HomeMy WebLinkAboutMiscellaneous - 268 RALEIGH TAVERN LANE 4/30/2018Date ... ............
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that -&- L', �\ �0 .......
.................................................
has pennission to perforin
-A .... .. I�A
wiring in the buildiLig of ............. ...
............................................................
at ................. ( ... P... W- ........
...... North Andover, Mass.
F'ee..�a� Lic. No. ........
pEaKAL NS �EC�
Check, 16 '54
III Ran,
Commonwealth of Massachusetts
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
Permit No. - \ZZ-�,Q
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 Code (NMC), 527 CMR 12.00
(PLE-4SE PRINT 1ATNK OR TYPEALL MFORW TION) Date: 1 C>1 1 -7 1 ?- -2 14
City or Town of. NORTH ANDOVER To the Inspector of Wires:
By this application the -undersigned gives notice of his or her intention to perform the electrical work described below.
'V
Location (Street& Number) 2t=!F5 0 1 V\'
Owner or Tenant 6--.-- c) rae 5
TelephoneNo.
4�� j
Owner's Address kx�
Is this permit in'conjunction wit', a building permit? Yes No jK (Check Appropriate 13ox)
Purpose of Building DJ, - -Nk Utility Authorization No.
Existing Service Amps volts Overhead El UndgrdF] No. of Meters
New Service - Amps volts Overhead Undgrd No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: W � f, �,&k -6<- 4 - 0 , iae�%
Completion ofthefollowin table maybe waived by the Inspector of Wires.
No. of Recessed Luminaires
No. of Ce1-Susp. (Paddle) Fans
No. of Total
Transformers KVA
No. of Luminaire Outlets
No. of Hot Tubs
Generators KVA
No. of Luminaires
Swimming Pool Above Ei In- E]
arnd. arrid.
jNo. of Emergency Lighting
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
JN'o. of Zones
No. of Switches
No. of Gas Burners
No. of Detection and
Initiating Devices
No. of Ranges
No. of Air Cond. Total
Tons
No. of Alerting Devices
No. of Waste Disposers
Heat Pump
Totals:
..........
J.KW ..........
............
No. of Self -Contained
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heating KW
LocalEl Municippl r] Other
Connection
No. of Dryers
Heating Appliances KW
Security Systerns:*
No. of Devices or Equivalent
No. of Water KW
Heaters
lNo.
No. of No. of
Signs Ballasts
Data Wiring:
. No. of Devices or Equivalent
Wo. Hydromassage Bathtubs
of Motors Total UP
Telecommunications Wiring:
No. of Devices or Eauivalent
OTHER:
Attach additional detail f(desired, or as reqtdred by the Inspector of 97res.
Estimated Value of Electrical WorA 3 7 5- (When required by municipal policy.)
Work to Start: lr�spections to be requested in accordance with WC 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.
CBECK ONE: INSURANCE & BONDE] OTBERF] (Specify:)
I certtfy, under th ndpenalties qfperjury, that the information on this application is true and complete.
FIRM NAME: T&--A�" V�- C �01 , & � - 'Aff - �, 1� &- V*% LIC. NO.:
Licensee: kk " , " S � P ,.- -, Signature LIC. NO.:
(If applicable, enter "exempt" in the llcense�number line) Bus. Tel. No. -
Address: Alt. Tel. No.:
*Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coveragenormally
required by law. By my signature below, I hereby waive this requirement. I am the (check one) [I owner El owner'sAgent.
