HomeMy WebLinkAboutMiscellaneous - 211 COVENTRY LANE 4/30/201810217
Aa
Date 10.44./a .......
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
,114 t,
This certifies that ... . ....
............... /
/ .. ............... ...............
has permissionto perform ....... e P" 0
................................................................
plumbing in the buildings of ...... ........................................
at ....... iz2. Z/ �7ci .., -/
................................................................................. North Andover, Mass.
Fee..p . ......... Lic. No. ....................................................................
Check # �-3 Kz— PLUMBING INSPECTOR
P
TYPE OR
PRINT
CLEARLY
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY MA DATE (PERMIT #
JOBSITE ADDRESS J(_ „ /�y Z=/11 OWNER'S NAME o
OWNER ADDRESS I TEL FAX
OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL 6 ,1
NEW: 0l RENOVATION: D REPLACEMENT: 0
PLANS SUBMITTED: YES M N00
FIXTURES Z FLOOR- I BSM X 1 1 2 1 3 1 4 1 5 1 6 1 7 1 8 1 9 1 10 1 11 1 12 1 13 1 14
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
DRINKING FOUNTAIN
FOOD DISPOSER
FLOOR / AREA DRAIN
INTERCEPTOR (INTEF
KITCHEN SINK
LAVATORY
SHOWER STALL
SERVICE / MOP SINK
TOIt'ET
URINAL
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER F .
�' INSURANCE COVERAGE:
1 I,Iave a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES ._ 0 _;
IF YOU CHECKED YES, PLEASE INDICATE THE T OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY 0{ BOND D
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 Q AGENT 10
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
and that all plumbing work and installations performed under the permit issued for this application will be in plia e
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S N
_ ILICENSE
MID JP �aI CORPORATION 0#PARTNERSHIP 0#�
COMPANY NAME « ADDRESS
CITY_...._._.._1 TEZIP TEL
FAX E CELL L
ast Or my Knowe
provision of the
OR
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Ss
Ix
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LL
IN
Date .... ah
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
. ...... .. .....
This certifies that ...
w 0
has permission for gas installation ........ ...........
in the buildings of ...... e�".I .....................................................................
at ........ cP.1.1 ....... ................... . North Andover, Mass.
............ Lic. No.
Check,16%21 GAS INSPECMR
C 9, 20
DIRECT VENT HEATER I.. I _--i I -
DRYER =I
FIREPLACE
FRYOLATOR! I I
FURNACE -
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN T
POOL HEATER
ROOM / SPACE HEATER
ROOFTOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER �. _...) L...__ _ _ L ----- - __ ..
OTHER1 . .... .._.._
........... ... ....... ............. r - - -
INSURANCE COVERAGE
have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES _._ NO
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY � OTHER TYPE INDEMNITY 0 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: OWNER0! 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 t e best of my knowledge
Z�qd that all plumbing work and installations performed under the permit issued for this application will be in compHvnce with all ent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLU;rMGFt
TER NAME �LICENSE # C ( ( S AT
MP JP [3 JGFLPGI 0 CORPORATION Q# =PARTNERSHIP 0# LLC [#
COMPANY NAME:S U rvi ` ADDRESS �J
CITY j� STATZIP RTEL
L
FAX �-w1 CELL __ —
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FIT•••///T�ING WORK
`e
CITY
✓t ✓ MA DATESl PERM
#-�-
JOBSITE ADDRESS
-IT
2 l l ;pV-e✓f OWNER'S NAME
GOWNER
ADDRESS,iA4:TE
L�p� FAX I
TYPE OR
PRT)?rL
OCCUPANCY TYPE
CO �! EDUCATIONAL RESIDENTIAL
C1�,EARLY
NEW: [� . RENOVATION: _PLACEMENT: 11 PLANS SUBMITTED: YES 7 NO R
APPLIANCES 7
FLOORS-
BSM ' 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
�-E
CONVERSION BURNER1
J
COOK STOVE
DIRECT VENT HEATER I.. I _--i I -
DRYER =I
FIREPLACE
FRYOLATOR! I I
FURNACE -
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT
OVEN T
POOL HEATER
ROOM / SPACE HEATER
ROOFTOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER �. _...) L...__ _ _ L ----- - __ ..
