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HomeMy WebLinkAboutMiscellaneous - 249 CARLTON LANE 4/30/2018 (2)N) 6/16/2016 20599 This is an e -permit. To learn more. scan this barcode or visit northandoverma.viewpointcloud.com/#/records/20599 OF NORTy 4,y �2OG �4SSACHUS�S TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that Robert J Holmes has permission to perform replace broken drain pipe plumbing in the buildings of GRIFFIN. ARTHUR at 249 CARLTON LANE, North Andover, Mass. Lic. No. 15194 Date: June 16, 2016 ❑ ❑ ❑ .a 1/1 x , Vail MIA ............. ......................... --- ------- - -- cii AM w~ Town of North Andover, MA 20599 *Pturnhing PfMolt - Replacement of rwturelAppliance lCurnmerciall or Residential] TIMEUNE Submission re,,Ired Jun 15,2016 . 3MI P. Plumbing Permit Review In proz- 0 Permir Fee. P" -t Mffi_�rl Wednesday, Jun 15, 2016 03:07 PM Your request is in progress We'll let you lorm of any updates via email. Feel free to check the status at any time by coming back to this page. Ca"fol �n al'aw. r.10 L111—I Robert Holmes 249 CARLTON LANE, NORTH ANDOVER, MA 0.1 r° ARTHUR Attachments 0TYjIYI00 I F_Wedjnl 52016_19:07:.PDF C5 15 � 2016 Primary Contractor Search for your contractor using the search bar be]=. Either the Firm's Name or licensee # 1, required. - w . The Commonwealth of Massachusetts z Department of IndustrialAcciclents I Congress Street, Suite 100 Boston, MA. 02114-2017 www mass.gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE (FILED WITH THE PERMITTING AUTHORITY. Applicant Information n Please Print Leaib Name (Business/Organization/Individual): } 1 n U M D" I U M 1 f) q o.�—jnq ��o� n C bo -#i) /Z� Address: / 6(� t'U/L2 / Z vV City/State/Zip: &x 4 -d Inti O l3al Phone #:. Are you an employer? Check the appropriate box: 7 97 30 7 6�F 3 1. ❑ 1 am a employer with ! employees (fall and/or part-time)." 2.t5�1 am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required] 3. r] I am a homeowner doing all work myself. [No workers' comp..insurance required.] t 4. ❑ I 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. ❑ 1 am a general contractor and 1 have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.* 6. ❑ We are a corporation and its ofcers have exercised their tight of exemption per MGL c. 152, § 1(4), and we have ntq employees. [No workers' comp, insurance required.] Type of project ()required): 7. I] New construction 8. Remodeling 9. ❑ Demolition 10 [i Building addition 11. [] Electrical repairs or additions 12. K1.'lumbing repairs or additions 13. F1 Roof repairs 14. F]' Other Any appucant that Me= box #1 must also till out the section below showing their workers' compensation policy information. Homeowners who stbnlit this affidavit indicating they are doing all work and then hire outside contractors Aust submit a new affidavit indicating such. ?Contractors that check this box must•atfached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. ithe sub -contractors liave employees, they must provide their workers' comp, policy number.' .. I am an employer that is providiiag worlisrs' compensation insurance for my employees.' .below 'the policy and job site information. Insurance Company Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: t!9 CQr I h r, S 4- 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 MGL o. 152, §25A is a criminal violation punishable by a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORD ORDER and a fine of up to $250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Iuvestigations of the DIA, for insurance coverage verification. Y do hereby ce! ftunder the pain�enalties of perjury that the information provided above is true and correct. Phone #: -2 D .36 7 (1/8,3 Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): i 1. Boar 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 cl x 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 contrdct of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, ox 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 ba deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or Iocal licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall. enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority.". Applicants Please fill -out -the workers' compensation affidavit completely, by checking the'boxes that apply to your situation and, if necessary, supply sub=contractors) name(s), address(es) and -phone number(s) along with their certificate(s) of insurance. LimitedLiability 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 foi• 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' compensatioii'policy, please call the Department at the number listed below. Self-iiisuxed companies should'enter their self-insurance laeense 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 proofthat 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 0 2 6 Date ..... ..... .. .. . . .... .. 0, TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ........ .......... ........................................................ ry has permission to perform..... W.. -.-� . . ......... ...... ................. wiring in the building of ......d1.. 14,-,Tti ..................................................................... at ..... .......... /'- 14 . ............. jVorth Andover, ass. 7-- Lic . No . e.. 7411 �Of . . . . . . i� . . . . . . . . . . . . . . . . . . . . . I . . . . . . Fee .... 121A 7 ... I Check # /z- yy-.i ELECTRICAL INSPEGiOR 7 Commonwealth of Mss saehusettsFPermitN.. Official Use Only Department of Fire Services I(9��BOARD OF FIRE PREVENTION REGULAT)ONS cY and Fee Checked PERMITGeV- 1/07] eave blank APPLICATION FOR PERMIT 1'® PERFORM ELECTRICAL its® All work to be performed in accordance dance �� the Massachusetts Ele R� Ni'ININK OR TYPE ALL NFp ate: Code (MBC), 527 CMR 12.00 City or Town oh NORTH AND �R O� Date: BY this application the undersigned gives notice of his o To .the Inspector of Wires: Location (Street &Number) �C� er in tion to Perform the electrical work described below. Owner or Tenant 4 h7 � Owner's Address In Telephone No. Is this permit in conjunction with a bundin �--- Purpose of Bundin g Permit • Yes ❑ No g (Check Appropriate Box) Existing Service Utility ,Authorization No. '— `APs _____,.,__Volts Overhead ❑ New_ Service Amps e �" ❑ No. of Meters Number of Feeders n$ d. `"Volts Overhead Und Ampacity ❑ Undgrd ❑ No. of Meters Location and Natpre of Proposed Electrical Work: o. of Recessed Luminaires o. of Luminaire Outlets s. &i'Luxajaalres of Receptacle Outlets Of Switches of Ranges of Waste Disposers 1110. of Dishwashers ers-0 f of ieartm��KW o.ofe -- CeiL-Susp. (Paddle) Fans Nt'.k, of Hot: T;.Ft?v I Stemming Pool ``above d. ❑ Ko. of Oil Burners Vo. of Gas Burners 'o. of AirCon,& _o pace/Area Heating K [eating Appliances o. of __ xW win table may be waived b the Inspect No. of Transformers Tota �A g•'-�:uet•atv�a� o. o mergency �....-- .t .. rg e =RE Ai.ARMSNo.-ofZones o..of Detection an Wtaiatiri� Devices D. of Alerting Devices ❑ Mmticipa tf—Connection ❑ Other No. Hydromassage Bathtubs 01IMS Ballasts . Uata Wiring: No. of Motors No. of Devices ar OAR, Total HP Telecommunications Estimated Value of lectrical Work: Attach additional detail i Work to Start '7 p `!J� l; `ii a or as required by the I i (When required by municipal policy.) of Wires INSURANCE CO lhsPectiOns to be requested in accordance with ) VERAGE: 'Unless waived by the owner, no a MEC Rule 10, and upon completion. the licensee provides proof of liability insurance includingP rmit for the performance of electrical work may issue undersigned certifies that such coverage is in force, and hs �mpleted operation,, Coverage or its substantial Y unless CHECK ONE: INSURANCE exhibited proof of same to the equivalent The Icertify, under the ❑ BOND ❑ O Permit issuing office. pains an_d penalties o THER ❑.(Specify:) FIRM NAME: %� 6 J /.1 f J*--irrformalion on this ✓7� aPphcahon i e and complete. Licensee: � S� C. NO.: (IfaPPlicable enter"exempt" in the license numb line,) Signature �► Address: LIC. NO.: s� *Per M.G.L c. I47, s. 57-61 - w -� Bus. Tel. NO.: OWNER'S INSURANCE W° requires that rtrn of Public Safe �� Tel. No.: required b law. B AVER: I am aware that the Licensee does not have the cense: Lie. No. Y y my signature below, I hereby waive this liability insurance coverage normally Own tura nt requirement. I am the (check one Signature one)EI ❑owner's agezrt Telephone No. PERMIT FEE: $ ELECTRICAL PERMIT NO. INSPECTION REPORT: ELECTRICAL INSPECTOR - DOUG SMALL 1. ROUGH INSPECTION: Passed — [ ) Failed — [ ] Re -inspection required ($50.00) - [ J Inspectors' comments: (Inspectors' Signature - no initials) Date 2. FINAL INSPECTION: Passed — W Failed — [ ] Re -inspection required ($50.00) - [ ] Inspectors' comments: (Inspectors' Signature - no initials) Date 3. UNDER GROUND INSPECTION: Passed — [ J Failed — [ ) Re -inspection required ($50.00) - [ ] Inspectors' comments: (Inspectors' Signature - no initials) Date 4. INSPECTION — SERVICE: DATE CALLED NATIONAL GRID: NAME: Passed — [ ) Failed — [ ) Re -inspection required ($50.00) - [ ] Inspectors' comments: r (Inspectors' Signature - no initials) Date 5. INSPECTION - OTHER: Passed — [ ] Failed — ( ] Re -inspection required ($50.00) - [ ] Inspectors' comments: (Inspectors' Signature - no initials) Date DOOR TAGS ARE TO BE FILLED OUT AND LEFT ON SITE IF THE AREA TO BE INSPECTED IS NOT ACCESSIBLE AND A RE -INSPECTION OF $50.00 IS TO BE CHARGED.