The URL can be used to link to this page

Home My WebLink AboutMiscellaneous - 272 MASSACHUSETTS AVENUE 4/30/2018r ri I (3) W i�3 m 0 z N) 4 -0 0 CD 'I 0 (D Ul 3 ;:� C) > 0') N) Cn Cn (D n CD 00 > z,T C/) cn CD m --i o o --1 , " CD 0 3 n cn M Z m C (J) Z En 0' m M < 1 0 0 CL z o z 0 o Ll (D ;:� o 3 > m Z T. Q- N) 0 0 0 0 < --+, CD CL z 0 < �(D -n 0 3 0 CD _0 2. > 0 z C: P� 0 0 3 0 (D < 0 2 m CD C) N) C� 0'> (A) M in z 0 (D 0 (D zT (.0 z CD cf) cf) CD CD CY) U) C7, M 0— M CD cn < z 0 —% 0- h 3 0 > :3 0 < CD 0 Z 0 :F- 0 CL 0) M Cl (D > 0 0, = z Ln. < .0 0 0 D7 c z D Q- 0 < 0- 1� -n 0 3 (D 0 CD _0 0 2. 0 0 0 z CD 0 0 3 (D 0 i� CD 0 m Q - z N) 0 %r CD 0 C� CY) elmmanweahh &/ Maja4ajem 2.P.,t..t / gie SeVie3 OARD OF FIRE PREVENTION REGULATIONS I Prin Official Use Only Permit No. Occupancy and Fee Checked [Rev- 11071 blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be perfornred in accordance with the Massachusetts Electrical Code (M5Q, 5 /7 CMR 12.00 (PLFA SE PRflVT flV JIVK OR TYPE ALLWFORMA TION) Date: d'y 51 / (, City or Town of- 1<42o0J'W To the lnspec'tor'of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) 75-f IM 11-J Owner or Tenant 106�272VP,*- -7-- Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes Purpose of Building V Existing Service Amps Volts Overhead New Service Amps Volts OverheadEl Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: No E (Check Appropriate Box) ity Authorization No. UndgrdE1 No. of Meters UndgrdFj No. of Meters Ce 1.fi— nffhp -1,1- — L- ..—*--J L- L- 1-1- No. of Recessed Luminaires ::=--. — .—J No. of Cefl.-Susp. (Paddle) Fans y tric Irtapuciur ul vy tres. Total Transformers K -VA No. of Luminaire Outlets No. of Hot Tubs Generators K -VA No. of Luminaires Swimming Pool aove o In- grnd. El W-5—.of Emergency Lighting BatteKy Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. 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 P T( ..19n.s .......... NW I No of Self -Contained Det'ection/Alerting Devices No. of Dishwashers Space/Area Heating KW Locall F] Municipal - Connection El other No. of Dryers Heating Appliances KW Securi Systems:* No. of Devices or Equivalent No. of Water Heaters KW No. —of No. of Signs Ballasts — Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total UP Telecommunications Wirmg: No. of Devices or Equivalent OTHER: Atta additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: ' Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation7 coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE Z BONDE] OTHER F] (Specify:) *flo* -on is true and conViete. I certify, under thepains andpenalfies ofperjury, that the information on t �Is Z FIRM NAME: DAVID ELECTRICAL CONTRACTING LLC LIC. NO.: Licensee: DAVID HAGGAR Signature LIC. NO.: 14963 (If applicable, enter "exempt" in the license number line.) Bus. Tel. No., 978-682-6262 Address: 87 BELMONT ST, NORTH ANDOVER, MA. 01845 Alt Tel. No.: 978-375-5734 *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 coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one)EI owner Downer's t Owner/Agent Signature Telephone No. PERMIT FEE. S 0 AC"RV CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 01/12/2016 TYPE OF INSURANCE ADDL INSR THIS- CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CgRTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),, AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER FEDERATED MUTUAL INSURANCE COMPANY HOME OFFICE: P.O. BOX 328 CONT�CT NAME. CLIENT CONTACT CENTER F AX PHONE 8 " No): 507446-4664 tAx, No. Et): 88 -333A949 (A E-MAIL ADDRESS: CLIENTCONTACTCENTERO-FEDINS.COM OWATONNA, MN 55060 INSURER(S) AFFORDING COVERAGE NAIC # DAMAGE TO RENTED PR..ISESE. occurn�nce) $100,000 INSURER A: FEDERATED MUTUAL INSURANCE COMPANY 13935 PERSONAL & ADV INJURY $1,000,000 'INSURED 366-407-5 INSURER 8: DAVID ELECTRICAL CONTRACTING LLC 87 BELMONT ST INSURER C: INSURER 0: NORTH ANDOVER, MA 01845-1520 INSURER E: N INSURER F: 9353691 COVERAGES CERTIFICATE NUMBER: 37 REVISION NUMBER: 0 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL INSR SUBR WVD POLICY NUMBER POLICY EFF IMMIDDIYYYYI POLICY EXP IMMIDDIYYYY) LIMITS A GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY CLAJMS-MADE 1XI OCCUR X BUSINESS OWNER'S LIABILITY N N 9353692 03/01/2016 03/01/2017 EACH OCCURRENCE $1,000,000 DAMAGE TO RENTED PR..ISESE. occurn�nce) $100,000 MED EXP (Any one person) PERSONAL & ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: JECT LOC nx—POUCY F� PRI F-] PRODUCTS - COMPIOP AGG $2,000,000 A AUTOMOBILE LIABILITY X ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIRED AUTOS AUTOS N N 9353691 03/01/2016 03/01/2017 COMBINED SINGLE LIMIT Mal ..id.0 $1,000,wo BODILY INJURY (Per person) BODILY INJURY (Per accident) PROPERTY DAMAGE Wer accident) A X I UMBRELLA LIAB EXCESS LIAS X ITC11 OCCUR Lmms-mADE N N 