OTHER1 . .... .._.._
........... ... ....... ............. r - - -
INSURANCE COVERAGE
have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES _._ NO
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY � OTHER TYPE INDEMNITY 0 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: OWNER0! 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 t e best of my knowledge
Z�qd that all plumbing work and installations performed under the permit issued for this application will be in compHvnce with all ent provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLU;rMGFt
TER NAME �LICENSE # C ( ( S AT
MP JP [3 JGFLPGI 0 CORPORATION Q# =PARTNERSHIP 0# LLC [#
COMPANY NAME:S U rvi ` ADDRESS �J
CITY j� STATZIP RTEL
L
FAX �-w1 CELL __ —
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The Commonwealth ofMassachusetts
Department ofIndustrigl-4ccidents
Office of Investigations
600 Washington Street
Boston, ,NIA. 02111
www.massgov/d'ia
'workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Name
Address:
Phone #: 27 L
Are you an employer? Check the appropriate bog:
Type of project (required):
I. ❑ I am ployer with
C loyees (full and/oxpari-time) x
4. ❑ I am a general contractor and I
have ]iiredthesub-contractors
Nooonsiruction
6. WOM
,
x
7•odehn g
2. am a sole proprietor or partner-
listed on the attached sheet.
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 area corporation and its
10,[] Electrical repairs or additions
required.]
officers have exercised their
3. ❑ I am a homeowner doing all work
right of exemption per MGL
1 l.[] Plumbing repairs or additions
myself. [Noworkers' comp.
c.152, §1(4), and we have no
12.❑Roof repairs
insurance required.] t
employees. [No workers'
1311 Other
comp. insurance required.]
*Any applicant that checks box#1 must also fill outthe section below showing their workers' compensation policy information.
T Homeowners who submit this affidavit indicating they tCre 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.
1a m an employer that is providing workers' compensation insuranceforYrty employees Below is the policy an job site
information.
.Insurance Company Name:. !�. (J'e Yr/J S ,
Policy # or Self -ins, Lic. 9: 4 f44 -7 l Expiration Date: f
rob Site Address: [ r/1� �� City/State/Zip:-G. .
Attach a. copy of the workers' compensation policy $eclaration 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 ills statement maybe forwarded, to the Office of
Investigations of the DIA for insurance coverage verification.
X do Hereby cert)fy u r r the l dinsAd penalties ofperjury that the information provided above, is tale and correct.
Official use onol . Do not write X this area, to be completed by city or town official.
City or Town: Permitucense #
Issuing Authority (cycle one):
x. Board of Health 2. Building Department 3. City/Town Clerk 4. EIectrical Inspector 5. Plumbing Inspector
6. Other - -
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 employes."
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 b con 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) andphone number(s) along withtheir 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, apolicy is required. De advised that this affidavit maybe submitted to the Department of Industrial
Accidents fox 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 -cornplete-and rinted legib1Y. The D epar(ment ifsprovided a sae-a—
tlie-botfom-
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 whichwill 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 maybe 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 Com or��eaMo;��tassa�husPtts
Departmexit o fadustdal .A,coldonts
offzee ofwestigatiou
600 Washingtau Street
Boston} MA, 02111
Tel # 617-727-4900 e-406 or. 1 -8.77 -Sq
MA.
Revised s--m-ni Fax# 617-727-7749
71
E}MMONWEALTH OF MASSACHUSETT
PLUMBERS AN.I GASFITTERS
LICENSED AS A-fu�kSTER PLUMBER
t ISSUES THE ABOVE LICENSE TO:
E
MARK T JACQUES s:.
