HomeMy WebLinkAboutMiscellaneous - 26 SUTTON PLACE 4/30/2018I
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TOWN OFMORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that ..............
has permission to perform ... ......
plumbing in the buildings of i ...........
at 0(0 ... 4Y .......... North Andover, Mass.
Fee. Lic. No.. ............. ..... ......
L41 PLUMBING INSPECTOR
Check
8370
N2 4631
US
This certifies that
Date,//:-�
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
. . . . . . . . . . . . . . .
has permission to perform .... I � -C�'/ �� q .......................
plumbing in the buildings of .............
at. Z ........... North Andover, Mass.
Lic. No.. . .............. .......
Fee. A4::r
�,LUIVIBING INSPECYOR
Check #
WHITE: Applicant CANARY: Building Dept PINK: Treasurer
MASSACHUSETTS UNIFORMAPPLICATONFORPERMrrTODO GAS F11TING
(Type or print) Date
NORTH ANDOVER, MASSACHUSETTS /z/
Building Locations Permit #
Amount $
Owner's Name
New Renovation Replacement Plans Submitted
(Print or type
Name
Name of Licensed Plumber or Gas Fitter
Check one: Certificate Installing Company
-Fj Corp.
rlPartner.
Firm/Co.
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substan * tial equivalent. Yes NoO
If you have checked yes, please indicate the type coverage by checking the appropriate box.
Liability insurance policy Other type of indemnity 13 Bond 0
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:
1 Signature of Owner or Owner's Agent Owner E3 Agent 0
7 �4A, �L — -11 : - — . I
...��i,,auun MVU bUULWLtrU kor enierea) in above application are true and accurate to the
best of my knowledge and that all pl ng work and installati rformed )Pem3jossued fopthis application will be in
compliance with all pertinent provisions of the Massachuserlay�as Co hgVr 14VXe General Laws.
By.
Title
City/Town
APPROVED (OFFICE USE ONLY)
V
SigVKture of Libensed
El Plumber
Gas Fitter 77C
r7l,*ra—ster
LAdlu
r-1 Journeyman
Fitter
�S U B -B A S E M EN T
MMMMMMM
2ASEM ENT
-MMMMMMM
mm
mm
IST. FLOOR
12ND.FLOOR
�-==
i3RD. FLOOR
MMMMM
�4TH. FLOOR
MMMMMMM
:5TH. FLO OR
i6TH. FLOOR
7T9. FLOOR-=======
&TH, FLOOR
mmmmmmm
(Print or type
Name
Name of Licensed Plumber or Gas Fitter
Check one: Certificate Installing Company
-Fj Corp.
rlPartner.
Firm/Co.
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substan * tial equivalent. Yes NoO
If you have checked yes, please indicate the type coverage by checking the appropriate box.
Liability insurance policy Other type of indemnity 13 Bond 0
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:
1 Signature of Owner or Owner's Agent Owner E3 Agent 0
7 �4A, �L — -11 : - — . I
...��i,,auun MVU bUULWLtrU kor enierea) in above application are true and accurate to the
best of my knowledge and that all pl ng work and installati rformed )Pem3jossued fopthis application will be in
compliance with all pertinent provisions of the Massachuserlay�as Co hgVr 14VXe General Laws.
By.
Title
City/Town
APPROVED (OFFICE USE ONLY)
V
SigVKture of Libensed
El Plumber
Gas Fitter 77C
r7l,*ra—ster
LAdlu
r-1 Journeyman
Fitter
The Commonwealth of Massachusetts
Department qf Industrial Accidents
Office of Investigations
600 Washington Street
Boston, A11A 02111
www.mass.gov1dia
Workers' Compensation Insurance Affidavit: Buflders/Contractors/Electricians/Plumbers
Applicant Information
Pley - - Print Le_oib
Name (Business/Organization/Individual):
Address:
City/State/Zip: Phone #:
Are you an employer? Check the appropriate boxi
LEI I am a employer with
. 4. F-1 I am' a general contractor and I
EI employees (full and/or part-time).*
I
have hired the sub -contractors
am a sole proprietor or partner-
listed on 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. 0 We '
are a corporation and Its
required.)
3. 1 am a homeowner doing all work
officers have exercised their
right'Of exemption per MGL
myself. [No workers' comp.
c. 152, § 1 (4), and we have no
insurance required -1 t
employees - [No workers'
A- , . V _.
cOmP,
- insurance required.]
