HomeMy WebLinkAboutMiscellaneous - 27 CIDERPRESS WAY 4/30/2018Q'I
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PO BOX 55098
Boston, MA 02205-5098
617-951-0600
Faff-
Form of Notice of Casuafty Loss to Building,
Under MASS. GEN. LAWS, Ch. 139, Sec. 3B
To: Building Commissioner or Board of Health or
Inspector of Buildings Board of Selectman
City Hall City Hall
NORTH ANDOVER, MA 0 1845 NORTH ANDOVER, MA 0 1845
RE: Insured:
PATRICIA FERULLO
Property Address:
27 CIDERPRESS WAY UNIT 2-3, NORTH ANDOVER, MA
Policy Number:
HMA 0383544
Claim Number:
BOS00056672
Date of Loss:
2/19/2015
Company:
Safety Insurance Company
Claim has been made involving loss, damage or destruction of the above -captioned property,
which may either exceed $1,000.00 or cause Mass. Gen. Laws, Chuter 143, Section 6 to be
applicable. If any notice under Mass. Gen. Laws, Chqpter 139, Section 3B is appropriate, please
direct it to the attention of the writer and include a reference to the captioned insured, location,
policy number, date of loss and claim number.
Bryan Savosik Claim Examiner
Safety Insurance Company
Homeowners Claims Unit
P. 0. Box 55098
Boston, MA 02205-5098
Phone: (617) 951-0600 EXT 2070
Fax: (617) 535-5841
Email: BryanSavosik@Safetylnsurance.com
3/20/2015
Date ......
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
This certifies that ............... /�.. /.�. C ( � (
has perrnission to perform ............ ...........................................
wiring in the building of Alf C
.................................... ..............................................
at ....... 7 North Andover, Mass.
..... . ....................... ..............................
-3 Fee Lic. No^.,��
CAL iNSPECrOR
Check# Ij
Commonwealth of Massachusetts
Department of Fire Services
BOARD OF FIRE PREVENTION REGULATIONS
Official Use Only
Permit No.
Occupancy and Fee Checked
[Rev- 1/071 (leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (NMC 527CMR12.00
(PLEA SE PRAT IN NK OR YYPEA LL I YFORMA TION) Date:
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.
Location (Street& Number) Z-) Cc'lt�to& P,4_ 17
,�S S �,�Aaj
Owner or Tenant—V-46R& DCV4t��LJJA-CO±,�L elephoneNo.
- ,�AC-E�C -
Owner's Address 7 8� ,, �( - I jo , 'A,: I i
Is this permit in conjunction with a building permit? Yes [q" No El * (Cheek'Appropriate Box)
') e t 1\ A'(
Purpose of Building 94F-!� (A Utility Authorization No.
Existing Service_ Amps volts Overhead UndgrdF] No. of Meters
New Servic — Amps Volts Overhead Undgrd No. of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: L C-; ca�;�o
Comnletinn ofthp fn1lowina tnhlp m.,7v hp wnivprl hv thp Tn.vnPrtnr nf Wiras�
No. of Recessed Luminaires
q
No. of Ceil.-Susp. (Paddle) Fans
No. of Total
Transformers KVA
No. of Luminalre Outlets to
No. of Hot Tubs
Generators KVA
No. of Luminaires P
Swimming Pool Above Ei In- El
arnd. grnd.
NO-50-fEmergency Lighting
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
iNo. of Zones
No. of Switches
�tp
No. of Gas Burners
No. of Detection and
Initiating Devices
No. of Ranges
Total
No. of Air Cond. Tons
No. of Alerting Devices
No. of Waste Disposers
Heatpump,
Totals:
..... .....
J.K.W ...........
No. of Self -Contained
Detection/Alerting Devi es
No. of Dishwashers t
Space/Area Heating KW
Local El Municipal El Other
Connection
No. of Dryers
Heating Appliances KW
Security Systems:*
No. of Devices or Equivalent
No. of Water KW
Heaters
No. of No. of
Signs Ballasts
Data Wiring:
, No. of Devices or Equivalent
No. Hydromassage Bathtubs
No. of Motors Total HP
In
Telecommunications Wiri :
No. of Devices or EanivIglent
OTHER: I
10 4tiach additional detail ifdesired or as required by the Inspector of 97res.
EstimatedValue fEl tr* alWork: (When required by municipal policy.)
Work to Start: —Inspections to be requested in accordance with NIEC 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 operation7 coverage or its substantial equivalent. The
undersigned certifies that such coveggelis in force, and has exhibited proof of same to the permit issuing office.
