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Home My WebLink AboutMiscellaneous - 187 SOUTH BRADFORD STREET 4/30/2018 (2)h.- 4� .,r-. ��, ;,��' ., r �,. s-" xq:� x.: .�rw:, 1 t r Date ... ?/Z (o� 3 .............. TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION t This certifies that.............�.!... �i................................................................................ has permission for gas installation............P,1'.......................... ..................... in the buildings of /� .. ..P ... ....................................................................... ... .r at .... ... ..... �.... .......... � 1..�North Andover, Mass. Fee .... 4°..- Lic. No. .�& (od .... .. :!�................................................ 7 GAS INSPECTOR Check #2V6 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY MA DATE?-�PERMIT# �%�41 C'—' JOBSITE ADDRESS��,�, _.._..� OWNER'S NAME � � 7�� GOWNER ADDRESS TEL _ FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL PST RESIDENTIAL CLEARLY NEW:E] RENOVATION: 0 REPLACEMENT: ® PLANS SUBMITTED: YES 0 NO APPLIANCES 1 FLOORS- BSM' 1 2 3 E4 5 6 7 8 9 10 11 12 13 14 BOILERL. E-A 1_ BOOSTER I� I ( I I - [III I II III fill H . 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 P40OF TOP 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 1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERA Y CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY ® BOND OWNER'S 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. SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER 0I AGENT f 1 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. Te PLUMBER -G . SFITTER NAME LICENSE # SIGNATURE MP MGF El JP ® JGF 0 LPGI CORPORATION ®2 S(J ( PARTNERSHIP 0#= LLC [# COMPANY NAME: ADDRESS CITY _ STATE CY'' TEL FAX rCELLEMAIL �� Ayp P`, c44>,- q d"� pe�-„� O z O M W r' � o Z O N� W � W H LU a z° U w �* V a W CO a ui O > za w w C a 0 a a a ice. U J a a � � w x w F- LL W H °z 0 H U a C�7 w_� I The Commonwealth of Massachusetts Department ofIndustrigl Accidents Office of Investigations 600 Washington Street Boston, MA 02111 quo www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information PIease Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: 9&.456—? eihone #: - %�� ' %% e�o Are y an employer? Check the appropriate box: 1. 91 am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. I ship and'have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] i employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11. ❑ Plumbing repairs or additions 1211 Roofrepairs 13.❑ 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 tie 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 their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. „ _ a Insurance Company Policy # or Self --ins. Lic. Job Site Address: / O / Ae LtX/(i °�T i Attach a copy of the workers' compensation policy Expiration Date: 2_/7 ✓id'` City/State/Zip: 67 ep, 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. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. 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 - - - II Contact Person: Phone #: II 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 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-insured companies should enter their self-insurance license number on the appropriate he. 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 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 Mossachusotts Deparment of Industrial .Accidents Office of Investigation 600 Wasbington. Street Boston., MA 02111 '1'ol, # 617-727-4900 at 406 or 1-877rMASSAFB Revised 5-26-05 Fax # 617-727-7749 _WWW-Mass,gov/dia CO LU mC/) Ln a:..j- U)f—CL LLI (1) < LLix cnui Lu <�o — C) LL W -j 0 q LU > C0 0 • <LL -i as LL < cncn X LU ul LU (n C) 20 2 -JLU Of UJ z 0 a. Lu �-q LU 0 z z