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HomeMy WebLinkAboutMiscellaneous - 20 CABOT ROAD 4/30/2018/ 20 CABOT ROAD - - 210/015.0-0024-0000.0 t ^ DEVAL L. PATRICK �s`'' GREGORY BIALECKI ('kVERNOR SECRETARY OF HOUSING + fly Commonwealth of Massachusetts AND ECONOMIC DEVELOPMENT TIMOTHY P. MURRAY Division of Professional Licensure BARBARA ANTHONY LIEUTENANT GOVERNOR 1000 Washington Street. Boston • Suite 710 "OF CONSUMER AFFAISECRETARY OF RS Massachusetts • 02118 January 2, 2013 Mr. Dick Doherty Plumbing & Gas Inspector 1600 Osgood Street North, Andover, MA. 01845 Re: PL-13-020 Watkins vs. Psomas Dear Mr. Doherty: I have been assigned to investigate a formal complaint.filed by Cheryl Watkins who owns property located at 20 Cabot Road. The complaint filed is against Ken Psomas, Journeyman plumber#30791 Also listed as Summit Plumbing and Heating. In order to properly investigate this matter, please research your office records from January 1, 20011 to Present and forward to this office copies of any of the following associated with the aforementioned address: 1. Copies of plumbing and/or gas application(s) and permit(s). 2. Copies of written approval(s) or violation(s) found as a result of inspection(s) performed. 3. Copies of relevant correspondence, facsimile or reports associated with this complaint. 4. Any other information you feel is pertinent to this investigation. 5. Please use city/town stationary for personal correspondence. If you have any questions please call 617 727-1738. Thank you in advance for your time and consideration in this matter. Your uly, Scott C.Padden State Investigator. ��',�' TELEPHONE: (617)727-3074 . FAX: (617)727-1944 TTY/TDD: 617.727.2099 http://www.mass.gov/dpl 12,1711-3 r 00 TOWN OF NORTH ANDOVER [PIr Office of the Building Department of ORT qq, Community Development and Services '� 9t.t• +�616 0 - - p 1600 Osgood Street, Bldg.20,Suite 2035 y North Andover, MA 01845 T y �gSSACHUS���� Richard Doherty—Plumbing and Gas Inspector January 8,2013 To:Scott C. Padden Fr: Richard Doherty Re:Watkins vs. Psomas Dear Mr. Padden, We received your letter regarding Watkins vs. Psomas on January 8,2013. The original permit pulled by Ken Psomas was on July 29, 2012. A letter from the homeowner, Cheryl Watkins,was received by our office on August 24, 2012 stating that she was changing plumbers. Two new permits were pulled on September 11,2012 by Joseph Bell.Copies of all aforementioned are enclosed. Sincerely, Richard Doherty Plumbing and Gas Inspector i lvWl- 116/2-d/3 �. TOWN OF NORTH ANDOVER C 0 P Y Office of the Building Department %A, TF/ q o ti Community Development and Services s "61 6 °A 1600 Osgood Street, Bldg. 20,Suite 2035 y North Andover, MA 01845 T h A�O9 � 10 7a AopAToo S`rAC HU`+� Richard Doherty\Plumbing and Gas Inspector January 8, 2013 To:Scott C. Padden Fr: Richard Doherty Re:Watkins vs. Psomas Dear Mr. Padden, We received your letter regarding Watkins vs. Psomas on January 8, 2013. The original permit pulled by Ken Psomas was on July 29, 2012. A letter from the homeowner, Cheryl Watkins,was received by our office on August 24,2012 stating that she was changing plumbers. Two new permits were pulled on September 11, 2012 by Joseph Bell. Copies of all aforementioned are enclosed. Sincerely, I Richard Doherty Plumbing and Gas Inspector Date.. ! ((.k . ... .. .. 1 „ORTN 0.,,-" , - 1 " 3� TOWN OF NORTH ANDOVER O 9 . i PERMIT FOR GAS INSTALLATION x; ��SSAC 14 This certifies that . . . . e � . has permission for gas install tion . . �?. . '�/v.' in the buildings of .t�• . (. .1. !�7. . . . . . . . . . . . . . . . at :Q . . . . . ?P '. . , Noo ver, Mass. 2X0 . . Lic. No.,3t)3Q. . . . . . . . . . . . . . . . . . . ii GA INS ECTOH Check# t �p r� 8324 l - r� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK r CITYo:._Y_ t lkl E� ? �( MA DATE _'_ PERMIT# JOBSITE ADDRESS �.