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HomeMy WebLinkAboutMiscellaneous - 24 EDMANDS ROAD 4/30/2018N O O p O � g� �Z 0 N O 0 � D 0 v Date ... ..... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING 1. It-...�!...DWfi .................................................... has permission to perform .... -r ............ . ......................... plumbing in the buildings of-L—A..'A ................ I . ....................................................... ........................................... North Andover, Mass. Fee,.'-) Lic. NO \(JQ .......... ..................... I ........................................................... PLUMBING INSPECTOR Check # (5-f 011-2o��'A21L(i-15 NO 1' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY �J i MA DATE 21- -7 PERMIT# �1 JOBSITE ADDRESS M+� flS Y2 -k OWNER'S NAME tLE �Ff� ILE_ POWNER ADDRESSTEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL Q EDUCATIONAL ® RESIDENTIAL. PRINT CLEARLY NEW: 0 RENOVATION: ® REPLACEMENT: PLANS SUBMITTED: YES Q NOM FIXTURES -1 FLOOR--> BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM ...___._J _. DEDICATED GAS/OIL/SAND SYSTEM I_._-._._ _► _.___�-___..._! _____I .Y___ ___ .__ _I ____I ____...J I i DEDICATED GREASE SYSTEM _ I _.._A DEDICATED GRAY WATER SYSTEM I ._._ _ I I --- __ DEDICATED WATER RECYCLE SYSTEM DISHWASHER I ._-_-- f _._._. DRINKING FOUNTAIN I' i .-.._ I ._.._._I _ �I I __.._ ; ..__._._.I .__......} 1 .___.__ 1 ........._`_ FOOD DISPOSER FLOOR/ AREA DRAIN v I ! ---.--1 ! _..__ I ! _....__( _....,_.1 I --- ---. INTERCEPTOR (INTERIOR) f r ---. ( I � I ---- ___1 KITCHEN SINK I _ .[ .—..._l 6 _--_._.! LAVATORY; _--I _.__— .-_.__! _____I .--.____1 ._-.—_I _-- ( __.___I .-__...._J ...___.._( _.___- � L ROOF DRAIN ! I _ SHOWER STALL SERVICE / MOP SINK TOILET _ _I I I I ! URINAL WASHING MACHINE CONNECTION i WATER HEATER ALL TYPES _I f . I f _] i -_ � I i WATER PIPING .......-_ I . _....._.... _I .................._{ �_I - - - I ........._.. 1, � i INSURANCE COVERAGE: 1 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 0 OTHER TYPE OF INDEMNITY D BOND MI 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 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 rov (M " assachusetts State Plumbing Code and Chapter 142 of the General Laws. and that all plumbing work and installations performed under the permit issued for this application will be in compli nce wit�Pertiz1V0At24z— PLUMBER'SNAME _ A.• 1 D�•c.p+ ( LICENSE #_ ( SIGNATURE IMPB_ JP Q CORPORATION F-11 #E=PARTNERSHIPLLC COMPANY NAME IJP ^�y�� T (' € ADDRESS y x -+--E CITY IL,L.� ESTATE M� ;ZIP b1€�3� TEL4" All FAX ( CELLy, EMAIL w w LL ---.The Commonwealth of Massachusetts Department ofIndustrialAccidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 - r www mass.gov1dia VPorkers', Compensation Insurance Affidavit: Builders/Contxactors/Electricians/�luna ers. TO BE TILED WITHTHE PEM TTTING A(JTilORITY. Please Print Le 'bl A • • licant Information Nara (Business/Organization/Individual):. Address: City/State/Zip: I Are you an employer? S� the appropriate box: Phone #: l.[] 1 am a employer with employees (frill and/or part time).* 2.t& am a sole proprietor or partnership and have no employees Working for me in any capacity. [No workers' comp. insurance required.] 3.Q T am a homeowner doing all work myself. [No workers' comp. insurance required.] t <1 I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. s. 1 am a general contracto and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.$ 6. Q We are a corporation and its, officers have exercised their right of exemption per MGL c. 152 §1(4) and'we have no employees. [No workers' comp. insurance required.] Type of project (required): 7. ❑ New'constriiction 8. E] Remodeling 9. ❑ Demolition 10 [] Building addition 11.0 Electrical repairs or additions 1-.4oZonbing repairs or additions 110 Ro6f repairs 14. [] Other *Any applicant that check's box1 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 I Contractors that check this box must attached' n additional sheet showing the name of the sub -contractors and state whether or not those, entities, have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I compensation insurance for my