CBECK ONE: INSURANCE Y BOND [I OTBER F] (Specify:)
I certify, under thepains andpenalties ofperjury, that the information on this application is true and com
,plete.
FIRMNAME- LIC. NO.: A-1 9��:
Licensee: I -LV --U4,,-3- AAAr`j,�,- --\�LIC. NO.: Jr j)5�-
jA,,4,;&nature.
(Yapplicable, entpe "exempt" in the license number line.) Bus. Tel. No.: 1,03 a A 2�-ZD7
t!�7A..A_ - --Ili i-, AV 0-3 �-6 Alt. Tel. No.: 22 h: 32 C -�-16
Address: t f C-� /a IA-, C Y
*Per M.G.L c. 147, s. 57-6 1, security work requires Department bf PuBlic Safety "S" License: Lic. 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 (che one) El owner 0 owner's agent.
Owner/Agent
Signature Telephone No._ PEPR MIT FEE: $
0 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.
0 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.
0 Rule 8 — Permit/Date Closed: Note: Reapply for new permit 0
0 Permit Extension Act — Permit/Date Closed:
Trench Inspection
Pass M
Failed
Re- Inspection Required D
Inspectors Comments:
Inspectors Signature:
Date:
SERVICE INSPECTION:
Pass M
Failed
Re- Inspection Required 0
Inspectors Comments:
Inspectors Signature:
Date:
PARTLAL ROUGH INSPECTION:
Pass R?
Failed
Re- Inspection Required ($.) D
Inspectors Comments:
Inspectors Signature:
Date:
ROUGH INSPECTION:
Pass M V
Failed
Re- Inspection Required 0
Inspecto s Comme
r , "'hts
Inspectors Signature:
Date:
FINAL INSPECTION:
V
Pass M V
Failed
Re- Inspection Required 0
Inspectors Co;6nts:
I Inspectors Signature:
Date:
DEBWEINHOLD ... TOWN OF MERRIMAC, MA . ....... dweinhold@townofmerrimae.com
The Commonwealth of Massachusetts
Department of IndustrialAccW�ls
Office of Investigations
600 Washington Street
Boston, MA 02111
UT www.mass.gov1dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legiblv
Name (Business/Organization/Individual): LL L. tk A��_
Address:
City/State/Zip:
41kh—one
Are yqu an employer? Check the appropriate box:
1. F�trI am a employer with f6,
4. 0 1 am a general contractor and I
employees (fall and/or part-time).*
have hired the sub -contractors
2. 1 am a sole proprietor or partner-
E]
listed on the attached sheet. I
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
3. 1 am a homeowner doing all work
E]
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. EE�gew construction
7. F1 Remodeling
8. E] Demolition
9. rl Building addition
10. 0 Electrical repairs or additions
ILEI Plumbing repairs or additions
12. Roof repairs
Un Other
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
f Homeowners who submit this affidavit indicating they aie 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.
Iam an employer that isproviding workers'compensation insuranceformy employees. Below is thepolicy andjoh, site
information.
Insurance Company Name:. k_A,,DQCfVS,-
Policy # or Self -ins. Lic. #:.
Expiration Date:
Job Site Address: Ck'kk- ity/S iv: 'A
S L, -4--P C tate/Z
Attach a copy of the workers' compensation -policy ddclaration page (show! I ng the policy number and expiration date , ). Ot �Y S—
Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP. WORK ORDER and a fine
.of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
investigations of the DIA for insurance coverage verification.
I do hereby certffi�under thepains andpenalties ofperjury that the information provided above is true and correct.
Official use only. Do not write in this area, to he completed by city or town offlicial
City or Town:
Permit/License N
9-1 /, I C
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. CitylTown 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 eDaployees.
Pursuant to this statute, an employee is deffired as "....every person in the service of another under any contract ofhire,
express or implied, oral or written."
An employer1s 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 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-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 may be submitted to the Department of Industrial
Accidents for confmnation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple pennit/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 fiffled 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 Mlassachvsetts
Department of Industrial Accidents
Office of Investigations
6 00 Washington Street
Boston., MA 02111
Tel, # 617-727"4900 oxt. 406 or 1-877.7MASSAFE
Revised 5-26-05 Fax # 617-727-7749
__www.mass,gov1dia
Date ... j E/ .1112 .....
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
e // I-
1,-16,) � ,0/* , . I --1 11/1.1 -
This certifies that ...... ...............................................................
has permission for gas i allation
.................
in the buildings of
....... ...............
at .......... 1 .......... nj ............. ........ . North Andover, Mass.
Fee./O ... . .... Lic. No./'Wt;../ ...... ........................................................
