ Replacement;E' Plans Submitted: Yes ❑ No ❑ FIXTURES W W Q coN U m 2 LU W U H W w �O O Z O W w W N W O W 2 O � � O Z N W w LU g m O a a I- w X - cn u w w O a z = m N w t' o W w LL U W Z J Z W} N J H Q H Q O m Z W J O O Z LL 016- I J Z LL, W W v a o u- 0 0 D 1z X= O a. W n n> O SUB BSMT. BASEMENT 1 FLOOR 2 Nu FLOOR 3 Ru FLOOR 4 FLOOR 51H FLOOR 6 TH FLOOR 7 FLOOR 8 FLOOR / Check One Only Certificate # Installing Company Name: C WI±L(-,c f �# 'tel 9 L orporation 7 /(," Address j i�L�c..J lol✓f �City/Town: ,� l /v� ,I �Txp0L fL State: Business Tel: q 6 F29,):� 3 Fax: ❑ Partnership ->,L El Finn/Company Name of Licensed Plumber/Gas Fitter: dur ,G INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes [J No ❑ If you have checked Yes, please indicate the type of coverage by checking the appropriate box below. A liability insurance policy Er Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: 1 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 Owner's Aaent By checking this box ❑; I hereby certify that all of the details and information I have submitted for entered) reaardino this aonlication are true and accurate to the best of my Knowledge and that all plumbing work and installations pOrformed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State PlumbinglOog� nd,Qhapter 142 of the General Laws. Type of License: ,//1Z7—/ By ['Plumber Title ❑ Gas Fitter Sigr 'of Licensed Plumber/Gas Fitter 9 -Master /— City/Town ❑.lourneyman License Number: OPPRnvFn tnFFir F I ISF ANI vi 0 LP Installer Date. >.. j.. _ .. . NORTH 141 TOWN OF NORTH ANDOVER PERMIT FOR -GAS INSTALLATION lo �.._ This certifies that . . r '' has permission for gas ,installa ono . x ,..1.... . in the buildings of`—,., .... ... ....... . at " r~'�� � .. '�.... , North Andover, Mass. Fee--& ._ Lic: No'l-3AI... � .. GABS INSPEG��R' Check # z:'? MASSACHUSETTS UNIFORM APPLUCATON FOR PERM 'To DO GAS FfrMG (Type orprint) NORTH ANDOVER, MASSACHUSETTS Date BuildinL, Lncatinnc / .Y(1 (o Owner's Name New Renovation n Replacement D G SU B -BASEM ENT BASEMENT 1ST. .FLOOR 2ND. FLOOR 3RD. FLOOR aTH. FLOOR iTH. FLOOR .TH. FLOOR STH. FLOOR. TH. FLO.O R. Permit# �. w Amount $• Plans Submitted ❑ (Print or r Name. (hf a A dress k �f us14- mess a ep one 3 �Aame of.Licensed Piumber'or Gas Fi / f PLL( n Check one: Certificate Installing Company Corp. Partner. Firm7Co. NSURANCE RANCECOVERAGE e a current liability Insurance, policy or it's substantial equivalent. Check one: If you have checked ves, please indicateeYes [I box. the type coverage by checking the appropriate NoQ Liability in policy Other type of indemnity D Bond13 Owner's Insurance Waiver. I am aware that the licensee doesnot have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this.permit application waives this requirement. Signature of Owner or Owner's Agent Check one: t hereby certifythat all of the details and inform ion I have submitte Owner 13 ge D best of my knowledge and that all plumbing wo k and installations (or ent d) i abo a ap tion are true and accurate to the compliance with all pertinent provisions of the sachusetts S p o� n r e it a for this application will be in d Chap ,14 f the General Laws. By: Title nature of Plumber City/'I'own +. D Gas Fitter Xl-master APPROVED (OFFICE USE ONLY) Journeyman sea member Or Gas Fitter /—_/' d 3 v License lumber �_ � � w v� U Z ea Q x z z t, z Q a z w a z E w � C fw, w O w w U x ° � � � > z Q e o o° z W c � G O -] U o! S C W (Print or r Name. (hf a A dress k �f us14- mess a ep one 3 �Aame of.Licensed Piumber'or Gas Fi / f PLL( n Check one: Certificate Installing Company Corp. Partner. Firm7Co. NSURANCE RANCECOVERAGE e a current liability Insurance, policy or it's substantial equivalent. Check one: If you have checked ves, please indicateeYes [I box. the type coverage by checking the appropriate NoQ Liability in policy Other type of indemnity D Bond13 Owner's Insurance Waiver. I am aware that the licensee doesnot have the insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this.permit application waives this requirement. Signature of Owner or Owner's Agent Check one: t hereby certifythat all of the details and inform ion I have submitte Owner 13 ge D best of my knowledge and that all plumbing wo k and installations (or ent d) i abo a ap tion are true and accurate to the compliance with all pertinent provisions of the sachusetts S p o� n r e it a for this application will be in d Chap ,14 f the General Laws. By: Title nature of Plumber City/'I'own +. D Gas Fitter Xl-master APPROVED (OFFICE USE ONLY) Journeyman sea member Or Gas Fitter /—_/' d 3 v License lumber �_ ! 