employees. Below is the policy and job site Yam an employer that is providing -workers information. Insurance Company Name:, Policy # or Self -ins. Lie. Expiration Date, City/State/Zip: Job Site Address: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to $1,500.00 as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a and/or one-year imprisonment, as well ay be forwarded to the Office of Investigations of the DIA for insurance day against the violator. A copy of this statement m coverage verification. I do hereby certify under tliepains andpe erjury that the information provided above is true and correct. - Phone #: Iy, 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 Phone Contact 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 We, 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 b6 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 Pleasb 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 certificates) 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 fndustrial•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 thai 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 Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MA.SSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia Date......... ............... I ................. TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that........................tL...... �........'/1�1..�..d................................... has permission for gas i tall tion ........--a J . ............................................ inthe buildings of ............ ::i......:.. �'.....................`.................................................. r(11 at ...... .-l.... M ✓ .5 .................................. North Andover, Mass. Fee'Jd........... Lic. No....���.��....................................................................... { GAS INSPECTOR Check # {l 10172 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK f CITY r,.�'M ��. k'_D MA DATE 9 - a I / PERMIT # - - JOBSITE ADDRESS t>DM OWNER'S NAME ��rctrL _ GOWNER ADDRESS `i �M a..flJs TEI� FAX � TYPE OR OCCUPANCY TYPE COMMERCIAL ® EDUCATIONAL © RESIDENTIAL& PRINT CLEARLY NEW: F-- RENOVATION: E] REPLACEMENT: PLANS SUBMITTED: YES 0 NON APPLIANCES 7 FLOORS- BSM 1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER E::j [:::;A! - BOOSTER�..__�I _ �- - =- CONVERSION BURNER _� __., c._.... = -1 __-1 �.- __� ._ZD COOK STOVE DIRECT VENT HEATER --- DRYER FIREPLACE FRYOLATOR- FURNACE �J=JI 1—Di _ �- -- -- --- -- _ GENERATOR GRILLE �- . _ ( _ �. __.. _ .. -- INFRARED HEATER c - . -. ----_ -- -- - LABORATORY COCKS MAKEUP AIR UNIT OVENPOOL HEATERHEATER_ ROOM / SPACE HEATER— ROOF TOP UNIT --- TEST UNIT HEATER-- UNVENTED ROOM HEATER WATER HEATER�- OTHEh ...... ................................................................. INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL. Ch.142 YES 12KNO [0 I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 5&- 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 Q AGENT SIGNATURE OF OWNER OR AGENT 1 hereby certify that all of the details and information 1 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 ith all Pertinent provision Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME JjAbp� LICENSE# It ( SIGNATURE MP 5d MGF 0 JP ® JGF �_( LPGI © CORPORATION Ej# � PARTNERSHIP 0#= LLC #= COMPANY NAME: A, _ _ �,._ r�Qa ADDRESS CITY WO STATE]ZIPyl,317_ TEL , ^ FAX CELL 41 71 6�� I EMAIL �El z The Commonwealth of Massachusetts Department of IndustrialAccidents I Congress Street, Suite 100 Boston, MA. 02114-2017 qr www mass.gov/dia ol kers' Compensation Insurance Affidavit: Builder/C V�1ontractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Name (Business/Orgauization/Individual):, Address: City/State/Zip:_ Are you an employer? the appropriate box: Phone ff: i.[] 1 am a employer with employees (full and/or pari time).* 20 1 am a sole proprietor or partnership and have no employees working for me, in any capacity. [No workers' comp. insurance required.] 3.0 1 am a homeowner doing all work myself [No workers' comp. insurance required.] t 4.❑1 am a homeowner and will be hiring contractors to conduct all work on my property. 