12 AVERILL ROAD
3 MIDDLETON MA L1949-1300 r ;'
11239 05/01/14 168713
2 r
COMMONWEALTH OF MASSACHUSETTS _
PLUMBERS AND GASFITTERS
`LICENSED AS A JOURNEYMAN PLUME L
ISSUES THE ABOVE LICENSE TO:
MARK T JACQUES
m
�.e12 AVERILL ROAD:
MIDDLETON - MA 01949-1300
168714
21498 05/01/14
Date ..... y ................
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ..... \7P/
.......................................................................................................................
has permission to perform ........... k ... 4Q&j ry d,
wiring in the building of .......... ktj .............................. o .........................
at ...... 2 ov
// ( 1, P, xe
............................................. .................................. . Aorth Andover, Mass.
V / 6V
'Fee..91 .... . .......... Lic. No.�"
................. Zm ................ I
. .............. ... . .
ELE icAL INspEcrm
Check# A2.4113
V
Sri
Commonwealth of Massachusetts
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
Permit No.
Occupancy and Fee Checked
[Rev. 1/071 (leave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Cod (MEC), 527 CMR 12.00
(PLEASE PRINT JN NK OR TTPE ALL INF0R1kMT10A9 Date:
City or Town of: NORTH ANDOVER To the In ec or of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location (Street & Number)JI I Com* /A $�
Owner or Tenant
Owner's Address
Is this permit in conjunction with a building permit? Yes �K No ❑
Purpose of Building m N2!0
Existing
Existing Service .---I Amps Overhead ❑ Undgrd ❑
New Service "` Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters
Telephone No.
(Check Appropriate Box)
Utility Authorization No. ----
Amps
Volts
No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
Completion of the_ following 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
Swimming Pool Above ❑ In- ❑
rnd. rnd.
o. o mergency Lighting
Batter Units
No., of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
No. of Zones
No. of Switches Z
No. of Gas Burners
No. of Detection and
Initiatin Devices
No. of Ranges
No. of Air Cond. TotTons
No. of Alerting Devices
No. of Waste Disposers
Heat Pump
Totals:
Number
Tons
"
KW
......................Detection/AlertingDevices
No. of Self -Contained
No. of Dishwashers
Space/Area Heating KW
Local ❑ Municipal ❑ Other
Connection—
onnectionNo..of
No. . of
Dryers
Heating Appliances KW
Security Systems:*
No. of Devices or Equivalent
No. of Water KW
Heaters
No. of No. of
Signs Ballasts
Data Wiring:
No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
Telecommunications Wiring:
No. of Devices or Equivalent
OTHER:
Attach additional detail i1.f desired or as required by the Inspector of Wires.
Estimated Value of Electrical Work: DC`s ,� (When required by municipal policy.)
Work,to Start: jp ) 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 penalties of perjury, that the information on this application is true and complete.
FIRM N LTC. NO.:
Licens : Signature LTC. NO.:
(If applicable en r "e em t" in the license nurrhber line.) us. Tel. No -
Address:_ Alt. Tel. No.:i0'SIoS$
*Per M.G.L c. 147, s. 57-61, se urity work requires Departmen of Public Safety "S" License: Lie. 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 PERMIT FEE. $
Signature Telephone No.
❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance -with the provisions of M.G.L. c. 143, § 3L, the �s
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
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 invalid if he
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.
❑ Rule 8 — Permit/Date Closed: *** Note: Reapply for new permit ❑
❑ Permit Extension Act — Permit/Date Closed:
Trench Inspection
Pass F?1
Failed M
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
SERVICE INSPECTION:
Pass 0
Failed
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
PARTIAL ROUGH INSPECTION:
Pass M
Failed 0
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
ROUGH INSPECTION:
Pass 0
Failed
Re- Inspection Required ($.) ❑
Inspector mme s:
r_ / [Wfl-A
' e,-, 1 3
Inspectors Signature:
�
Date:
FINAL INSPECTION:
Pass 0
Failed 0
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
DEB WEINHOLD ... TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com
10
The Commonwealth of Massachusetts
Department of IndustrialAccWnts
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contrac-
Natn usiness/ rganization/Individual):
Address: ln,,�
Are you an employer? Check the appropriate box:
S
1.' I am a employer with
4. ❑ I am a general contractor and I
_
employees (full and/or pari -time).*
have hired the sub -contractors
2. ❑ 1 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 -Ell 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.lectrical repairs or additions
11. ❑ 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.