Owner/Agent t
Signature Telephone No. PPRMIT FEE.- $
7elSY6 A4,1C
.3
o
I
2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance -with the provisions of M.G.L. c. 143, § 3L, the
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 0
• Permit Extension Act — Permit/Date Closed:
Trench Inspection
Pass M
Failed
Re- Inspection Required 0
Inspectors Comments:
Inspectors Signature:
Date:
SERVICE INSPECTION:
Pass
Failed
Re- Inspection Required 0
Inspectors Comments:
4
Inspectors Signature:
Date:
PARTIAL ROUGH INSPECTION:
Pass Rl
Failed
Re- Inspection Required El
Inspectors Comments:
Inspectors Signature:
Date:
ROUGH INSPECTION:
Pass IN
Failed
Re- Inspection Required 0
Inspectors Comments:
Inspectors Signature:
Date:
FINAL INSPECTION:
Pass M
Failed
Re- Inspection Required ($.) El
Inspectorgomments:
Inspectors Signature:
Date:
DEB WEINHOLD ... TOWN OF MERRIMAC, MA . ....... dweinhold@townofmerrimac.com
The Comraonwealth ofMassachuseffs
Department ofbidustrialAccidints
Office offfivesfigaflons
660 Washington Street
Boston., MA 02111
vww.massg;ov1d1a
Workers' Compensation Ynsurance Affidavit: BundersfContractor6fFIectricians/pliimberq
A heant Wormation Please Print Leal
'Name CBu-sinossiorgani-zation&dvidual):
V\,
Address: 0
city/statemp: L -a � v\.- PfK ot _3- Phone:#: 711 0-11 Q
Are you an employer? Check the appropriatelbox: Type of project (required):
1. D I am a employer with 4. n I am a general contractor and 1 6. El New construction
./\einployees (fall and/or part-finae).* have hired the sub -contractors
2n�a�n a solD proprietor or partner- listed on the attached shoot. 7. E] Remodeling
ship and1aveno-employees These sub -contractors have 8. Demolition
worldng for me in any c workers' comp. hisurance, I
apacity. 9. Building addition
[No workors, comp. insurance 5. El We are a corporation and its I �kEle ctdo al repairs or additions
required.] officers have exercised.their
All lamahomeovmer6ingallwork right of exemption p or MOL 1Q] Plumbingrepairs or additions
myself. [No workers' comp. c. 152, § 1 (4), and we have no 12.Q RODfrepairs
insurancerepire4.] t einploye6s. [No workers' 1311 other
comp, insurance required.]
'Any appliomt that &ecksbm #I must also fill out the section below showingth-,Irwbrkers'conipensatiolLpouoy information.
T-Horneowners; who Bubmit1his aEUdavitindicatinitheyk�dgingallworKand then hire outside contractors must submit anow affidavit indicatnigsuch.
lContractors that check Us box mustattached an 9dditionalsheetshowhigtho name of the sub -contractors and their workers' comp. policy information.
I am an emyloyer that isproviding workeml compensation insurancefor my em
,ployees. Below is thepolley andjob site
infolmation.
Insuance Company
11011cy # or 8 elf' ias. Lio. ff : Expiration Date;
Job Site Address: Citv/State/Zhx
Attach a copy ofthe workers' compensation-polleydeclaratlon page (showing the policy number and expiration date).
Failure to securo covorago.as reqI Aledunder Section 25A ofMGL o. 152 can lead to the Juiposition of criminal penalties of a
fma up to $ 1,5 0 0.0 0 and/or onu-year impris onment, as wellas cK p enalties in the form. of a STOP. WORK ORDER and a fMG
of up to $250.00 a day against the -violator. Be advised that a copy of this statement maybe forwarded to the Office of
lavestigatio-w of the DIA for insurance, coverage verification.
Mo 1,eTPbrre_73W uiidert7zep'ainsandpenaltiesofpe.-jurytlzattlie informadonprovided above is true andcomect
Date: /_7
Phone #:
off
,cial use oply. Do not write M this area, to be conTleted by c1V or town official
City or Town: Perml-Mcense ff
Issuing Autherity (circle dne):
1. Board of Health 2. Building Department 3. C41T-own Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contactrerson: Phone
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers, compensation for their employees.
Pursuaiit to this statute, an ernployee is dofineil as 11 ... every person in the servic 0 o r d ra yco t of -
express orimp]14 oral orwritten." 0 fan the un c n iftrac hire,
An em
ploydis defaied as "an individual, partnership, ass 0 claflon, corp oration or other legal entity, or any two or mole
of the f6rejo ' kj engaged in aj oint enterprise, and including the legal repres entatives of a� deceas ed eiuployp�, or the
redelv&r okmstee' of an individual, partnership, askciation or other legal entity, employing employees. &V�evcr&6
owner of a dwelling house having notmore than three apartments and who resides therelu, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work'on su6h dwelling house
or on the grounds or building appurtenant thereto shall not because of such employmentbe, deemedto be an employer."
MGL chapter 152, §25C(6) also states that "every state or l6bal lie-enslag 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 c
overage required."
Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political sub 6visions shall
enter iuto a -fly contract for the p orformance ofpublic work until acceptable evidence of complipice with the insurance,
requirements of this chapter have b eon presented to the contracting atithority."
Applicants
Pleas.o.fill out ffio workers' com fidavit completely, by cheoldng tho boxes that apply to your situation and, if
-pens ailon af
nccegsary� supply sub-contractor(s) name(s), address(es) and phone number(s) along with their cortificate(s) of
insurance. Limited Liability Companies (LLQ or Limited Liability Partnerships (LLP) with no employees other than the
members or partners, are not required to cany workers' compensation insurance. If auLT—C orLLP does have
employaos,apolicyismquired. Be advised that thi� affldavit may be submitted to the Department of Industrial
Accidents for confinuationofinsurance coverage. Aho be sure to sign and date the affldavit. 1heaffidavitshould,
be returned to the city or town that the application for the, permit or license is being requested, not the Dep'artment of
Industrial Accidents. Shouldyou have any questions regarding the law or if you are required to obtain a-�arkersl
con�ponsationpollqy, please call the Department at thanumberlisted below. Self-hisured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete andprintedlegibly. The Department has provided a space attho bottom
of the at[idavit foryou to fill out in the, event the Offf cc of Investigations has to contact you regarding the applicant.
Pleas ' a bo -sure to fiff in the permit/license number which will be used as a reference number, Th addition., anappEcant
that must submitmultiple permit/license applications in any ,
given year, need only submit one, affidavit indicating curr6nt
policy inflaTmation (if necessary) and inider "fob Site Address'; the applicant should write "all locations in I (Citv or
towly)." A 6opy of'tho afff davit that has b con officially stamp ed or marked by the city or town may b u provided Fo iha�
applicant as proof that a valid affidavit. ii on ffic'for fature 4
permits or licenses. Anew affidavit rmist be, MeA out each
year. *Where a !ionic owner or citizen is obtafiffig alicense or -permit not related to any business or commercial venture
(i.e. a dog license oriermit to burn leaves etc.) said person is NOT required to complete this affldavit.
The Office of Investigation.- would Eke to thauk you in advance for Your cooperation and shouldy9u, have any questions,
please do not hasitita to give us a call.
The Department's address, telephone aiiA fax number:
The CQmmonwaalth of Mo s�acahv
Dapaftaut of Tndu*ial Accidents
off ice. Qf limstfoa0mg
60 Waft&n Stcoa
Bogon, MA 02111
T01 # 617-7.27-4900 W, 406 or- 1 -877 -MAS
SAM
Revised 5-26-05 Fax 0 617-727-7749
_WWW-MwgQ-VM4
'.
�'
{
i
r
"I,
Bill 9784092640 p.2
The Commonivealth ofMassachuse tts
U? -DepaphnP-nt of-TndustrialAccidintv
Ofj7ee oflnvesdgations
600 Washington Street
Boston, MA 0211-1
www.mass.govldia
Workers'COMPensation Insurance Affidavit: Bizildp_rs/ContractorsmiectriciansiTlumbers
Ap-plicant Information Please Print LegibLy
NaMe (Business/Organizalionffiidividual) ' . -i , - - I
E- I e cL n
Ad&ess:—/c29�
CitY/S`tate,/ZiP: S2Jj,S�,k)UrV ) A,4 011Whone #:
Are you an employer? Check the appropriate box: Type of oJect (required):
El I am a employer with 4. El I am a general contractor and I
6. Wew con-straction
_qmfoyaes (fall and/or part-tima).* have fiked. the sub -contractors
2. LVI am a solD propri.-tor or partner- listed on the attached she et. 1 7. E] Remodeling
ship and'kave no employees These sub-cantactors have 8. n Demolition
working for me. in any capacity. workers' comp. insuranc I
9. 0 Building addition
e
No worRus' comp. insurance 5. El We area corp oya�on and its
r -quired.] officers have exercised their 10.0 Elechicalrepairs oraddidon-s
r
3. 1 am a homaowner doing all woxk right of exemption per b1GL RE] Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1 (4), and -vie have -no 12.E] Roofrepairs
insurance required.] employees. fHo workers, 13. F* Other
comp. instiranco required.]