1 will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5.F] 1 am a general contractor and 1 have hired the sub -contractors listed on the attached sheet. s have employees and have workers' comp. insurance These sub-contractor 6. ❑ We are a corporation and its, officers have exercised their right of exemption per MGL c. 152 § 1(4) and we have no employees: [No workers' comp. insurance required.] Type of project ()required): 7. ❑ New'construotion 8. [] Remodeling 9. ❑ Demolition 10 [] Building addition 11.[] Electrical repairs or additions 12. Plumbing repairs or additions 13•.[] Rb6f repairs 14.[] Other *Any applicant that checks box #1, wrist also fill out the section below showing their workers' compensation policy information. i Homeowners who submitithis affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such TContmctors that check this Box must attached an additional sheet showing the name of the sub -contractors and state whether or not flrose entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. X am an employer that is providingtiwrkers' compensation insurance for my employees. $elow is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date:, City/State/Zip: Job Site Address: mpensation policy declaration page (showing the policy number and expiration date). Attach a copy of the workers' co c. 152, §25A is a criminal violation punishable by a fine up to $1,500.00 Failure to secure coverage as required under MGL and/or one-year imprisonment, olat z xiAmcot y of this statement may be forwarded to theffice of fnveesies in the form of a STOP WORK tigaiions of the DIA. for insurancER and a fine of up to 0 a day against thep coverage verification. X do hereby certify under tliepains and penalties ofperjury that the information provided above is true and correct. Date: Signature: Official use only. Do not write in this area, to he completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): i 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact 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 h0o, express or implied, oral or written." An employer is' d'efuied 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 b6 deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local Iicensing 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 whd has not produced -acceptable evidence of compliance with the insurance coverage requiired." 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 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 IndustrialAccidents. 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 Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia q:.COMMONWEALTH OF MASSACHUSETTS BOARD OF PLUMBERS AND GASFITTERS SSU.E,S.THE FOLLOWING' L I CENSE L (CENSED AS AMASTER/P UMBE_R,� "_ MAlZK" A D I DUCALU LU 40 LocKE S'T' APT 233 HAVERHILL MA 01830-5514. nS/n_t/tb ��Rtnn if . Date.�,l. —040 ..`Pl ........ TOWN OF NORTH ANDOVER PERMIT FOR WPRING A e This certifies that ... ..... L./... �? . .............................;..................... has permission to perform ........ rp??.!nn......W /.Ae�. . .................. wiring in the building of /Mlll:- -7 ......... ................ at :. ... L4!/!�!. � `....... �:�............ORICAL . North Andover, Mass. Fee.. 3`5............ Lic. No.............. �� .......... INSPECTOR Check '1 -/0 (� 9012 rj Commonwealth of Massachusetts70ccupancy Official Use Only Department of Fire Services 96/2, BOARD OF FIRE PREVENTION REGULATIONS d Fee Checked _ [Rev. 1107) Qeave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WOR All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINTININK OR TYPE ALL INFORMATION) Date: � — / y— 013 City or Town of: NORTH ANDOVER By this application the under -signed ed To .the Inspector of Wires: gn gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) 02 j -✓1 /� Owner or Tenant�i'} A (Z, I& if ,4 K Owner's Address ►�i-� Telephone No. Is this permit in conjunction with a building permit? Yes Purpose of Building � �f � NO ❑ (Check Appropriate Bog) ✓11 Utility Authorization No. Existing Service Amps _ / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: .v/?7 Com letion o the ollowin table may be waived bi, the Ins ector of Wires. No. of Recessed Luminaires No. of Ceil.