--CYI- , _ _ OWNER'S NAME I _��c eyL OWNER ADDRESS TE 7SFAX PRPEVOT OCCUPANCY TYPE COMMERCIAL I EDUCATIONAL RESIDENTIAL CLEARLY NEW:13 RENOVATION: REPLACEMENT: -1 PLANS SUBMITTED: YES[1__f NO APPLIANCES 7 FLOORS- BSM 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 .. _ f —--T=— — FURNACE -_I 1— 1 .. . =-1f[— GENERATOR GRILLE INFRARED HEATER — LABORATORY COCKS MAKEUP AIR UNIT - lam_-,._ L ------�I_= POOL HEATER ROOM/SPACE HEATER --- ROOF TOP U NIT �I .�1J TES UNIT HEATER UNVENTED ROOM HEATER F7A=! ___..,.f WATER HEATER 1-11=1-- I i--J I__.-1 _ _-(I --i i�!I �i—A . f .._— --I --- ---� l�—. V _ .:.— �!__--- -t----=-1'—��1.--h I:—Jl����l_�_.�I_�_:_�►I —,__l.�_� —==I INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES _.__ NO D IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVEBY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY RA OTHER TYPE INDEMNITY BOND !—I 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 0 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 d 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 comp' ce with II Pertinent�n of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUM BER-GASFITTER NAME rjLICENSE SIGNATURE — MP 0 MGF 0 JP WJGF LPGI __�-_d CORPORATION 0#=PAR N SHIP0f#1—�__��LLCf# COMPANYNAME: (/1')1(� ��dn(a�`�~' , ADDRESS CITY w+ S �.. --- _� STATE 1 ZIP TEL FAX CELL � EMAIL OY l l 06 6 Cow% h-s /U4T ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT FEE: $ PERMIT# PLAN REVIEW NOTES I , The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA.02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual):�l Address: 2 City/State/Zip:_ ,2y- � !y�} c3ygftone#:_ �7$ S 5_7 175-1-- Are 75-1--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 e oyees(full and/or part-time).* have Hired the sub-contractors 2. I am a sole proprietor or partner- listed on the attached sheet. 7• E]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 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 MGL M❑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.] 1311 Other !Any applicant that checks box 91 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. #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.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 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 certlo u . er to pal s a/nd penalties of rjury that the information provided above is true and correct. Signafore: ` a2 ��� Date:Phone#: 7�/ 7 7,7, ty,"a only. Do not write in this area,to be completed by city or town official. Foit 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#• 1 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 ofhire,• implied,or express oral or written" p 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 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. Anew 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 COMmoxlwealth of Massaclhvsetts Department of.Industrial Accidents Office ofInvestigations 600 Washington Street Boston?MA 02111 `QL#417-7274900 ext 406 or 1-877,MASSAFE Revised 5-26-05 Fax#617-727-7749 www.mass,govldia 7-j 7 Date. . 9574 %ORT#1 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING 3 CHUS f. r. This certifies that J.6 - . . . . J .. . . . . . . . . . . . . . . . . . has permission to perform . '.S. . . . . . .. O . . . . . . . . . . . . . . plumbing in the buildings of .w C" Vl'! -`7 . . . . . . . . . . . . . . . . . . . . at. .2U. . .00' 4 . �Pe�. . . . . . . . . . .. North Andover, Mass. FeeAO,00. .Lic. No,5J550 . . . . . . . . . . . . . . PLUMBING INSPECTOR Check S A\ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY LP°y .9 ct 1 -11 MA DATE PERMIT# JOBSITEADDRESS OWNER'SNAME Luf�L OWNER ADDRESS TEL __� TYPE OR OCCUPANCY TYPE COMMERCIAL[71 EDUCATIONAL Eli RESIDENTIAL PRINT CLEARLY NEW: Q RENOVATION:Ej REPLACEMENT: PLANS SUBMITTED: YES Q NOME FIXTURES'l FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB _.__( CROSS CONNECTION DEVICE J _j DEDICATED SPECIAL WASTE SYSTEM _.. { ._____E _-..----t DEDICATED GASIOILISAND SYSTEM DEDICATED GREASE SYSTEM =_1 _..