GASINSPECMR
Check# C�'�16 -3
v �A o 6 \-I -1! 1)
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
E
CITY MA DATE4���
JOBSITE ADDRESS OWNER'SNAME
G
L01
OWNER ADDRESS TE FAX[—,
TYPE OR
I RESIDENTIAL
OCCUPAN PE COMMEkIAL El EDUCATIONAL L]
PRINT
CLEARLY
NEW: ;�:NOVATION:E-] REPLACEMENT: El PLANS SUBMITTED: YESF-11 NOD
APPLIANCES -1 FLOORS- BSM 1 2 3 4 5 6 7
8 1 9 1 10 11 12 13 14
BOILER
BOOSTER
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER j
DRYER
FIREPLACE IL
FRYOLATOR
tr
FURNACE F -7--j
GENERATOR - - �
GRILLE E-7-:1 1—C—AL Lmmm�j --I --j
INFRARED HEATER --j
LABORATORY COCKS
MAKEUP AIR UNIT
LZ 1 --
OVEN --F
POOL HEATER
ROOM / SPACE HEATER
ROOF TOP UNIT - - - - - - - - . . . . .
TEST L L—j
UNIT HEATER
UNVENTED ROOM HEATER
WATER HEATER 1-7=1 L
OTHEO
L
---I
I F E-7], I
INSURANCE COVERAGE
I have a current liabili!y nsurance policy or its substantial equivalent which meets the requirements of MOL. Ch. 142 YES &��hO [J]
I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERA CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY — OTHER TYPE INDEMNITY [] BONDEJ
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 L 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 knowledpe
Pe t -
and that all plumbing work and installations performed under the permit issued for this application will be in compliance w t all ine �i
Massachusetts state Plumbing Code and Chapter 142 of the G aws. We
/I
LICENSE#
PLUM BER-GASF ITTER NAME SICAATURE
I JGF LPG1 CORPORATIONE]# PARTNERSHIP 0#= LLC
IMPV9"MGF[j-1 JPF] E
A
COMPANY NAME: DDRESS -------
�TE
CITY STATE ZIP _]TE
FAXI !CELL MAIL
v �A o 6 \-I -1! 1)
on
ell\
CI
El
Llj
w
U-
_CN The Commonwealth ofMassachuseas
Department ofindustriqlAccidints
Office of Investigations
600 Washington Street
Boston, MA 02111
qu www.mass.govIdia
Workers' Compensation Insurance Affidavit: Buffders/ContractorsfFIectricians/Plumbers
City/State/Zip;
Phone #: (�O� — 3� xn�-?2 �
Are �du fin employer? Check the appropriate box:
Type of project (required):
I am a employer with 4. n I am a general contractor and 1
6. [] Now constraction
employees (full and/or paA_time,),* have, hired the sub -contractors
2. El I am a sole proprietor or partner- listed on the attached shoot, t
7 . . E] Remo deag
ship and'have no employees These sub -contractors have
S. 0 Demolition
working for me in any capacity. workers' comp. insurance.
9. El Building addition
[No workers' comp. insurance 5. We are a corporation and its
10.0 Electrical repairs or additions
required.] officers have exercised their
.
3. El I am a homeowner doing all work right of exemption per MOL
I I .[I Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4), a -ad we have no
12.El Roofrepairs
insurance required.] t employees. [No worke&
13.0 other
comp. msurancerequiredJ
'Any applicant that checks box#1 must also fill out the section below showing their workers' compensation policy information.
T Homeowners who submitthis affidavit indicating they tLie doing all worVand then hire outside contractors must submit anew affidavit indicating such.
lContractors that check this box must attached an additional sheet showing the name of the sub-contraGtors and their workers' comp. policy information.
lam an em
plover that isproviding workers'compensation insurancefor my employees. Below is thepolley andjob site
information
Insurance Company Name%
Policy or Self -ins. Lic. 4: Expiration Date:
Job Site Address: Citv/State/Ziv:
S � -
Attach a.copy of the workers' compensation -policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as requlredunderSoction25A of MGLo. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or onc�yearimprlsonmcnt, as wellas civil penalties in file form of a STOP. WORK ORDER and a fine
ofup to $250.0 0 a day against the -violator. 13c advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
Idoherehycertiou der thepains gpdpenalflespf
_n — pedpyy that the information provided abo�e is true and correct.
Official use on7y. Do not -write in this area, to he completed by city or town offl"clal
City or Town: Permit/lAcense 0
Issuing Authority (circle wie):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Information and ffustrueflois
Massachusetts General Laws chapter 152 requires all employers to provide, workers' comperisationfor their employees.