-Sus No. of Total . p. (Paddle) Fans Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑ �_ o. o mergency Ig g CL rnd. Bette Units No. of Receptacle Outlets No. of Oil Burgers FIRE ALARMS No, of 7- N o. of Switches No. of Gas Burners No. of Detection and No. of Ranges Initiating Devices g • No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers Heat Pump Number ons KW No. of Self -Contained Totals: __•`.__._.._...____._..... Detection/Alert'm Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal Connection ❑ �� No. of Dryers Heating Appliances, Security Systems: * i . No. of Water No. of No. of Devices or E uivalent Heaters , ° °f Data Wiring: Si s Ballasts No. of Devices or L uivalent Nu. Hydromassage Bathtubs No, of Motors Total HP No. Wiring: OTHER: rIq A" > (Ty�J No. of Devices or Eq uivalent Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: Work to Stark(When required by municipal policy.) 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 El OTHER [I (Specify:) I certify, under the pains andpenalties o perjury, that the information on this application is true and complete - FIRM NAME: 0'bGv a14q Licensee: ,� `SE - LIC. NO.: 6 9 Signator LIC. NO.: / (If applicable, enter "exem t " in the lice umber line. Address: / �U hj , b3 7 a Bus. TeL No.AVi1��=jj6) *Per M.G.L c. 147, s. 57-61, security work requires D artment of Public Safety "S" License: Alt L cl. 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: $ I rQ� k1; ii%�► 1.26 // The Common wealth of Massachusetts Department of Industrial Accidents Office of'Ircvesdgations 600 NMashinwton Street Boston, MA 02111 c ` www nzass.gov/dia . Workers' Compensation lmkrance Affidavit: Builders/Contractors/Eiectricians/Plumbers DDBCAnt stfnv-ma+;n- Nanle (Business/Drgenization/Individual): e Ad&ess:_Z�/ City/State/Zip:, Phone #:. &G3 -j136 --q. 13 % Are you an employer? Check.the appropriate box: 1. ❑ I a employer with 4. ❑ 1 am a general contractor and I — loyees (full and/or part-time).* have bred the sub-comractors 2. I am.a:sole proprietor or partner_Iisted ori the attached sheet, t ship and have no employees These sub -contractors have working for me in any capacity. [No workers' comp. insurance workers' comp. insurance. 5. ❑ We are a corporation and its required.] 3. ❑ I am a homeowner doing officers have exercised their all work right of exemption per MGL mysel£ [No•workers' comp, c 152, § 1(4), and we have no insurance required.] t .employees. [No workers' comp. izisurence required..] Any applicant that cheeks bo> t€ l most also flit out the section below showing their workers' compensatio t N Type of project (required): 6. ❑ Naw construction 7. ❑ Remodeling $• Q Demoiition 9. ❑ Building addition 10. ❑ Electrical repairs or additions 11.Q Plumbing repairs or additions 12.❑ Roof repairs I3.Q.Other omeowners who submit this affidavit indicating they are doing all work and then hire outside contractees must submit a new affidavit indicating ;Coritractots that check this box must attached an additional sheet Showing. the rremc of su such. b -contractors and their wo kr;' comp. policy inmrmadon. 1 am an employer that is Providing: workersI compensation insurance or a to information. .f my np yeas: Below is the palicy acid job site 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 expire ion da4e}. 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. Ido here�ify der tw'L P 1 enakies o er iP !J' that the information provided above true and correct Official use only. Do not write i t this area, to he completend by chy 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 #: Information and Instructions Massachusetts General Laws chapter 152 requires all emp ;} oyers 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, assvoiation, 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 reviver 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 apartanents 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, IAGL 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 requin:meri s 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 toyour situation and, if necessary, supply sub -contractors) name(s), address(es) mind phone numbers) along with their certificates) 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, not1he Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please can the Department at the nurnber. listed below. Self-insured companies should entertheir N 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 xvilI be used as a reference number. In addition, an applicant tharpriustsubmit 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 towrA." 