T Homeowners who submit this affidavit indicating they hie 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 N
Policy # or Self -ins. Lie. #: Expiration Date:
Job Site Address: r 0 Al- • City/State/Zip: e ?W oo
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 q.ed& unkr the pains and penalties ofperjury that the information provided above is true and correct.
Official use only. Do not write in this area, to be completed by city or town official.
City or Town:
Permit/License #
Issuing Authority (circle one):
1. Board, of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other, - - -
Contact Person: Phone #:
44
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 ofpublic 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 numbers) 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 Washirtpa Street
Boston,, MA, 02111
Tel, # 617-727-4900 ext 406 or 1-877rMASSAFE
Revised 5-26-05 Fax # 617-727-7749
_WWW-mass,goV1dia
i
Date �-/- 'f -)-
This certifies that * ..............
has
yermission to perform .... ........................
plumbing in the buildings of .... M. C ... Aw el �: A .............
at .... Co -P Xf n f j� ......... North Andover, Mass.
6)—
Fee—) Lic. No. 3
..... .......
MBING INSPECTOR
Check # � -3
7660
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
SA
US
This certifies that * ..............
has
yermission to perform .... ........................
plumbing in the buildings of .... M. C ... Aw el �: A .............
at .... Co -P Xf n f j� ......... North Andover, Mass.
6)—
Fee—) Lic. No. 3
..... .......
MBING INSPECTOR
Check # � -3
7660
`Grr,s�
MAS5At:nuSt:t IS UNIFORMAPP.LICATIUN FURIPPERMITTO DO PLUMBING
(PAnt or Type)
North Andover , mass. Date—2040' Permit* "7'�
Building Location % 9 1 f. n ii/ A u t r y ! a n Q owner's Name Amy McManus
'eype of O upancy Residential
New 13 Renovation O Replacement i>� Pians Submitted: Yes O No O
FIXTURES
SIFUCAF
tailing Company Name _Andover Plumbing & Heating Co., Inc. Cheecc � one: Certificate
dress 20 Aegean Drive 0jn•i t #10 : corporation 2122
Methuen, Ma. 01844
dnessUephone (978) 685-8383 11 Partnership
❑ Firm/Co.
ne of Licensed Plumber or Gas Fitter GeoraelaRose -
ISURANCE -- -
have acurrent liability insurance policy or its substantial equivalent, which meets the requirements of MGLdh. 142.
Yes No O
you have checkedves. piease 'ndicate the type of coverage by Cheung the appropriate box.
liability insurance policy Other type of indemnity O Bond O
wNER'S iNSURNACEwA1VER: i am aware that the licensee does not have the insurance coverage required by Chapter
12 of the Mass. General Laws, and that my signature on this permit application waives this requirement.
gnature of Owner or Owner's Agent
Check bne:
Owner O Agent O
-eby certify that all of the details and -Information i have submitted (or entered) In above•appiication are true and accurate to the best of
cnowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with
ertinent provisions of the Massachusetts State Plumbing Code and ChaptOr 942 of the General La -%s.
By
Tidt
City/Town
APPROVED (OFHC'c USE 5FLY)
Signature 9�Udensed Plumber
Type of License: aster
99$3
O Journeyman
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tailing Company Name _Andover Plumbing & Heating Co., Inc. Cheecc � one: Certificate
dress 20 Aegean Drive 0jn•i t #10 : corporation 2122
Methuen, Ma. 01844
dnessUephone (978) 685-8383 11 Partnership
❑ Firm/Co.
ne of Licensed Plumber or Gas Fitter GeoraelaRose -
ISURANCE -- -
have acurrent liability insurance policy or its substantial equivalent, which meets the requirements of MGLdh. 142.
