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HomeMy WebLinkAboutMiscellaneous - 196 COTUIT STREET 4/30/2018 196 COTUIT STREET 210/023.0-0023-0000.0 Date.../.1.`/..//..57........ OF NORTF�,�O TOWN OF NORTH ANDOVER ° p PERMIT FOR PLUMBING �CHu This certifies that.... ........................................ Chas permission to perform...........k"l-.!.-K !..{..:Ar..J. - .. ..................................... plumbing in the buildings of .` ! ...................................................... at........................... ............ o .. ...., North Andover, Mass. Fee . .....Lic. No. &(v...!�o. ................................................................................. opG q5� PLUMBING INSPECTOR Check# 4 S-N MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY; _ . _. G6.0 2 MA DATE' PERMIT# 2 1 JOBSITE ADDRESS OWNER'S NAME!�a-J► OWNER ADDRESS ` _ v ., _ , __. _ TEL:, '-qj -...—FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL [- RESIDENTIAL PRINT CLEARLY NEW: ^ RENOVATION:[- REPLACEMENT:, PLANS SUBMITTED: YES[ j N FIXTURES Z FLOOR BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE •al- DEDICATED SPECIAL WASTE SYSTEM _ DEDICATED GAS/OIUSAND SYSTEM D ICATED GREASE SYSTEM DICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER — FLOOR/AREA DRAIN (� INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN - SHOWER STALL SERVICE/MOP SINK _ - TOILET URINAL WASHING MACHINE CONNECTION - WATER HEATER ALL TYPES WATER PIPING OTHER I - - - -- INSURANCE COVERAGE: I hive a current liabili insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES I NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY - , OTHER TYPE OF INDEMNITY [— BOND E' OWNER'S INSURANCE WAIVER:I a 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 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 compliance with all Perti rovision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME it ;/lj(4pj . St.r2�1�24'tJ•. i'''J.- LICENSE# G'LE'�If_ SIGNATURE MP-^ JP CORPORATION PARTNERSHIP[_ .#'LLC F# COMPANY NAME,�,l,7)1}7L31 S- - m.6�. V- �✓. c ADDRESS F�f X.l/� /1 I i; CITY , STATE' ZIP 3 TEL' c FAX F7(/ ')7(j CELL _ EMAIL I. 4(--t At 7172,21.4�=�c��?d/.�. I Date..?/ ............................. OF NORTM,� TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION sSACmus� This certifies that .. !........... ...........�. .^^..a^-s...................................... has permission for gas installation in the buildings of...... ,r?.. 40 j ..... ....................................................... ........................ at..........1.�.9...�...... c k..................�......' .......... North Andover, Mass. ...... Fee. �. .... Lic. No. .f 0(0 �...... ..................................................................... �6 7 GASINSPECTOR Check# 561 /"I�-- d0%t (�- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WOR - CITYMA DATE PERMIT# JOBSITE ADDRESS� - u`i _ OWNER'S NAME _ _ ., j �a GOWNER ADDRESS FAX TYRE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL E-- PRINT CLEARLY NEW:C RENOVATION:[ REPLACEMENT:Lq PLANS SUBMITTED: YES El NO APPLIANCES 1 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE p: - DIRECT VENT HEATER DRYER _ _... FIREPLACE - FRYOLATOR FURNACE ' GENERATOR GRILLE INFRARED HEATER - LABORATORY COCKS MAKEUP AIR UNIT OVEN - - _ ..._. POOL HEATER - _ ROOM I SPACE HEATER ROOF TOP UNIT TEST - UNIT HEATER _ UNVENTED ROOM HEATER WATER HEATER OTHER L - - - - INSURANCE COVERAGE I Piave a current liabilitt nsurance 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 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 ( , AGENT I 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 Sion of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME LICENSE# _ i"(�, SIGNATURE II.ic�;��f-w X47)/7—rS— . �crr i� MP MGF� 1 JP I- JGF;, LPGI E] CORPORATION[)#�t;?� PARTNERSHIP—#I--"LLC '# T COMPANY NAME: Ph-A21�I �tn �T.t��!i��=__ iADDRESS We i?`X:liy;. _�/ /<� .c(. CITY ti STATE /�J I'L ZIP 1' TEL /� ,CELL - EMAIL_ 7�G7J .�7?.b/� _�C�r _ FAX L7�f-7 __YJ ____ The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations . � 600 Washington Street r Boston,MA 02111 Lam ` www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/individual): 9 jt �{ Ic Address: Qt r 1/ � 1/ (✓r City/State/Zip:�,,�bt,�r lo L A)4 6 3F7Y y Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1. I am a employer with 4. ❑ I am a general contractor and I 6. New construction G'- employees(full and/orart-time).* have hired the sub-contractors P 2. i am a I listed on the attached sheet, t E] Remodeling ❑ sole proprietor or artner- P P P ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. q. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions right of exemption per MGL 11.