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 fume 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 DTartmcmt of Industria( Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-7274900 6x;t 406 or 1-977-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia f Date -1511 1.`.'. . TOWN OF NORTH ANDOVER ° p PERMIT FOR PLUMBING °•Arun �r•`44 p, SSAC04USi This certifies that ................ has permission to perform ..... %� .�.4 �.�'. .................... plumbing in the buildings of ,................... . at .. r,1. ��...�! ` .` `� .r..../k.C...... , North Andover, Mass. ... Fee..(.. Lic. No.... '�...�� V �""�!�!......... PLUMBING INSPECTOR Check # � 3/)- 8221 /)/ 8221 0 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Date Building Location S Owners Name Permit # %-7— Amount -JAmount Type of Occupancy New Renovation Replacement ri Plans Submitted Yes ❑ No ❑ (Print or type) Check one: Certificate Installing Company Name 4141 p ❑Corp. Address G�� ��C ✓� �/��� Partner. Business Telephone — – El Firm/Co. Name of Licensed Plumber: Insurance Coverage: Indicate the a 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 installations performed under P 't IsLr142 for his application will be in compliance with all pertinent provisions of the Massachusetts State ing Code d e General Laws. SignatureBy: 51 Zicenstuum er Type o c lumbi License Title 3 b City/Town icense um er Master 0 Journeyman APPROVED �or-FicE USE oivL.Y `D I -�.-.----��-�-m-----�---- ..:' n0jQMn--------M-- m-.--- ..•M®®Mi0MMM mmmm e MM MM MMMMMWMMMM MMM (Print or type) Check one: Certificate Installing Company Name 4141 p ❑Corp. Address G�� ��C ✓� �/��� Partner. Business Telephone — – El Firm/Co. Name of Licensed Plumber: Insurance Coverage: Indicate the a 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 installations performed under P 't IsLr142 for his application will be in compliance with all pertinent provisions of the Massachusetts State ing Code d e General Laws. SignatureBy: 51 Zicenstuum er Type o c lumbi License Title 3 b City/Town icense um er Master 0 Journeyman APPROVED �or-FicE USE oivL.Y .Cr t .0 iii;;► ,' rz The Commonwealth of Massachusetts Department of industrial Accidents Office of Investigations 600 Nrashangton Street Boston, jk,r4 #2111 Workers' Cwww nuws gov/dia . ompensation Imitrance Affici.;avit: Builders/Contractors/Eiectricians/Pfambers ficant Tnformatinn Name (Business/OrganiZationAndividual):_ Address: City/State/Zip: Phone #: . A�Y� on employer? Check the appropriate bot: I. I' player with 4. ❑ I am a general contractor:and Type pr°1eci (rega►rsd). oY� (full and/or part-time).* have hired the sub-contra 6• Q New construction 2• am .a.sole proprietor or partner- listed on the attached sheet 3 7• ❑ Remodeling ship and have no employees working for me in These sub -contractors have 8• Q Demolition an Y capacity. [No workers' comp. insurance workers' comp. insurance. 5. ❑ We are: a corporation and its g, Builth ❑ ng addition required.] 3. Q I ain a homeowner doing officers have exercised their 1Q•❑ Electrical repairs oradditions. all work myself [No -workers' comp. right of exemption per MOL c 152, § 1(4), and we have no 11.❑ PIumbing repairs or additions insurance required.] t .em io ees P Y [No workers' 12.❑ Roof repairs `Any applieown attt that beams boZ f# I moat also fnl out the t homeowners who submit this iii compinsurance required ] section below showing their workers' oompensation I3.