___..I _._ 1 __._.--_{ ---...__.1 _ I .._.._.__I _..._...-..__I _--.---_Ir.-___._.i .__ I ._.---__..I __T€ _JI DEDICATED 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 .______I URINAL _.....__...! _- -._€ ___.....__..€ -----._-_ __.-._..J- _.__._._i. ....._...__.I .--- WASHING MACHINE CONNECTION WATER HEATER ALL TYPES - WATER PIPING OTHER INSURANCE COVERAGE: I have a current liab_ ility insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142, YES NO IF YOU CHECKED YES,PLEASE INDICATE TH�TYPE OVERAGE BY CHECKING THE APPROPRIATE BOX BELOW 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 _i AGENT �Q SIGNATURE OF OWNER OR AGENT R 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'S NAME .lI%t �,( _ ;!LICENSE -3�53D._ SIGNATURE MP D JP CORPORATION R# _ �PARTNERSHIP _-I#�_ �J LLC #€ COMPANY NAME rt�1ADDRESS L� i - f-- - CITY ,STATE ---�--- ---_._.. ._....._.. -� i ZIP 0.3g�_! TEL A01 FAX r-- CELL _._.._....._...._-_.__3 EMAIL _���i¢�e_[ t ..-------..._..-- ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# t PLAN REVIEW NOTES IE I t i I I �I I -a- The Commonwealth of Massachusetts Department of Industrial Accidents Office of Invesdgations 600 Washington Street Boston,MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): _�� Address: 2 tr-& City/State/Zip: esW A1+ 63 0i`f( Phone Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a eTpJoyer with 4. ❑ I am a general contractor and I em ees(full and/or part-time).* have hired the sub-contractors 6• ❑New construction 2. am a sole proprietor or partner- listed on the attached sheet. ❑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 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 MGL 11.❑Plumbing repairs or additions myself. [No workers'comp. c. 152, §1(4),and we have no 12.❑Roof repairs insurance required.]i 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. 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. .ram an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site reformation. nsurance Company Name: 'olicy#or Self-ins.Lie.#: Expiration Date: ob Site Address: City/State/Zip: attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ine 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 ,f up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of nvestigations of the DIA for insurance coverage verification. do hereby certify i der the pains and penalties of per' ry that the information provided above is true and correct. i ature: —' f i - Date: / G •'� ?i' hone#: ' / —17s"S_ 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 necessary,supply sub-contractor(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 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 Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE evised 5-26-05 Fax#617-727-7749 www,mass.gov/dia Date.. . 1 i L 'HOFTH °�° TOWN OF NORTH ANDOVER 3 � PERMIT FOR GAS INSTALLATION • � a o This certifies that . . . ./X �`?. . . © . . . . . . . has permission for gas installation in the buildings of,. ihS. . . . at . . . . . .. . . . . . . . . . .S . . . . . . . Norah AAdover,-Mass. Fee �9� . Lic. No.A >�. . GAS INSPECTOO R , Check# �Oy 8276 i MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK �2 CITY „� �,�,� MA DATE PERMIT# JOBSITE ADDRESS OWNER'S NAME „fig GOWNER ADDRESS TE FAX TYPE OR OCCUPANCY TYPE COMMERCIAL _I EDUCATIONAL I RESIDENTIAL �1 PRINT CLEARLY NEWT-1 RENOVATION:D REPLACEMENT: PLANS SUBMITTED: YES NOD APPLIANCES Z FLOORS- BSM 1 2 3 4 5 1 6 7 1 8 9 10 11 12 1 13 14 BOILER -:j E: I. ._ L.J11 BOOSTER =— �^ _� == c, CONVERSION BURNER COOK STOVE DIRECT VENT HEATER _ DRYER FIREPLACE r_J I: A FRYOLATOR �-- FURNACE — - s J GENERATOR r--_,� �__I.I-vl 1. _-�( t,,, -� 1-1 GRILLE 2�Q lti-4� INFRARED HEATER LABORATORY COCKSY�__._ _ I I n MAKEUP AIR UNIT OVEN POOL HEATER [^ .J ._. I _—r a I ..1. ROOM/SPACE HEATER -- ROOF TOP UNIT f —TEST I II, J. .:I -- _I I _l. _ -- i UNIT HEATER !,INVENTED ROOM HEATER NATER HEATER I —1.