�y �Jyj-=L LUUL$A1ULZL2i UV)Lffi YmISJU150 HLIOUFMORCCUon Dejo-W Sj-ojWg their Wj)r.,ors, corr-p�-nsationpolicyirifommtion.
t'Homeowners who submit this Effidavit irldiratingthey Aie doing all work and then hire outside contractors must submit anew affidavit indicating such.
�Contrzctws that check this boxmustatfached an additional sheet Showing the name of the sub -contractors andtheirwojb.Ts, comp. policy iafbnmtjon.
I am an employer that isprovidbig Wollkers'compensation insurance-jor my employees. Below is thepolicy andjob site
11formation.
rT"Rcc CoInpany Name% Harv-G)ni Re?- insora=
P 0 l'i"CY # or Self -ins. Lie. #: QS5 &&VY 9?otO KpiratioaDatte.
Job Site Address:33Pejach —Ire -c (-4\S Pity/State/Zip:!\)gf�h )Wc-VCrjAff.CAq-f
I
Attach a copy of the workers' compens2tion -policy declaration page (shoWing the policy number and expiration date).
�ailure to Secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the Enposition of criminal penalties of a
fine up to $1,50 0.00 and/or one-year imprisonment, a's well as civil penalties in the fonn of a STOP -WORK ORDFR and a fine
of up to $250.00 a day against the violator. 13e advised that a copy of this statement maybe forwarded to the Office vf
Iavesti,gatloas ofthe DIA for insurance, coverage verification.
I do 11 ereby cert4 utider A epains an dp eKalyies OfPerj"TY Mai i(I e infOrM410,,�Pro Vided ah ove is true and comect,
— q-�2 3 — --?S 9
Of
r1eial use only. DO nOt wfitc in this area, to -be completed by city or town officitri
City or Town:
Permit)LIcense
-7
Issuing Authority (circle one):
I. Board of He2lth 2. Building Department 3. Cityffown Clerk 4. Electrical IRSP eetor 5-Flumbing Inspecior
6. Other
Contact Person: Phone
10807
Date .... W-711-�---
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
.This certifies that . ....................... ..........
has permission to perform.. . ....... .....
4�Ac"'k'
plumbing in the buildings of...
at .... 2f,.,,.� . ........ e
.................... �'North Andover, Mass.
Fee ... 99 ..... Lic. No. /"'�--719 ... ........ Me ........................................................
PLUMBING INSPECTOR
Check # I L) ;,*
_bTHE�7_
. ......... J j J
I J
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES NO Ell
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 9j OTHER TYPE OF INDEMNITY 01 BOND 0
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance cove rage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER M-1 AGENT JE11
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
and that all plumbing work and installations performed under the permit issued for this application %M11 be in compliance with all Pertinent provision ofthe
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME
Y4 P) tQ __11LICENSE# 41" SIGMAIME
Mp ip CORPORATION FIA PARTNERSHIPD# LLC E�
COMPANY NAME 'JADDRESS
4 iH647JA4 I -
CITY STATEF-/-i-,f -11 zip TEL -
FAX EMAIL g
CELL L
Q
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY
MICK
--:]I MA DATE PERMIT# 16VA
JOBSITE ADDRESS
ER'S NAME 14
P
OWNER ADDRESS
L._JAMtL_
il TEL 0 AXI
TYPE OR
OCCUPANCYTYPE
COMMERCIAL DI
EDUCATIONAL RESIDENTIAL
PRINT
CLEARLY
NEW: RENOVATION: F-11 REPLACEMENT: Eff
PLANS SUBMITTED: YES Ell NO
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
DEDICATED GAS10IL/SAND SYSTEM
I —A
__J1 _J1
—il
DEDICATED GREASE SYSTEM
DEDICATED GRAY WATER -SYSTEM
DEDICATED WATER RECYCLE SYSTEM
DISHWASHER
J
DRINKING FOUNTAIN
_J11===F:_____j
_j j _1
FOOD DISPOSER
FLOOR/AREADRAIN
INTERCEPTOR QNTERIOR�
J --.-j
KITCHEN SINK
LAVATORY
----- --- E-73,
ROOF DRAIN
SHOWER STALL
_bTHE�7_
. ......... J j J
I J
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES NO Ell
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY 9j OTHER TYPE OF INDEMNITY 01 BOND 0
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance cove rage required by Chapter 142 of the
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
CHECK ONE ONLY: OWNER M-1 AGENT JE11
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
and that all plumbing work and installations performed under the permit issued for this application %M11 be in compliance with all Pertinent provision ofthe
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER'S NAME
Y4 P) tQ __11LICENSE# 41" SIGMAIME
Mp ip CORPORATION FIA PARTNERSHIPD# LLC E�
COMPANY NAME 'JADDRESS
4 iH647JA4 I -
CITY STATEF-/-i-,f -11 zip TEL -
FAX EMAIL g
CELL L
Q
Elf)
0
4 1�
0 El
z
LLI
Ix
iii
LLJ
LL
The Commonwealth ofMassachusetts
Department of lndustrlqlAccid��ts