❑.other policy information, s(i avit indiesdng they are 3aing di work and then hie outside contractors must submit a new affidavit m* ouc 3Caotrnctnrs that check this box must ettsehed an rdditioaa sheet showing the name of the cub-indih. conttactots and their workers' caner. Policy neon. 1 Dist ar ,Mph, er that y°R:7r4fing:workers' aomperrsad0ft insurance or information. f �' eniP�Yees . Below is ae policy and job site . Insurance Company Name: ' Policy # or Self -ins. Lie. #: Expiration Date: Job Site Address: CitylState/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 S1,550.00,00 and/or one-year imprisonment; as well tis civil penalties in the form of a STOP WORK ORDER and a fine In a to tions 0 a day against the violator- Be advised that a copy of this statement may be forwarded to the Ofiice of Investigations of the DIA for insurance coverage verification. I do hereby certify the the information Pm'vided above is nueyand coned tectal tlSP Only. Do not write in this area, to be completmd-+ for town o � City or Town _ Permit/License # Issuing Authority (circle one): 1. Board of Health 2 Building Department 3. City/Tovvu Clerk 4. Electri 6. Other cal Inspector S. Pinh..... m 561 Contact Person: Phone #: Information a nd Instructions Massachusetts General Laws chapter 152 requires all emp 3oyers 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, assodiation, corporation or other legal entity, or any two ormore of the'fomping engaged in a joint enterprise, and includir-ig the legal representatives of a deceased employer, or the receiver ortrustee -of an individual, partnership, associatioin or other legal entity, employing employees. 'However the owner of a dwelling house having not more than thre- apm a -t ments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maimtenance, 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 as employer." MGL chapter 152, §25C(6) also states that "every state oar local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or *e construct buildings is the commonwealth for any applicant who has not produced acceptable evidence -of compliance with the insurance coverage required." Additionally, MOL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political .subdivisions shall errtcr into any contract for the per%rmance of public work until—acceptable evidence of conrplionce with the insurance requirements of this dbapter have been presented to the cotritracting authority.".. Applicants Please fill out the workers' compensation, affidavit compi'am-tely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), addresses) mind phone numbers) along with their certificates) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, arc not require Tito carry workers' cr rnpensation 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 'Ib a sure to sign and -date the affidavit. The affidavit should, be returned to the city or town brat 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 t D obtain a workers' compensation policy, please -call the Department at the number listed below. Self --Le Lred Crrnpanim shoLId en+-th' self insurance license number on tite*appr opiate 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 applicMt. Please be sure to fill in the pwrnit/Iicense number which A -ill 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 indust ng -current policy;information (if necessary) and under "Job Sit- 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 affidaViit is on file for Tutu= pwmi#s or licenses. A new affidavit must be filled out each year. When 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 pmw* r3 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 Indisstrial Accidemts Office of Envestibations 600 Washington Street Bastion, A!iA 42111 TeL # 617-727-4900 ext 406 or 1-9.77-MASSAFE Rsvised 5-26-05 Fax # 617-727-774 wwwmass.gov/dia .. .. .... .. TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ... has permission for gas ............... in the buildings-, of at North Andover, Mass. Fee''�-.�.... Lic. No......�� GAS INSPE .TOR Check 4 MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS G (Type or print) Date NORTH ANDOVER, MASSACHUSETTS Building Locations L- h U NIJ S / Permit # Amount $ Owner's Name LA New Renovation Replacement 13--� Plans Submitted (Print or type) Name - c f- Co e: Certificate Installing Company Checkorp. x �ey /J � U w � y U Zz � w v� Cv U W x eF C > Ew- C7 F z Q x W C W a mLk F^ W U CA o > Q a H o SUB -BASEM ENT BASEM ENT 1ST. FLOOR 2ND. FLOOR 3RD. FLOOR 4TH. FLOG R 5TH. FLOOR 6TH. FLOOR 7TH. FLOOR 8TH. FLOOR (Print or type) Name - c f- Co e: Certificate Installing Company Checkorp. x �ey /J