Yes No O
you have checkedves. piease 'ndicate the type of coverage by Cheung the appropriate box.
liability insurance policy Other type of indemnity O Bond O
wNER'S iNSURNACEwA1VER: i am aware that the licensee does not have the insurance coverage required by Chapter
12 of the Mass. General Laws, and that my signature on this permit application waives this requirement.
gnature of Owner or Owner's Agent
Check bne:
Owner O Agent O
-eby certify that all of the details and -Information i have submitted (or entered) In above•appiication are true and accurate to the best of
cnowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with
ertinent provisions of the Massachusetts State Plumbing Code and ChaptOr 942 of the General La -%s.
By
Tidt
City/Town
APPROVED (OFHC'c USE 5FLY)
Signature 9�Udensed Plumber
Type of License: aster
99$3
O Journeyman
Date. / 0./.� . � ......
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
CH
This certifies that ... /0�.c j C. -r
has permission for gas installation ..................
in the buildings of .... Ab. f-. .....................
at North Andover, Mass.
Fee.2,0.�'—.. Lic. .........
GAS INSPEC'rOR
Check# 5 (,( 3
6552
G
1im;&* wSffm Ui+Umm NF'Ptk'd& 10WEASM
_
Nncth Ando er _ mss. Made D X 20 ,07 Pelmft# Z
tacaecm 211 Coventry Lane Amy McManus
mea con Rmi dential
l�rp Reaof�aap Reom
t Sammi Yes p tto p
•InSta11111e ComPanY Name : Andover P1 umbi rig & Heating Co., Inc. chmir one: Certificate
; -, Address 20 Aecteah Dr. Unit #10 corporation 21.22
Methuen. Ma. '01844
• hips .
Business Iredephone (QNLfi rz R�Rm p Partner
p Firmlcm
Name OFUmadPhintwordasFitter 6Rorae LaRose
UfStl � - _
I- lac COs paid orifi sms eqa ridt ebe eeqdo mum --ft- of UM CI- zs2.
yes
tt'yt�l�tlte��s•I� lllel�eOfO�6L?�e�all09t
Atia1�46 votacl e� toe of taoawA
� fl
442 oFRtBsass,tLa■s, md OWt=F5bOAbAFefla1 nqdmd by Chapter
Oaaesfr0le'S
Ckamme:
Omm fl minfl
1 hw'eby certify that aU oP the details and information 1 have submitted for ent woo In above application are true and accurate to the best i
my xnoltAedpe and ttmt alt Plumbing work and installations performed tinder tine permit Issaed for this application void be In compliance 1*
aU Pertinent: Provisions of the Massachusetts State Gas Code and Chapter 942 of the GeAerai ws.
OFLkmmm
By
�-zLt7 _ t?ll:amc�ttrf;as>•ctter
w�on�nen�tsr-c�e� o� _
3ioes9e»ner
s
11
- • • •
i��iiiiiil��s���isi0
•InSta11111e ComPanY Name : Andover P1 umbi rig & Heating Co., Inc. chmir one: Certificate
; -, Address 20 Aecteah Dr. Unit #10 corporation 21.22
Methuen. Ma. '01844
• hips .
Business Iredephone (QNLfi rz R�Rm p Partner
p Firmlcm
Name OFUmadPhintwordasFitter 6Rorae LaRose
UfStl � - _
I- lac COs paid orifi sms eqa ridt ebe eeqdo mum --ft- of UM CI- zs2.
yes
tt'yt�l�tlte��s•I� lllel�eOfO�6L?�e�all09t
Atia1�46 votacl e� toe of taoawA
� fl
442 oFRtBsass,tLa■s, md OWt=F5bOAbAFefla1 nqdmd by Chapter
Oaaesfr0le'S
Ckamme:
Omm fl minfl
1 hw'eby certify that aU oP the details and information 1 have submitted for ent woo In above application are true and accurate to the best i
my xnoltAedpe and ttmt alt Plumbing work and installations performed tinder tine permit Issaed for this application void be In compliance 1*
aU Pertinent: Provisions of the Massachusetts State Gas Code and Chapter 942 of the GeAerai ws.
