HomeMy WebLinkAboutMiscellaneous - 21 HEATH ROAD 4/30/2018N
J
O
N
O
D =
o �
b
O
O D
� O
O
Date . /. 014 7./ t7.
• 1YLRb3
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that..`(� ..�....�..... .. . • •��' � •
has permission for gas installation ..� /L P .... • . .
in the buildings of. ?? !� I It A.5 ..........................
,at.. c�. (... ��'¢ i.h ... 1 G........... . , North Andover, Mass.
FeeLic. No.P% .
GASINSPECTOR
Check # ) 3 �y
�1
wa,
11
•`
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
-A
-�
CITY �,(! , Fi' � vy---�� MA DATE PERMIT #
V�
JOBSITE ADDRESS i J;- i!L�OWNER'S NAME EP,/2-_,'
GOWNER
ADDRESS s-i� 11 TELF _ _ FAX
TYPE OR
PRINT
OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL
CLEARLY
NEW: [ RENOVATION: REPLACEMENT: F_'3' PLANS SUBMITTED: YES 0 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
DIRECT VENT HEATER Y -,I..- . �J ......._ f ,-,- I . _. _ --- J I * 1 _... _ -.
DRYER t)
FIREPLACE
FRYOLATOR
FURNACE l I�_l T :. _.. .-. , �_ -- ---= r + - =j
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM / SPACE HEATER , ..
ROOF TOP UNIT -
TEST I I_
UNIT HEATER
UNVENTED ROOM HEATER,-� I I I f
WATER HEATER
OTHER !
INSURANCE COVERAGE
have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch.142 YES ENO[
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY ER- OTHER TYPE INDEMNITY E] 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 (l AGENT �,,.J
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 est of my knowledge
'§yon
and that all plumbing work and installations performed under the permit issued for this application will be in co n with al Perit provi of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
✓/�---P
PLUMBER GASFITTER NAME `� l�.C(�w_Z_LICENSE# ( SIGNATURE
MP 0 MGF E-11 JP JGF 0 LPGI CORPORATION PARTNERSHIP 0#= LLC # �
COMPANY NAME: ADDRESS
CITY STATE _j!i_-i- ZIP / TEL L
FAX fv'k�� CES �TIJ�7_ S.._ EMAIL .._
T_
O
z
0
F
U
W
a
w
a z❑
o °y' ❑
�-
W
'� ~ W
a H
�
O wa Z
LLI
a w �
N a
� w
O
w
w C a
o a
a a
J
H a
CL
C w
s w
F- w
W
H
O
z
0
H
U
C7
°a
0
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
kvi. www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):
Address:
City/State/Zip:
Phone #:
Are you an employer? Check the appropriate box:
L ❑ I 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.
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
I1.❑ Plumbing repairs or additions
12.❑ Roof repairs
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 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.
f do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Signature: Date
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 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
Revised 5-26-05
Fax # 617-727-7749
www.mass,gov/dia
Location derr-RI D
No. 3 7 1 Date
$-DZ
f gORTh
0.4t.•o •14<
.a
,SSACHUSEt
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
ound tion Permit Fee $
Permit Fee $
Sewer Connection Fee $
Water Connection Fee $
TOTAL
$622
y�
Q..)6$
Aid
•50A16ding Inspector
Div. Public Works
W
Q
a
Y
0
0
m
W
F -
Q
W
N
YI
a
N
W
z
0 u
Z
W
0
0
a3 Ul
W_
� m
0 0 m
0 0
w W N
a 0
N d Z
z 0 \
H m r
0 N 1
W
a z
Q
F`JN
WIa
0
0:
O
z
N
h
N
N
C
W
m
i
F
A:
0
0
J
4
LL
0
W
N
N
to
w
W
Z
Y
u
x
h
I
N Z
K 0
J 0 <
a la {7 0
Z
LL O
0 0 Z
U. 0
Lo
Z LL 0
0 0 I.
w LL
Z x 0
< % N
y O x to
a i
N
Z {
{
z
O
0
L �Q
0
J {
i
120 vv
m
U
�
U.
0 {
9
m
LL
O 1
Q
Z
Z
m
f �
m
K
0 i
Z
a'C
66
•
0
W
0
N
m
L
Z
Z
m
L
0
o
u
5
uu
o
Z�
f
a
IL
UU
Q
W W
W
0
U
0
m
0
m
0
m
a
u
W
Z
1-
F
1-
I-.
h
II
Z
O
M
J
W
W
W
0
U U S
a i
N
Z {
{
z
O
0
J {
i
m
U
U.