Office of Investigations
600 Washington Street
Boston., MA 02111
Uf www.mass.gov1dia
Workers' Compensation Insurance Affidavit: BuildersfContractors/Electricians/Plumbers
Applicant Information Please Print Legib
NaMe (Business/Organization/Individual): 6f� A -Z
Address: /"- ;rfe-,41-k 57 r"'1(7-
City/State/Zip: Cc4qC&C /1,J e1?4DL. Phone#: &77�
Are you an employer? Check the appropriate box:
1. F1 I am a employer with
4. F1 I am a general contractor and I
_PMployees (Rd and/or part-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. El We are a corporation and its
required.]
officers have exercised their
3111 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.] t
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. n Now con struction
7. 21k emodeling
8. rJ Demolition
9. 0 Building addition
10.E1 Electrical repairs or additions
ILEI Plumbing repairs or additions
12.E] Roofrepairs;
13.Ei 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 tfre doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors 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 isproviding workers' compensation insurancefor my employees. Below is thepolley andjoh site
information.
Insurance Company
Policy # or Self -ins. Lic. #: Expiration Date:
Job Site Address:—' City/State/Zip:
Attach a copy of the workers' compensation -policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as 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 h ereby certify u n der th e pa ins an dp en aftles ofperjury th at th e information pro vided ab ove is true an d correct
lip -Irl - / �/
Phone#:
Official use only. Do not write in this area, to he completed hy c4 or town official.
City or Town:
PermittLicense 9
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#:
I
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 ofhire,
express or implied, oral or written."
An employeiis defined as "an individual, partnership, association, corporation or other legal entity, or any two or -more
of the foregoing engaged in ajoint 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.21
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 subdivi!sions 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 ffic boxes that apply to your situation and, if
necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLQ 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 maybe submitted to the Department of Industrial
Accidents for confimi]ationof insurance coverage. Also be sure to sign and date the affidavit. ihe 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,
Pleas ' e 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 officiaRy 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 p* ermit 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 M-assachmetts
Department of %dustrial Accidents
Office of lavesfigatiom
600 Wasbington StrQet
Boston., MA 02111
Tel, # 617-727-4900ext 406 or 1-877�MASSAF
Revised 5-26-05 Fax # 617-727-7749
_WWW-Mass,govNia
Date .... IV.71 ...............
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that (�S P++
..............................
has permission for gas i tallatinnn ...........
...... ...................................
in the buildings of... ...... ;r
..........................................................................................................
at ...... Z�e.S ....... ? ...... �!�t'North Andover, Mass.
Fee..91) .......... Lic. No SA ...... H.P� . ...................................................
GASINSPECTOR
Check #
9604
FRYOLATOR I
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT FF --JJ
OVEN
POOL HEATER
ROOM / SPACE HEATER
ROOF TOP UNIT
TEST J7
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
–bT—HER F
...... ......
.... ........ --' ........... .
F-77
INSURANCE COVERAGE
I have a current liabilify ins�ur`ance policy or its substantial equivalent which meets the requirements of MOL. Ch. 142 YES ONO
I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Ef 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: OWNER F—] AGENT
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
and that all plumbing work and installations performed under the permit issued for this application will be in compliance With all Pert. mt provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUM BER-GASFITTER NAME SIGNATUKE
LICENSE #F
IVIP 0 MGF Ej JP16 JGF D LPGI MJ CORPORATION Dl# = PARTNERSHIP [3#= LLC [j#
COMPANY NAME: _r, _PLUMIAIS f-HelIPAIC ADDRESS J_tO
CITY STATE ZIP ]TEL
- .