ParsuRnttO 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 employeils defined as "an individual, partnership, association, corporation or other legal entity, or any two or mole
Ofthe 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 ma1teriance, 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 -neceptable evidence of compliance with the insurance coverage requ.lred."
Additionally, MGL chapter 15�, §25C(7) states "Neither the commonwealth nor any of its political sub6isions shall
enter into any contract for the performance ofpublic work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the, workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, Supply sub-contractor(s) name(s), address(es) and phone 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 carry workers' compensation insurance. If an LTLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents ffir confiniationofrusurance coverage, Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that thie application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the. law or ifyou. are required to obtain a workers' .
compensation policy, please call the Department at the numberlisted below. Self-insured comparries should enter their
self-insurance license number on the appropriate Eno.
City or Town Officials
-Please -be sure -that-the affidavit is -complete andprinted'logibly. TffdDbp-attfn��tliCs�f6-�id8dilip—k6a-fik6-b(�tfom-
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 parmit/liceris o applications in any given year, need only submit one, affidavit indicating current
Policy information (ifnecessary) and wider "Job Site Address" . the applicant should write "all locations in (citv or
to wn) ." A c opy of the affi d avit that h as b a an offici ally stamp e d or m arked by the city or town may b u pro -J-de _dto ih e -
applicant as proof that a valid affidavit is' on file for future permits or licenses. Anew affidavit must be fffle�d out each
year. Where a home owner or citizen is obtaining a license or*pjarmit not related to any business or commercial -venture
(i.e. a dog license or p* ermit to burn leaves etc) said person is NOT required to complete this affidavit.
The Office of Investigations'would like to thank you in advance for your cooperation and shQuld you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone, a�nd fax number:
The Coinmonw(-Wth ofWamachmetU
Department of Judustdal Moldoxits
OfAce of
600 WasWVw ft�-t
BoAon,MA,02111
Tel, 0 617-727-4900 at 406 ox- 1-8.77,MA8,9AFF,
t
a
��COMMONWEA-L'M OF MASSACtfubr- i TS
PLUMBERS AND GASFITTERS
LICENSED AS A MASTER PLUMBER
ISSUES THE ABOVE LICENSE TO:
MICHAEL W KELLER
20 KENNEDY DR
PE,LHAM H 1!, (13 0 76 2 6 0 5
15157 05 ol 17�161
IA- 111,A .........
This certifies that
Zi
has permission to perform ...............
plumbing in the buildings
at ... F;? -7- .01 ...... , North Andover, Mass.
Fee,2ik.'—Lic. No./�5��. 7 .. ... /�� ................. ...
PLUMBING INSPECTOR
Check # -"163
L%x�
" i
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
CITY AA MA DATE i!
-7�
JOBSITE ADDRESS OWNER'S NAME
at9-�
P
I a
OWNER ADDRESS i TEL
pzaet( I FAX
TYPE OR
OCCUPANCYTYPE COMMERCIAL EDUCATIONAL Ell RESIDENTIAL R(4
PRINT
CLEARLY
NEW: Be" RENOVATION: REPLACEMENT: D PLANS SUBMITTED: YES NOEJ
FIXTURES -1 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 1 11 12 13 14
BATHTUB I
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM ---- --
DEDICATED GAS/OIL/SAND SYSTEM C
DEDICATED GREASE SYSTEM L�j .......
DEDICATED GRAY WATER SYSTEM I - - - - - -
DEDICATED WATER RECYCLE SYSTEM f F ---j -------
DISHWASHER
DRINKING FOUNTAIN ------ -------
FOOD DISPOSER
FLOOR / AREA DRAIN
INTERCEPTOR (INTERIOR) - ----- -1
KITCHEN SINK
LAVATORY -- ----- -------
ROOF DRAIN
SHOWER STALL
SERVICE / MOP SINK -J F-1
TOILET --j====
URINAL 1 -1. - -J -- -----
WASHING MACHINE CONNECTION
WATER HEATER ALL TYPES
WATER PIPING
OTHER —I . .......
E77D F _jF;;;;�=-
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES SK'NO
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY N?"" OTHER TYPE OF INDEMNITY D; BOND [-11
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 0,' 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 withiall tR-,ertinen p is f the
Massachusetts State Plumbing Code and Chapte�" General Laws. /44Z
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PLUMBER'S NAME Z� -- LICENSE r tIGNA-ILIRE
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-cx The Commonwealth ofMassachusetts
Department oflndustrlqlAccidi�ts
Office of Investigations
600 Washington Street
Poston, MA 02111
UV.- w w w. m ass. go v1dia
Workeirs'Compensation Insurance Affidavit: Builders/Contractors/ElectriciansfPlumbers
NaMe (Business/Organization4ndividual):.