46�.'�� •IKi �'l71 r, .t tze Gommvnweealth of Massachusetts Department of Industrial Accidents Office of £n'C'V le ati0 ns 600 Washinoaton Street L'astoa�, M4 62117 w"7K "ass -t o1�1dia Workers' Compensation F>asuranee.Afidavit..g�ders/Contractors/EiectriciaIIs/D 3Iicant information � iumbers ----------------- Name (Business/Organization/Individual): Lap Address: City/State/Zip: 1, AS , Phone #: Are ya an employer? Check the appropriate box: — W 1� a employer with_ P Y"' (' to =s full and/or part-time).* c 4. ❑ I am a tro neralem have hired the contractor and I d the 2. ❑ I am a sole proprietor or partner- ship and have no employees sub -contractors listed ori the attached shut n' the working for me in any capacity. These n tractors have workers' comp, insurance.. [No workers' comp. insurance 5. ❑ We are .a corporation required.] ED 3. I an a homeowner doing all and tts e 'f5c rs have exercised.their work mvself. [No workers' comp. insurance --mption Per MGL C. 152, § 1(4) and we have required.] t no employees. [No workers' TYPe of project .(required): .6•. El New New construct 7• [] Remodeling 8• ❑ Demolition 9• ❑ Building addifi.on 10•0 Electrical repairs or additions I'1-❑ Plumbing repairs 'oradditions Roof repairs ' Am appficant.thar checks box #1 .must also fill out the section bcioow p.Insurance regUired,] I 13 LJ Other t rneowuers who subotit.fhis at; tdm it indicatitt,, they ar- doir:- 0 iv-11their workers' compertsation pob� rnmttnatton. IC on that chert: tris box.mersi Zrta hod an additional sheet showi �� Eh--nhireoutside eontrac'ors rnusi . the I'M -of. the sch ccatractors and Their wor su'nmii a new amciav ii incl sang s::ctt. t am an. e»tployer &Z is orovidircb work -em -S, co k=i camp. policy information. information. . . .�• "Itfz Ffer� me csurance for ny' employees. Beloml is the oft , P c1 and -job site Insurance Company Name: p tl^ C A I `/ / /1D Policy # or Self .ins. Lid. #: r V F �' G�"' c I A g _ nn � Job Site Address:- Ft , Expiration Date: �.a 4 vz (-- Attach a copy of the workers' compensation 'policy declaration City/Starr/Zip: Failure to secure coverage as required tinder Section 25A of pateer (showing the policy number and expiration date). line up to 31,500.00 and/or one-year imprisonment, as well MGL c. I S2 can lead to the imposition of criminal penalties of a of up to .1250.00 a da. Paint the violator. Be advised that a ccotvtl penalties in the form of a STOP WORK ORDER and a fine Y a= Investigations o DIA for insurance cov�ge verification. PY of this statement may be forwarded to the 'Office of 1 do hereb rfifj, undo the Signature: of perjurJ' tis¢( the informafion provided'above is true and correct 'hone #: % 9 Gfjicurl use only, Do not write in. this area, to be cn 1 'nP e[ed by city or town ofciaL City or Town: Issuine Authority (circle one): PermittLicense 4 1. Board of Health 2. Buiiding Department 3. City/To�,�,n.erk 4. Eiectrica[ inspector S. Piu o 6. Other mbinb Inspector Contact Person: Phone 4- iniorma.non 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 "very 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 incluciiTzg the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, associati on or other legal entity, employing employees. However the owner of a dwelling house -having not more than .three ap artrnents and who resides therein, or the occupant of the o dwe. lli house of another who, employs persons to do n$ P ) p maintenance, construction