❑Plumbing repairs or additions J.El 1 am a homeowner doing all work myself. [No workers'comp. c. 152, §I(4),and we have no 12.❑ Roof repairs insurance required.]' employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. i + 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 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. Insurance Company Name: YkiA c� &, .r Policy#or Self-ins. Lie.#: OIV q2,?� :7y yy Expiration Date: 0�Z34 Job Site Address: / g ( ( T � ']'L City/State/Zip: . A_-4�d_ &/I � - 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. I do hereb ceruder the air andpenaltes ofperjury that the information provided above is true and correct. Sitrnature: Date: -///,o lr Phone#: S 3 �7 Official use only. Do not write in this area,to be completed by city or town ofciaL 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 Contact Person: Phone#: ATE IDD ACCORO CERTIFICATE OF LIABILITY INSURANCE D7 13 20/'5) ii THIS 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(S), 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). PRODUCER CONTACT NAME: Cathy Merrifield Core Benefits Group IncaHCNN (603)329-4933 alAX No: (603)329-4924 2 Village Green Road E-DRESS:cmerrifield@mycoreinsurance.com Suite A-1 INSURERS)AFFORDING COVERAGE NAICk Hampstead NH 03841 INSURERA:Merchants Mutual Insurance Company 23329 INSURED INSURER B:NorGIIARD Insurance Company 31470 T & W Plumbing & Heating Inc INSURERC: Dba Simmons Plumbing & Hvac INSURER D: Po BOX 1199 INSURER E: Seabrook NH 03874-1199 INSURERF: COVERAGES CERTIFICATE NUMBER:CL1561100859 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 BEEN REDUCED BY PAID CLAIMS. ILTRR TYPE OF INSURANCE ADDL UBR POLICY NUMBER MD POLICY EFF POLICDN EXP LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADE ❑X OCCUR DAMAGE TO RENTED 500,000 PREMISES Ea occurrence $ BOPI071642 3/30/2015 3/30/2016 MED EXP(Any one person) $ 15,000 PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY RO PPRODUCTS-COMP/OP AGG $ JECT LOG 2,000,000 OTHER: Empl Practices Liab Ins $ 100,000 AUTOMOBILE LIABILITY Ea BINEDtSINGLE LIMIT $ 1,000,000 A ANY AUTO BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED CAP9267990 5/23/2015 5/23/2016 BODILY INJURY(Perident $ AUTOS AUTOS accident) X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident Medical Expense $ 5,000 X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 2,000,000 A EXCESS LIAR CLAIMS-MADE AGGREGATE $ 2,000,000 DED I X I RETENTION$ 10,000 CUP9146654 3/30/2015 3/30/2016 $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 500,000 OFFICERIMEMBER EXCLUDED? NIA A B (Mandatory in NH) TWWC656431 3/30/2015 3/30/2016 E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500 000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1600 Osgood Street ACCORDANCE WITH THE POLICY PROVISIONS. Building 20, Suite 2035 North Andover, MA 01845 AUTHORIZED REPRESENTATIVE C Merrifield/CATHY ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025(201401) s o COMMONWF` H OF M,..S. SETTS: MOBIL 9 ki. . BQA{3D`t�P PLUMBEIS; .AND GASFj,TTERS< ISSUES T;HE FOLLOWING' LIGE`NSE Q ; L 1 SENSED AS A JOURNEYMAN,PLUMBE.N a {RAO SALL I NGER s. 495 4JINNACUNNET R, 12 -- 1AMPTON NO 03842— 0 O:J,: :::]>6 <::::< 2 09 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance-with the provisions of M.G.L.c.143,§3L,the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166,§32,an Ai electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L.c.143,§3L. Permits shall-be limited as to the time of ongoing construction activity,and may be.deemed-by the-Inspector_of_Wires abandoned.and.in.validif_he.—_. ._ 4 or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence"during the qualifying period beginning on August 15,2008 and extending-through August 15,2012. [yule 8—Permit/Date Closed: � ���� /' ***Note:Reapply for new permit 0 Permit Extension Act—Permit/Date Closed: w // Date/-...(�....-.�.v...... NORTH °ft"`°:•,"° TOWN OF NORTH ANDOVER p PERMIT FOR WIRING ,s$ACMUSE� • 'this certifies that ......E�. . ..... .1.Z.s.I !..�- ............ . .............................. has permission to perform ......S 4`�.......37 1..�. .A vti.p 5,,� l i y wiring in the building of ���G.. G L C '` ... .............. ................................. q ......C..4 ,�'•. .......&....:.................. North Andoveh Mass. Fee: ,� Lic.No. 23✓l 4. . ............... ............. ................... .... . . ... ... ... .... E CTRICALINS PE Check # S Ir 9 + 9t Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. 9 BOARD OF FIRE PREVENTION UV REGULATIONS Occupancy and Fee Checked [Rev. 1/07) (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT W INK OR TYPE ALL INFORMATION) Date: City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) 1'� Ce C o. �" ; � 5 f- Owner or Tenant Dp o (yam N ( d1r le Telephone No. Owner's Address Ii Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building Blest , I Utility Authorization No. Existing Service Z&,,;, Amps lza /Z`f UVolts Overhead.® Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity w Location and Nature of Proposed Electrical Work: Completion of±hyollowing table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires 1 Swimming Pool Ad.bove El d.In- ❑ o.o Units cy ig g Batte Units -- No.of Receptacle Outlets I No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches 3No.of Gas Burners No.of Dal etection and Initiatin Devices al No.of Ranges No.of Air Cond. Tot No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: ' - - Detection/Alertin Devices No.of Dishwashers Space/Area HeatingKW Municipal Local❑ Connection ❑ Other No.of Dryers Heating Appliances KW Security Systems: ti No.of Water No.of No.of Devices or Equivalent Heaters KW Signs No.of Ballasts Data Wiring: : s° No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total Hp Telecommunications Wiring: OTHER: No.of Devices or Equivalent tb��4rn L-)-3- Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: 1- to- 0 Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE [� BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penaldes ofperjury, that the information on this application is true and complete FIRM NAME: G �� �h iC LIC.NO.: lZ 31n1 YL Licensee: 1_&w revs [. Signature LIC.NO.: ! Z 3 BIZ (If applicably ter"exempt"in the i nse numb line.) b Address: X Bus.Tel.No.:(p6 -3C,73 ss. �o� �►�1 l ���� L � l�ri lei^ 5 Alt.Tel.No.:1pb3-?18. Lo S`r'7 *Per M.G.L c. 147,s. 57-61,security work requires Department of Public Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one) ❑ owner ❑owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE. $ ' The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations U1 600 Washington Street Boston, AlA-02111 www.massgov/dia Workers' Compensation Insurance Affidavit: ra Builders/Contctors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): 2 L-e t o CVVI It e— Address: z:;,A ► Z� City/State/Zip: M,p� 834 Phone#: CF63 -c%Z(o- a�/ Are you an employer? Check the appropriate bog: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.1 I am a sole proprietor or partner- listed on the attached sheet. 7• ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑Building addition [No workers' comp. insurance S. ❑ We are a corporation and its 10. Electrical re ❑ airs or additions required.] officers have exercised their p 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' 13.[:] Other comp. insurance required.] t A-....ppli..ant t Jl1 m -, lso 111 ....y�,r.i„a..�that checks ,�, ..:,:� ,,.,. 111out 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 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. Insurance Company Name: Policy#or Self4ns. 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 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. I do hereby cert' nder the pa' andpi7qfties of perjury that the information provided above is true and correct � SignV , ature: Date: l �/ 1 G Phone#: 6:>63—'726- 3c;,-3, / 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 Contact Person: 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 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 a 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 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 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 Iicense or permit to bum 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 Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington.Street Boston, SIA 02111 Tel # 617-7274900 ext 406 or 1-877-M,ASSAFE Fax# 617-727-7749 Revised 5-26-OS vv%A,?v.mas ,govfdia Oe NORT;14, TOWN OF NORTH ANDOVER 3r 0 •• OL PERMIT FOR PLUMBING This certifies that . . . . . . . . . . .. . . . . . . . .�. . . . . . . . . . . . . . has permission to perform +.J! ". . . . . . . . . . . . . . plumbing in the buildings of . /.q�. . .�'o v/V► T S . . . . . . . . . . . . . . . . . at . . . . . .�.►.5 iWA.I. . . . . . . . . . . . . .f._. . . . . . . . . . , North Andover, Mass e. .' .Lic. No.. . "(J Y. . . . . . . . . . . . . . . . . . . . ... . . . . . . . PLUMBING INSPECTOR Check # � � S �f MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS Date 12-131v 9 Building Location Permit# J Amount Owner CU A w New rl Renovation Replacement �� Plans Submitted Yes [3 No FIXTURES MUM BMW 2MROCR 3M MM aMRIM 5M s1HEWM AHELOCK gmKIM (Print or type) /Pili / Check e: Certificate Installing Company Name ❑ 14 Corp. Address L� 1-1 Partner. '_�0 /l,/ Business Telephone y �Firm/C0. r M Name of Licensed Plumber: Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity Bond Insurance Waiver: I,the undersigned,have been made