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Home My WebLink AboutMiscellaneous - 19 UNION STREET 4/30/20181 10 .f .41 , " Date -2,/-*3/1"T TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING e- I cy—+A C� lk:c U Vq I t This certifies that tkit,,..v has permission to perform ..��-.<._..c,2— ................................................................................ plumbing in the buildings o- f .... L, .............................................. at ....'.....1....1xti.%'Yn !:!� A I .................., ....................... .... ............... North Andover, Mass. Fee.. % ........ Lic. No.1 ...... ..M.6 . ............................................................ PLUMBING INSPECTOR Check # I 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. PLUMBER NAME: M_LWA_Iip10 LICENSE # [j�" I SIGNATURE COMPANY NAME: G 4 i ADDRESS] N CITY : .. v ra/ ` STATE: y ZIP: FAX: TEL: k"L'Q0 wl O 3 4 CELL:IgAyj"— 01 I .I EMAIL: F777777 lot MASTER N JOURNEYMAN ❑ CORPORATION ❑ # 0 PARTNERSHIP 0 # LLC Y # MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK r - " POWNER TYPE OR PRINT CLEARLY , CITY 11/ V' 7 o\A1v1-- MA. DATE 1241 PERMIT # JOBSITE ADDRESS b OWNER'S NAME C I o L(1,1 ADDRESS: h9 wt),.wcj6.4t i jTEL:1q1oq5waFAX:1 OCCUPANCY TYPE: COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL` NEW: ❑ RENOVATION: ❑ REPLACEMENT:- PLANS SUBMITTED: YES ❑ NO FIXUTRES Z FLOORS- Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONN DEVICE DEDICATED SPECIAL WASTE SYS DEDICATED GAS/OIL/SAND SYS DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYS DEDICATED WATER REUSE SYS DISHWASHER DRINKING FOUNTAIN FOOD WASTE GRINDER UNIT Q FLOOR /AREA DRAIN Q INTERCEPTOR INTERIOR KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET yyy URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES i WATER PIPING ^^nn t�J INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES ❑1 NO ❑ If you have checked YES, please indicate the type of coverage by checking the appropriate box below. LIABILITY INSURANCE POLICY D' 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 ❑ 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 compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER NAME: M_LWA_Iip10 LICENSE # [j�" I SIGNATURE COMPANY NAME: G 4 i ADDRESS] N CITY : .. v ra/ ` STATE: y ZIP: FAX: TEL: k"L'Q0 wl O 3 4 CELL:IgAyj"— 01 I .I EMAIL: F777777 lot MASTER N JOURNEYMAN ❑ CORPORATION ❑ # 0 PARTNERSHIP 0 # LLC Y # Date !�!�J� TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION Tiis certifies that..( c9-IrcUlyY .................................. .................... I .............. has permission for gas installation ... &P � *-,-Ie— A,11,7 ............................................................... in the buildings of .......:..:......<...f" . ................................................................ at ......).--j...... � n4. e4' .............. North Andover, Mass. Fee92..t). Lic. No. ... ....... ............................................. GASINSPECTOR Check# . � 4. n -� Q .1 7 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 applicatiop will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER/GASFITTER NAME: rc G _Z)f _ LICENSE # SIGNATURE COMPANY NAME: Ca Ill Y r LLQ ADDRESS:IN.a CITY: of .1 I STATE: ZIP:01 FAX: TEL: a°1 CELL: 80 EMAIL: MASTER C�, JOURNEYMAN ❑ LP INSTALLER ❑ CORPORATION ❑ # PARTNERSHIP ❑ # LLC ❑ # MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK COWNER )TYPE OR PRINT CLEARLY CITY v -�/&G MA. DATE f2—/PERMIT # t 0 JOBSITE ADDRESS OWNER'S NAME I PA Y c,'( t' a/ ` ADDRESS: (J l .a �1lJ _ TEL: FAX: OCCUPANCY TYPE: COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL`fp NEW: ❑ RENOVATION: ❑ REPLACEMENT % PLANS SUBMITTED: YES ❑ NO FIXUTRES Z FLOOR— Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER A 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 indicate the type of coverage by 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 El AGENT El SIGNATURE OF OWNER OR AGENT 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 applicatiop will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER/GASFITTER NAME: rc G _Z)f _ LICENSE # SIGNATURE COMPANY NAME: Ca Ill Y r LLQ ADDRESS:IN.a CITY: of .1 I STATE: ZIP:01 FAX: TEL: a°1 CELL: 80 EMAIL: MASTER C�, JOURNEYMAN ❑ LP INSTALLER ❑ CORPORATION ❑ # PARTNERSHIP ❑ # LLC ❑ # ar. a The Commonwealth of Massachusetts , Department of)ndustrig1 Accidlents Offlce of Investigations 660 Washington Street ! Boston, MA 02111 www.mass govIdia Workers' Compensation Insurance Affidavit: BuUdens/Cont actors/Electricians/Pliimbexr� A liealnt Znforrnation Please Prr nt Le •bl -Name, (Businessl0rganization/1nd%vidrzal)' Address lZl. � �. ►-� '1� r, Dl '� � 5> Phone #: � � � o � CxiylSf�ic�l r% Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4• ❑ I am a general contractor and 1 employees (fall and/or pax time) * 2 1 a sole or partner- have nedthe sub -contractors listed on the attached sheet. am proprietor ship and'have no employees These sub -contractors have worldng forme in any capacity. workers' comp. insurance. 5. ❑ We are a corporation and its [No workers' comp. insurance xequired.] officers have exercised. their 3. ❑ I an a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, §1(4), and we have no insuranceregaired.J ; 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 ILL] Plumbingrepairs or additions 12.❑ Roofrepairs 13.❑ other x.Any applicaatthat checks box#i must also fill outihe section below showingtheir workers' compensation policy information. t'Homeowners who mbmitthis affidavit indicating they A're doing all work and then hire outside contractors must submit anew affidavit indicafiug such. tContractors that cheokthis box must attached as additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an emyloyer that is providing workers' compensation 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 requireduunder Saciion 25A of MGL o.152 can lead to the imposition of criminal penalties of a — •—• - — fmo trp-fo $1,500:00 and/or-one=year imprisonment; as w&ll-as civil penalizes ui the form:of aSTOP W032K ORDER an = a tiro 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 ver'if'ication. X do Zzereby cert' irKder the pains and penalties of perjury that the information provided�ve is true and Correct. Qum afi�ra-• �� xvuv. Oreial arse only. Do not write in t/lis 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 Cleric 4. Electrical Inspector 5. Plumbing Inspector 6. Other - f n�fa�f. PPY�nri: _ 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 iii the service of another under any contract ofhire,. express or implied, oral or written." An employei is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the ioregomg engaged in a joint enterprise, and including the legalrepresentatives of a•deceasedemployex,.ox the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having notmore than three apartments and who resides therein,, or the occupant of Me 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, deemedto 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 fbr 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 notrequired to cavy workers' compensation insurance. Tian LLC or LLP does have employees, a policy is required. Be advised thatthis affidavit maybe submitted to the Department of Tudustrial Accidents fog 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 thatthe affidavit is complete andpriated 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 submitmultiple pennit/Ecense applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant shouldwrite "all locations in (city or towir): ' 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 affidavitis on fide :for future permits or licenses..A new affidavit must be filled out each year.-Where-aomme-owner-orcitizen-is-obtaining a:license�xpernutnot elated-toanybusinessox_eommeraialventure _-� (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 questions, please do not hepitaie to give us a call. The Department's address, telephone aird fax number: The Coxr_monwoalt� of Tassachv._.seits - Pe,partment ofludusWal .Accidents Otte offAvestip-ao u'a 6.9Q Washiugtm Strod Bostw, MA 021 It Tel, # 617-72,,7,4.9QQ at 406 ox 1-$77-MASS.A.FF, Revised 5-26-05 Fax # 617"727'7749 w�vtc.�,ass,govfclia