0 {
W
N
O 1
Z
f �
Vl
0 i
Z
•
0
N
m
{
W
Z
Z
m
0
O
F
to
UU
W
W
i {
N
{A
I-.
h
II
a
0
0
h
to
J
J
f {
F
I�
u-
0
m
W
W
h l
U
m
a
a
W
t
1
+m
O
a
0 0)
y
O
M
OOn,nCCmT
AOA
A
>0
mOO
my nm
ND
D0INGZ
B;.ti
O
^'xD
yDm
OZ;DD
Nnzz
A n r)
�
p
00000
00QO
0 �
i2A
A00
0
Myy
m
ZzAzzoo5w
n
D
CA>GO
ZTT
N;
D
Z
>O
ZDN
{
O
O
mo
A
OZQT
p
N�
-'ZD
-<
0
j
ZC1
IAF_
1111111111
U111111111111
_
I
III
Z �^
O m-
O GI
r D
CAD
Z D
2
p Q
y T
O
A
m
y
-+;
0
y z
D Q
A
D
G
� y m
D O y
_
D C
O
D`
y
D
N
n 2
ODD
n
0
W
;
O
T T_
m z
T
Z
C O T
Z A D
S vi
D Z
IIY��
W
.�
cc^
Q N
('1
=
N
y v
a
n <<
D A
m
r
T
T O
T
r
r T
n
S y
y
A y=
0
m
O
_
n
T;
=
A A
S S
Z
m
v
T D
T{
Z` y
p
< C m
1/
T O
f1 F
A
D n
m y
G;
0 y
C
N
O
D
A
Z
N C
z 0
z
_A
D O
p
y
y
O
o
p
Z
13
n
D A<
-4
N N
y=
o A
p
O
T
'°
O m
N<;
'_
m
N
r
z
n
y
o
Z
0
O
N y-
A
y
A T
x
f z
O N x
C
C
Qp
T
n
N p
D
A
z
QZD
AD
~
yT
°�
I
1
7O`
DD
�o
T
I I I la
y
O A
Z
m Z
rnAO
N
x
Z
Z V
0
00
M
Z
l
A I I (-
I I I IJ
T A
IIIIIIIW
IIII
0
0
c
T
D
z
n
SON N
yrN
zm
a0
NZz
�cc
AKN
DU)
n
0q0
N0:E
vim
mx
-1zD
IUln
Noo
;az
-
mNi
HOZ
m
NCZ
F
N
000
-+
0r
•ANO
r -+
a
?�z
=v
0�
fol z
in
mm
00
D0
3
m
m
n
O
�v
v
CA
CDZ
O O
� r
CD
d �
Q
D
'C3
� O
v
Q
Q
0
CD O
5. Q
�C CD
CO)
10
CD
O
v,
CA
� O
O
y p
C.) t S
o ►�
C rp
y
C-)
CD
O "II
CD
CD
CD O
� n
y
CD
C4)
I
O
Z oq
CD
O
C
CD
cn
0
z
cn
! C
O
0
0
CD
O
O
O
O
CO
CO
CD
m
C
0
O
N
C
O
Q
H
N
CD
s
6
C=r o m 2
y O CSy
�0<m to
a.o m �
CC2 CD 0 m
y m a o 3 �o
?D y
CD rn
0..
m c?d �_ CA
m
O m y O --I
CD SDI
y a
O
-i
O
Z CO'f
O y t7
� ..
ay � -
� gm
C*
mS -
m y
ate.
C. 3
CA
G1 y
O. p�j CS
_ C
O.
O , F
Q3
C y
m •
CO2
m m
CD
CQ n
O O •
ED
O O :9
CA
� o
CD ,...
o m
CA
CD
os � -
o m
0
m tv
o�
a �
cl
CD
C, O
moo:
gyCD:
y
0
�
°
v.
�,
oil.
'-
tz
�,
�
�-
W
m
�'
a-
a-+
M?
y
0
�
°
zr
�,
oil.
'-
tz
�,
�
�-
a
m
�'
a-
yy
z
M?
CVQC"
CA
m
n�
3
-
a
a
w
Q
C
r
(
cp
a
x
o
9
o
0
c