OFLkmmm
By
�-zLt7 _ t?ll:amc�ttrf;as>•ctter
w�on�nen�tsr-c�e� o� _
3ioes9e»ner
Date. .
3815
+ TOWN OF NORTH ANDOVER
0
0
PERMIT FOR PLUMBING
Ui
t 4-#"" 6� 44
This certifies tha .............. ..............................
has permission to perform ---114
plumbing in the buildings of
. ........ .. ........
at North Andover, Mass"
............ . ...........
Fee ... �-7 .... L i c N �oe3 ..............................
PLUMBING INSPECTOR
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
r (Type or print)
NORTH ANDOVER,
Building Locations
New F1 Renovation. F1
Date d
Permit #�3 k§-
Amount
Owner's Name , •' �' VYIIANU
Replacement M Plans Submitted
IXTURES
(Print or type) r / Check one: J Certificate
Installing Company Name V(�i I`t r. 'l Corp. `609
10Address ► ti Partner.
1 Je) WA L)`
Business Telephone Firm/Co.
Name of Licensed Plumber: 1—Mt" bL*VjC 1= t f
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 13 Agent 13
best of my howled saa t= all phmmbmg wait aria � p�a+QPcrmk 19wea br , .� be m
compliance with all pertinent provisions of the Massach Sta PlC an 2 of the General Laws.
By: Igna e or Licensum er
Type of Plumbing license
Title
City/Town Igen mer Master Journeyman ❑
APPROVED (OFFICE USE ONLY __ I XDf
Date.
TOWN OF NORTH ANDOVER
r�-: " - - - � Z';'O� PERMIT FOR GAS INSTALLATIOff-
,:Jiro
T
This certifies that ......................
tas permission for gas installation ....................... 14
iq.the buildings of ..................
at i9h�': ............... North Andover, Mass.
Fee.� Lic. No.
GASINSPECTOR
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer
MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS FITTING
I
r print)
tNUx1H ANDOVER, MASSACHUSETTS
Building Locations
Date / , 11 19 g 8
Owner's Name Z MANUS
New ❑ Renovation ❑ Replacement ® Plans Submitted ❑
Permit # c-793
Amount $ /6 W
AlpalmaOr`'reGLll W vc� �\Il1 i I,IA��.11AJ� TJ�iLIY�I%
K%me of Licensed Plumber or Gas Fitter �(1 � _ gLK&y-Ae:T-
Chec one: Certificate I sta ing Company
Corp.
❑ Partner.
❑ Firm/Co.
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes M9 No❑
If you have checked M, please indicate the type coverage by checking the appropriate box.
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
Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent 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 installations performed under Permit Issued for this application will be in
' compliance with all pertinent provisions of the Massach48,9tts,IState Vias Cqdeand Chapter 142 of the General Laws.
tie
OVED (OFFICE USE ONLY)
Signature of Licensed Plumber Or Gas Fitter
Plumber'
Gas Fitter License Number
er
Master
Journeyman
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8TH. FLOOR
AlpalmaOr`'reGLll W vc� �\Il1 i I,IA��.11AJ� TJ�iLIY�I%
K%me of Licensed Plumber or Gas Fitter �(1 � _ gLK&y-Ae:T-
Chec one: Certificate I sta ing Company
Corp.
❑ Partner.
❑ Firm/Co.
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes M9 No❑
If you have checked M, please indicate the type coverage by checking the appropriate box.
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
Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent 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 installations performed under Permit Issued for this application will be in
' compliance with all pertinent provisions of the Massach48,9tts,IState Vias Cqdeand Chapter 142 of the General Laws.
tie
OVED (OFFICE USE ONLY)
Signature of Licensed Plumber Or Gas Fitter
Plumber'
Gas Fitter License Number
er
Master
Journeyman