aware that the licensee of this application does not have any one of the above three insurance signature Owner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and insfions erformed unre Permit Is d for this application will be in compliance with all pertinent provisions of the Massah`' S PI bung C and er the General Laws. �' Sifnalure o rcens um Title er Type of PIumbing Licens City/TownLicense 1Qi>mtz— Master Journevman 0 APPROVED(OFFICE USE ONLY ✓ The Commonwealth of Massachusetts Department of Industrial Accidents Office ofInvestigations 600 Washington Street Boston, MA 02111 www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LeQ><bly Name(Business/Organization/Individual): Address: City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with. 4. ❑ 1 am.a general contractor and I 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• ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any caPacit3workers' comp.insurance. 9, E]Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MG P p L ll-El Plumbing repairs or additions myself.[No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.] t employees. [No workers' comp.insurance required.] 13.0 Other 'Amy applicant that checLc box#1 must also fill out the section below _ �� h ---.,�n..b� er werrers'compensation policy info-ma-tion. 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 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. 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. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Signature: Date: Phone#: F[Other only. Do not write in this area, to be completed by city or town official Town: Permit/License# hority(circle one): Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.PIumbing Inspector son: 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 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-contactor(s)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 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 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 bum 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 Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. #617-72.7-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 5-26-05 w-wvv.mass..gov/dia Date. .. .. ... . . . . . . ... . . HpRTM pf „ao ,°,tip 3� TOWN OF NORTH ANDOVER O D PERMIT FOR GAS INSTALLATION ,SSACHUSEt This certifies that . . . ` . .(. . . . :. . . . . ... . . . . . . . . . . . . . . . . . . . . �-,( has permission for gas installation . . . . . . . . . . . . . . . . . . . . . . . . . . . . in the buildings of . : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . at . . ?. . . . . . . . . . . . . . .. . . . . . . . . . . . . .. North Andover, Mass. Fee. . . . . . . . . Lic. No.. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . GASINSPECTOR Check# �J MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) �f n ,MA Date /O _`2 20,OL Receipt# Permit# J �� Building Location /� u �' Owners Name W4 Map: Lot: Zone: Type of Occupancyjs+�'Y�' New ❑ Renovation rfA Replacement❑ Plans Submitted: Yes❑ No Fee: y y Y W U1 5 W Gy N N U Z F W N O cr N = F O W ¢ O V 0 f0 Z J N W } m Z S = _ Q Q O W Q S m Z O O Z F m N W W O d -9 _ W N O W Q = Z ~ N O ¢ > W () W t� Q G O W W to y — Q Z cc M W ¢ W ~ W ~ _ 2 V' F- Z J F 2 F W W O O > W F W J F W 2 Q W — Q M — F > N m 2 O 2 ¢ O y Z Q W > ¢ W n Z Q ¢ Q Q O O W _ O W �- X 0 a x LL n 3 0 a -j o ¢ > o a o SUB-BSMT. BASEMENT IST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR 5TH FLOOR 6TH FLOOR 7TH FLOOR 8TH FLOOR c Installing Company Name Checkone: Certificate Address �C Corporation EstimateValueofWork: ❑ Partnership Business Telephone7 ' -3` ❑ Firm/Co. Name of Licensed Plumber orGas Fitter Gb INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yeseb No ❑ If you have checked Les, please indicate the type coverage by checking the appropriate box. A liability insurance policy 0 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 Mass. General Laws, and that my signature on this permit application waives this requirement. Checkone: Owner❑ Agent❑ Signature of Owner or Owner's Agent I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the bestof my knowledge and that all plumbing work and installations performed underthe permitissued for ' application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General By Type of License: Plumber Signature of License/// g 'lumber or Gas Fitter Title Gasfitter / / g Master License Number— City/Town umberCity/Town Journeyman APPROVED (OFFICE USE ONLY) Revised 05/17/00 BELOW FOR OFFICE USE ONLY FINAL INSPECTION SKETCHES PROGRESS INSPECTION FEE NO. APPLICATION FOR PERMIT TO DO GASFITTING NAME &TYPE OF BULIDING LOCATION OF BULIDING PLUMBER OR GASFITTER LIC. NO. PERMIT GRANTED DATE 20 GASINSPECTOR