Type of project (required):
6. E] New co n*struction
7. [] Remodeling
8. Demolition
9. Building addition
lo-ElElectrical repairs or additions
111-1 Plumbing repairs or additions
12.0 Roof repairs
13 -El other
bv LLa oun Lae sean=_ nee S-0=9 u"CL—a'orkers, comp= --tion peii
h - CY
t Homeowners who submit this affidavit indicating they are doing'all�work and then hire outside contractors must submit a new affidavit indicating such.
lContractors that check this box must attached an additional sheet showing the. name of the sub -contractors and their workers' comp. policy information.
C tio
lam an employer that isproviding workers, OMPensa n in'sUranceformy employees. Below is the polio; andjob site
informatiom
Insurance Compa�ny Name:
Policy # or Self -ins. Lie. #: Expiration Date:
Job Sit-- Address:
City/State/Zip:
Attach a copy of the workers' compensation policy declaration page (showing the policy numboa and expirition date).
Failure to secure coverage as required under Section 25A of M . GL 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 c . erdfi7.under the pains andpenalties ofperjurjy thtzt the information provided above is frue and correct.
Simature: Date.:
Phone #:
r0;ff=Caluse only. Do not write in this area, to be completed by city or to. off,-ciaL
City or Town:
PermitfLicense #
Issuing Authority (circle one):
L Board of Health 2. Building, Department 3. CitY/TOWII Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other ft
Contact Person:
Phone #:
Information and Instructions k
Massachusetts General Laws chapter 152 requires all employczrs to provide workers' compensation for their employees.
Pursuant to this st . atute, an employee Is defined as "...every pf--non in the service of another under any contract of hire,
express or implied, oral or,written."
An employer is defined as "an midividual, partnership, associattion, corporation' or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including t1he legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association ox- other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartmLents and who resides therein, or the o ' ccupant of the
dwelling house of another who employs persons to do maiiite�3:iance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not be��ause 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 coxnpliance with the insurance coverage required."
Additionally, MGL chapter 15 * 2, §25C(7) states "Neither. the c--ommonwealth 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 chapterhave been presented to the cont-.vcting auffiority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificat�(s) of
insurance. Limited Liability Companies (LLC) or Limited Li.-ibility Partnerships (LLP) withno 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 siure to sign and date the affidavit. The affidavit should
be returned to the city or to -,m that the application for the perrmit-Or License is being reques not the Department of
Industrial.Accidents. Should you have any questions regardimg the law or if you are required toobtain a workers'
compensation policy, please call the Department at the numbf--r 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.'
Pleas% 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 writt- "all locations in (city or
town).N A copy of the affidavit that has been officiiilly stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on Ede for future perinits 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 v=ture
(i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. .
The Office of Investigations wouldlike tq�#iqpk you in advance f6r your cooperation and should you have any questions,
please do not hesitate to give us a call.
Tbe Department's address, telephone and fax number
The Commonwealth of Mas&wlusetts
Department of Indusffial Accidents
Office of Investigations
600 Washington Stree;t
. Boston, MA 02111
Tel. # 617-7274900 -ext 406 or 1-8 77-MASSAFE
Fax # 6.17-727-7749
Revised 5-26-05 wvrw.mass-gov/dia
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTHANDOVER, MASSACHUSETTS
Building Location 1;
V TtUt-,. /2 / 4-<- Owners Name 1" C
of Occupancy 0w -e11 -."*-V
/Da / / , a d
7L
ermit -(4
Amount C -
Renovation Replacement Plans �ub;�ZYes D No
New
FIXT"IRES
MMMMMMMMMMMMMMMMMMMMMMMM
=-.t,�.-Di�iagiommmmmmmmmmmmmmmmmMMMMMMMM
=F-imummmummmummmmmmmmmMMMMMMMMMM
m,lzolcfco-.EmmmmmmmmMMMMMMMMMMMMMMMMM
W-,ngmmmmmmmmmmmmmmmmMMMMMMMMMMM
w.li..82f-g-o..Emmmmmmmmmmmmmmmmmmmmmmmmm
W-1-1;19co�e�*lmmmmmmmmmmmmmmmmmmmmmmmmmm
M
MW
(Print or type) Check one: Certificate
Installing Company Name 11,74 Corp.
Address 130 V P tj V-;" Partner.
& /t/,4 i) -v.-e,-L [3—irimco.
Business Telephone ie) F7. 0 r -LO
Name ofLicensed Plumber.
Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box:
Liability insurance policy Other type of indemnity F1 Bond F1
Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above
threeinsurance A
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 ormed under Permit Issuo for this application will be in
-hu ta bing e and Ch±4�^e General Laws.
compliance with all pertinent provisions of the Massac
7szf�X-7 J,,
By: 7ig-n=or Licensed I 1 --yr
Type of Plumbing License
Title R-3 6,
CityfTown =i7ense Numoer Master []-- Journeyman El
JAPPROVED (OFFICE USE ONLY
Location 2-(D
No. Date
VkORTpl TOWN OF NORTH ANDOVER
0 '6 0
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee
Sewer Connection Fee
Water Connection Fee $
TOTAL
249
Building Inspector
245-00 PAID
06/27/95 13:47
TO
i.- 8659 Div. Public Works
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FORM U - WT RELEASE FORM
INSTRUCTIONS: This form is used to verify that all necessary
approvals/permits from Boards and Departments having jurisdiction
have been obtained. This does not relieve the applicant and/or
landowner from compliance with any applicable local or state law,
regulations or requirements.
****************Applicant fills out this section*****************
APPLICANT: S-1 CA4 Vk 0 VS P4_
Phone A9 ? 0 f
LOCATION: Assessor's Map Number Parcel 112 -
Subdivision Lot(s)
Street -4 -7-6 A.) St. Number
**0
***0 ficial Use Only************************
RECO D N OF YAGENT . S
�1221��
V/, Date Approved
Conservation AdmInistiator Date Rejected
Comments
Date Approved
Town Planner Date Rejected
Comments
Date Approved
Food Inspector -Health Date Rejected
Date Approved
Septic Inspector -Health Date Rejected
Comments
Public works - sewet/water connections
- driveway permit
v4ire Department
Received by Building Inspector Date
r -E
2,4 X/O
7-4KO 57 P- JW 411
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The Commonwealth of Massachusetts
Department of Industrial Accidents
600 Washington Street
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit
nam
-'7 -7A A h)(1 -h ru 5-h
city 0 0 Vek, VL1 il—T�l P)ew�`1211009#
I m a homeowner performing all work rn�self
._'o
Warn a sole proprietor and have no one working in any capacity
I am an employer
compensation for my employees working on this job.
.:A: ��r
corn anv:narne::::-::::
Failure to secure coverage as required under Section 25A of NIGL 152 can lead to the imposition of criminal penalties of a fine up to SI,5.00.00 and/or
one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of S100.00 a day against me. I understand that a
copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification.
I do hereby certify under the pains and penalties ofpeiyury that the infornzation provided above is true and correcL
Signature Date. (a7i i, r
V-% LAt 0 A.> 5 -
Print name 's F F S( —3hone # F, Z� - 17 P4 -
official use only do not write in this area to be completed by city or town official
city or town: pernlit/license A c'- ZA=� 011din' Department
�Ui.in,
oLicensing Board
0 check if immediate response is required oSelectmen's Office
I -]Health Department
contact person: phone#; ----00ther
(imsed 3/95 PJA)
a
. A 4
Information and Instructions
Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their
employees. As quoted from the "law", 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 section 25 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, 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.
li�7
t , 41 MCI' PIP. RE 7 R
NOW
Applicants
Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and
supplying company names, address and phone numbers as all affidavits mav 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.
S
City or Towns
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 Investi2ations 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. The affidavits may be returned to
the Department by mail or FAX unless other arrangements have been made.
The Office of Investigations would like to thank you in advance for you 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
Iffice of lovesfigations
600 Washing -ton Street
Boston, Ma. 02111
fax #: (617) 727-7749
phone #: (617) 7274900 ext. 406, 409 or 375
The Commonwealth ofMassachuseas
Department of Indusn-ial Accidents
AV= f/Iffirestwim
600 Washington StTeet
Boston,Mass. 02111
Workers' Compenmtion Insurance Affidavit
XMIMIM1131131 don -
name* S
location: -L, z?
VL4 1.q 3 n -hone 4 W-3 7- —
— I homeowner (circie one) and have hired the contractors listed below who have
LrT am a sole propnetor, eral contractor, o,
the following workers' c -.s:
0
CL2 S 71t-LIL 77dt) 1
company name -
5.
add re ss:
......... .
citv- phone
ingurnnee CO. nolicv wc�,OAI)0754�
Failure to secure coverage as required under Section 25A of NIGL 15-2 can lead to the imposition of criminal licnaldes Of 2 fine up to SI -500.00 and/or
one VC2rs' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine ofS100.00 a day against me. I understand that a
copy of this statement may be forwarded to the Office of Invescigarions of the DIA for coverage verification.
I do hereby cerrijly under the pains and penalties ofpe7�ui�v thm the infor"sadon provided above is true and correct
— -7 /-/!�: / 2 r
I ofricial use only do not write in this area to be completed by city or to- official
if � P Z- -/ -7,P4-
city or town: permit(UCCUMA r -,Building Department
CLicensing Board
check if immediate response is required C]Selectmen's OtTice
C3Health Department
contact person: pboac 0; 1710ther
(mvisM 3M PJA)