or repair work on such dwelling house or on theounds or building gr fib zpprartenant theta shall not bo..cause of such employment bed, -erred. to be an employer." MGL chapter 152, §25C(6) also states that "every state a r local licensing agency shall withhold the issuance or renewal of a license or permitto operate a business or to construct buildings in the commonwealth for -any applicant who has not produced acceptable evidence cm�f compliance with the insurance coverage required" Additionally, MGL chapter 152, §25C(7) states "Neither Th. e, commonwealth nor any of its poiitical subdivisions shall enter into any contract for the performance of public worll;< until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the corrtra.otin,, authority.". Applicants Please fill out the workers' compensation affidavit compZ-etely, by checking the boxes that apply to yow situation and, if necessary, supply sub-contractor(s) name(s), address(es) and 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 required to carryworkers' compensation insurance. If an LLC -or LLP does have .. employees, a policy is required_ Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. 'Also be sure to sign and date the affidavit. Theaffida.vitshouid 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 resEt_*-ding the lam, or if you are requi: rd to obtain a workers' compensation policy, please call the Department at the 11Mxmber:IisSelf-insured ted below. companies should enter their self-insurance Iicensenumber on the appropriate line. City or Town Officials Please be sure brat the a6idavit is complete and printed leorbly: The Department has provid--d a space at the bottom of the .affidavit foryou to fill but in the event the Office of Investigations has to contact you regarding the appiiwnt. Please be sure to fill in the permitllicense number which will be used as a reference number. In addition, an applicant that must submit multiple permit/iicense applications in arty = ven 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. Vkrhere a home owner or citizen is obtaining a Iicens� or permit not related to any business or commercial venture (i.e. a. dog license or permit to burn'Ieaves 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, teiephone and fax number. The Commonwes;ltb of Massa.chusetts Department of lmdusirial Accidents. Office of Lavestigafiom 600 WaShLi tQn Street Boston; MA 112111 Tel. # 617-727-4900 W;t 406 c r 1-877-1vL4SSAFE Revised 5-2645 Fax 4 61 7-72.7-7749 J.mass.Dov/dia V December 2, 2008 tcneBayStateGas A NiSource Company 55 Marston Street P.O. Box 869 Lawrence, MA 01841-2312 (978) 687.1105 Fax: (978) 688.1875 Maureen Yeazer Account Number: 7993520019 186 Rosemont Dr North Andover MA 01845 Dear Maureen Yeazer: This follow-up letter is to inform you that your gas Stove/Gas Piping located at 186 Rosemont Dr has been tagged due to a violation of state safety regulations. It is unsafe to use until the following condition has been corrected. Meter clocking, shut off valve to gas log in furnace room, meter stoped clocking, left valve off, also no shut off to stove, informed cust to have corrected & repaired & all piping air tested The Masachusetts code pertaining to the installation of gas appliances and gas piping, established under Chapter 737 Acts of 1960, requires that the condition be remedied. If you have questions or would like to discuss this issue, please call 978-687-1105 and ask for the Service supervisor. Please disregard this notice if the condition has been corrected. Sincerely, Service or Meter Department Bay State Gas Company CRR: CRR# CAdsupdatedletters\236 12202208 NORTH ANDOVER BUILDING DEPARTMENT 400 Osgood Street . Tel: 978-688-9545 Fax: 978-688-9542 BUSMESS FORM FOR TOWN CLERK DATE: 4 y NAME: O Z L ADDRESS: I e(o V O-� tZ M O Ay ( TAIL ZONING DISTRICT: x, L �j Iv G TYPE OF BUSINESS: BUILDING LAYOUT PROVIDED: YES 60 AVAILABLE PARKING SPACES: ZONING BY LAW USAGE: YES NO BUILDING INSPECTOR SIGNATURE Revived 11.5.04 BUSINESS FORM FOR TOWN CLERK