Address:
City/State./Zi.p__Le_
(110110 #: 6!�-3 - 81� 3-,,- � I/,' -
Are ygu an employer? Check the appro&late box:
Type of project (required):
I - VI am a employer with
4. El I am a general contractor and 1
6. F1 New construction
employees (fall and/or part-time.).*
2. El I am a sole proprietor or partner-
have hired the sub-contractoys
listed on the attached shoot. I
7 . . E] Remodeling
ship and'have no employees
These sub -contractors have
8. nDomolition
working for mein any capacity.
workers' comp. insurance.
9. E] Building addition
[No workers' comp. insurance
5. El We are a corporation and its
10.[] Electrical repairs or additions
required.)
officers have exercised their
3. 1 am a homeowner doing all work
right of exemption per MGL
I LEI Plumbing repairs or additions
myself [No workers' comp.
C. 152, § 1(4), and we. have no
12.El Roof repairs
insurance requiredJ t
employees. [No workers'.
13.D . Other
comp. insurance required.)
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
I Homeownerswho submit this affidavit indicating they Rie 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--
PoEcy or Solf-ins. Lic. ExpirationDate:
Job Site Address: Citv/State/Zip:
r I I
Attach a. copy of the workers' compensation -p olicy declaration page (showing the policy number and expiration date).
Failure to secure coverage as requir6clunder Section 25A ofMGL c. 152 can lead to the imposition of criminal penalties of a
ime up to $1,500.00 and/or one�yoar imprisonment, as well as civil penalties in the form of a STOP. WORK ORDER and a fine
ofup to $250.00 a day against the violator. Do advised that a copy of this statement maybe forwardedto the Office of
Investigations of the DIA for insurance coverage verification.
I do herehY certtO under th epains andp enalfles ofperj*UOi aWte information provided ah ove-Is true and correct
- A 53 - /2
Official use only. Do notYrile in this area, to he completed by c4 or town official
City or Town:
Permit/License#
rZ.-IJ
Issuing Authority (circle 6ne):
I. 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 employers to provide workers' compensation for their employees.
Pursuant to this statute, an einployee is defiried as "...every person in the service of another under any contract. ofhire,,.
express or implied, oral or written."
An emPrueiis defined as "an individual, partnership, association, corporation or other legal entity� or any two or more
of the, foregoIg engaged in ajoint enterprise, and including the legal representatives of a deceased employer, or tile
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 107cal 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 ofits 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 contracting authority."
Applicants
Please fill out the Workers' compensation affidavit completely, by chMking 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 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 canyworkers' compensation insurance. If anL1_C orLLP does have
employees, a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial
Accidents for confirm�ationofmsurance coverage, Also be sure to sign and date the affidavit. The affidavit should
be, returriedto the city or town that th'a application for the permit or license is being requested, not the Department of
ladustrial Accidents. Should you have any questions regarding the law or ifyou are requirea to obtain a workers' .
compensation policy, please call the Department at the number listed below. Sulf-insured companies should enter their
self-insurance license number on the appropriate Eno.
City or Town Officials
-P-1 e a s e b e, s ur e th at th e a ff i d avit - i s - c ompl etc - andp rint e d'l qg 11y. Tiff D dp-�ttffbjit -Ms -� i6 Vi Ed -a' Fp jo- 6- —af ff& -b 6-f [6m
of the affidavit for you to fill out in the, event tile Office of Investigations has to contact you regarding the applicant.
Pleas ' e be sure to 0 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 ye ar, 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 stamp ed or marked by the city or town may be provided to the
applicant as proof that a valid affidavit Is'on file for Riture permits or licenses. Anew affidavit must be fillqd out each
year. Where, a homeowner or citizen is obtaining a license of -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 Investigationi would like to thank you in advance for your cooperation and shQuld you have any qaestions,
please do not hesitate to give us a call.
The Department's address, telephone and faxnumber:
The Commonmalth of Mbssacahwott�
Department ofladustdal Accidents
Office Qf WeNfigatiom
600 Washingtou Sfteet
Boston, U& 02111
Tel, # 617-727-4900 at 406 or 1-877,MASSAFF,
Revised 5-26-05 Fax # 617-727-7749
10
.."COMMONWEA-L-tH OF MASSACHuzir- i TS
PLUMBERS AND GASFITTERS
LICENSED AS A MASTER PLUMBER
IS UE
S S THE ABOVE LICENSE TO:
MICHAEL W KELLER
2m
20 KENNEDY P R U)
t4 1.: 0 0 7
PE-LHAM I'6_;l 6 a 5
15157 G 5 a I ! I 17 ct 1, 6 1