( —f ___:_ _1 __ __I. -•-- _f_ I _ T w_�.'r,^�:—_— __,. .I _— —= OTHER . --s--J. . - C _ r - _ J . INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES (91NOD__I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY _�f_I OTHER TYPE INDEMNITY BOND 1—( OWNERS 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 [1 AGENT �f SIGNATURE OF OWNER OR AGENT e 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 wKMh Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUM BER-GASFITTER NAMEeN_ ✓v1 a_ LICENSE# _3? �_I SIGNATOR MP 0 MGF E-JI JP [ JGFD LPGI ( CORPORATION D#L� �I PARTNERSHIP D#=LLC D# COMPANY NAME: � �Z•{-�, ADDRESS 3 _ r CITY �' �_'° ^_ STATE ZIP �TEL FAX -CELL - EMAIL ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES 'fes ' N'o THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES a� q`r MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 'r CITY Ch �,,, �,,�,{,�_ MA DATEa/� PERMIT# JOBSITE ADDRESS S_ OWNER'S NAME GOWNER ADDRESS TEL[-- �__ FAX TYPE�OTR OCCUPANCY TYPE COMMERCIAL I EDUCATIONAL ® RESIDENTIAL(�1 CLEARLY NEWT] RENOVATION:0 REPLACEMENT: PLANS SUBMITTED: YES[II NO Q APPLIANCES 7 FLOORS- BSM 1 2 3 4 5 6 7 1 8 9 10 11 12 13 14 BOILER — �J J. I _ I L - BOOSTER ^ CONVERSION BURNER ._..;ill COOK STOVE .,J DIRECT VENT HEATER (L+ I DRYER FIREPLACE - FRYOLATORlil FURNACE . - ---GENERATORGRILLE INFRARED HEATERLABORATORY COCKS MAKEUP . :-- AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ._ ROOF TOP UNIT -TEST UNIT HEATER INVENTED ROOM HEATER '1jVATER HEATER OTHtR _. INSURANCE COVERAGE 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES QINO D_( I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER 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 0 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 w' Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUM BER-GASFITTER NAME --o- ta_3._ _=LICENSE#_ �?t`_� SIGNATUR MP 0 M G F JP J G F LPGI CORPORATION Q# PARTNERSHIP[.��(#=LLC # COMPANY NAME: , ,,n ADDRESS CITY STATE _�ZIP TEL r FAX CELL _ EMAIL ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES 'fes ' Nb THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES �r � c4 , The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations VV 600 Washington Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information L Please Print Legibly Name(Business/Organization/Individual): 4�u,, Z!L�11( Address: 3y S o GZ C_ City/State/Zip: , a 6L)d /14 A Phone#: ED 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 employees(full and/or part-time).* have hired the sub-contractors 2.U/I am a sole proprietor or partner- listed on the attached sheet. �• ❑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 5. ❑ We are a corporation and its officers have exercised their 10.El Electrical repairs or additions required.] 3.❑ I am a homeowner doing all work right of exemption per MGL 11.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.❑Other *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:. 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 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 certto und&the pains and penalties of perjury that the information provided above is true and correct. Signafore: Date: c7 .fid( Phone#: " (5 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#• M 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 ofhire,- 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 maybe 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.,MSA.02111 Tel,#617-727-4900 ext 406 or 1-877rMASS.AFB Revised 5-26-05 Fax#617-727-7749 www.mass.gov1dia Mr. Richard Danforth Town of North Andover 1600 Osgood St., Bldg 20 Ste. 2-36 North Andover, MA 01845 August 23, 2012 Mr. Danforth: Per your instructions, I am writing to let you know that I no longer wish to employ Ken Psomas, Summit Plumbing & Heating, as my contractor to install gas heating in my home. Please remove his name from Permit 8276. Thank you, Cheryl Watkins 20 Cabot Rd. North Andover, MA 01845 978-688-3583