FAXI 11 CELL EMAIL A%
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY /11
MA
DATE PERMIT#
JOBSITE ADDRESS
OWNER'S NAME A2 fiLd
G
OWNER ADDRESS
I TELF127 Ma =?�Ed & FAX
TYPE OR
PR1NT
OCCUPANCYTYPE
COMMERCIAL EDUCATIONAL RESIDENTIAL
CLEARLY
NEW:F.1 RENOVATION:
REPLACEMENT: Eff
PLANS SUBMITTED: YES F3 NO
APPLIANCES I FLOORS-
13SM 1 2 3
4
5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
IF 1=
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE
J L
FRYOLATOR I
FURNACE
GENERATOR
GRILLE
INFRARED HEATER
LABORATORY COCKS
MAKEUP AIR UNIT FF --JJ
OVEN
POOL HEATER
ROOM / SPACE HEATER
ROOF TOP UNIT
TEST J7
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER
–bT—HER F
...... ......
.... ........ --' ........... .
F-77
INSURANCE COVERAGE
I have a current liabilify ins�ur`ance policy or its substantial equivalent which meets the requirements of MOL. Ch. 142 YES ONO
I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY Ef 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: OWNER F—] AGENT
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
and that all plumbing work and installations performed under the permit issued for this application will be in compliance With all Pert. mt provision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUM BER-GASFITTER NAME SIGNATUKE
LICENSE #F
IVIP 0 MGF Ej JP16 JGF D LPGI MJ CORPORATION Dl# = PARTNERSHIP [3#= LLC [j#
COMPANY NAME: _r, _PLUMIAIS f-HelIPAIC ADDRESS J_tO
CITY STATE ZIP ]TEL
- .
FAXI 11 CELL EMAIL A%
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The Commonwealth ofMassachuse as
Department of lndustrialAcc!6�ts
Office of Investigations
600 Washington Street
Boston., MA 02111
qu www.mass.gov1dia
Workers' Compensation Insurance Affidavit: Builders/ContractorsfElectricians/Plumbers
Applicant Information Please Print Legib
NaMe (Business/Organizatiordfndividual): 6�cfct6cF _5///1 PkA C)
Address: - 57
City/State/Zip: Zoluf6- 44 o /FS -.X Phone#: c7>R qq:�_ f3041
Are you an employer? Check the appropriate box:
1. n I am a employer with
4. F1 I am a general contractor and I
employees (Rd and/or part-time).*
have hired the sub -contractors
2. Vi 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.
workers' comp. insurance.
[No workers' comp. insurance
5. El We are a corporation and its
required.]
officers have exercised their
3111 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.]
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. F1 New con ' struction
7. [R'ge-modeling
S. Demolition
9. Building addition
10. F1 Electrical repairs or additions
ILE] Plurnbing repairs or additions
12.E] Roof repairs
13.00ther
!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 aie doing all work and then hire outside contractors must submit anew affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information.
lam an employer that isproviding workers'compensation insuranceformy employees. Below is thepolley andjob site
information.
Insurance Company Name;
Policy # or Self -ins. Lie. #: Expiration Date;
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation -policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one�year imprisonment, as well as civil penalties in the form of a STOP. WORK ORDER and a fine
of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under thepains andpenalties ofperjury that the information provided above is true and correct.
Phone #: "T 2 a '19 K-1 3 6 q
Offilcialuseonly. Do not write in this area, to he completed by city or town official
City or Town:
Permit/License 9
Issuing Authority (circle one):
1. 13oard 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 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 ofhiro,.
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 ajoint 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 requ.1red."
Additional.ly, 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-contraotor(s) name(s), address(es) and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLQ 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,
Pleas ' e be sure to fill in the pennit/license number which will be used as a reference number. la 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 fature permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or'-permitnot 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 M-assachusetts
Department of Industrial Accidents,
Office of Investigations
600 Washington Street
Boston, MA 02111
TQL # 617-727-4900 ext 406 or 1-877,:MASSAM
Revised 5-26-05 Fax # 617-727-7749
__wwwmass.gov1dia