9353693 03/01/2016 03/01/2017 EACH OCCURRENCE $2,000,000 AGGREGATE $2,000,000 IDED I I RETENTION A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y/N ANY PROPRIETORIPARTNERIEXECUTIVE OFFICERIMEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below NIA1 N 9353694 03/0112016 03/01/2017 STATU OTN- X I TWOCR S1 I ER Y UMJ: E.L. EACH ACCIDENT $500,000 E.L DISEASE - EA EMPLOYEE $500,000 E.L DISEASE - POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional RemarKs Schedule. if more space is required) CERTIFICATE HOLDER CANCELLATION 366-407-5 370 TOWN OF NORTH ANDOVER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 120 MAIN ST THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN NORTH ANDOVER, MA 01845-2420 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 0 119M�0110 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of Industrial Accidents �4 Office of Investigations 4 600 Washington Street Boston, AM 02111 www.mss.gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): [ DAVID ELECTRICAL CONTRACTING LLC [L7.BELMONT ST Address: 7. [NORTH ANDOVER, MA.01845 F978-682-62-62 City/State/Zip: Phone #: Are you an employer? Check the appropriate box: I am a employer with 4 4. El I am a general contractor and I employees (full 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. We are a corporation and its required.) officers have exercised their 0 1 am a homeowner doing all work myself [No workers' comp. insurance required.] t right of exemption per MGL c. 152, § 1 (4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. [] New construction 7. E) Remodeling 8. Demolition 9. Building addition I OJ9 Electrical repairs or additions I L[] Plumbing repairs or additions 12JO Roof repairs 13.0 Other -Any appncammatcnecKS box#] must also fill out the section below showing theirworkers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. �Contractors that check this box must attached an additional sheet showing the name ofthe sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurancefor my enWloyees. Below is thepolicy andjob site inforinatjo& Insurance Company Name: FFEDERATED INSURANCE [0353694 Policy # or Self -ins. Lie. 4: Expiration Date: L3, 1 /16 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 insurpSe coverage verification. I do hereby certfft under dtte� ofperjury that the information provided qLoy� is Me and correct 7 ;? I 978-682-6262 Official use only. Do not write in this area, to be completed by city or town offickd City or Town: Permit/License # Issuing Authority (circle one): I. Board of Health 2. Building Department 3. Cityfrown Clerk 4. Electrical Inspector 5..Plumbing Inspector 6. Other Contact Person: Phone #:, 10 10254 Date .... ....... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ..... LA- C) -0 Z . ... ............ ......... ..... .......... ....... .... .... 0 ("NN-po+ has permission to perform ......... .......................................... plumbing in the buildings of.. ..... eAAI� e S ....................................... &j Vt Q)— ....................................... . ..... L4 . ........ 1— D(5�5 ................ 5!n .................... North Andover, Mass. Feeh. ...... Lic. No. Z? -,26 ... M.be ................................................................ Check # PLUMBING INSPECTOR MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 6�y MA DATE PERMIT # 6 & JOBSITE ADDRESS OWNER'S NAME P OWNER ADDRESS TEL �-WFAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL D RESIDENTIALM PRINT CLEARLY NEW: RENOVATION: REPLACEMENT:Xr PLANSSUBMITTED: YES01 NOJ� FIXTURES I FLOOR- BSM 1 1 2 3 4 5 6 7 8 9 10 .11 12 13 14 BATHTUB !IL--,'= CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM J =.Ji. --J ---I --,i I DEDICATED GREASE SYSTEM —J L ------- A= —J 'i DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM =L:J DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/ AREA DRAIN . ...... INTERCEPTOR (INTERIOR) KITCHEN SINK ------ LAVATORY . . . . . . . . . . . ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET I URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES IWATERPIPING OTHER -J E, EE f4- ----i F-1 INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES NO M1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY;d OTHER TYPE OF INDEMNITY Ell BOND MI 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. CHECKONEONLY: OWNER 0 AGENT IEJI SIGNATURE OF OWNER OR AGENT --f-h-ereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best ofmy knowledge -:::7 and that all plumbing work and installations performed under the permit issued for this application will be in o pli rtinent provision of the K4assachusefts State Plumbing Code and Chapter 142 of the General Laws. m iance wit e PLUMBER'S NAME LICENSE IGNATURE MP% ip CORPORATION DI #=PARTNERSHIP 01 #L LLC Ek COMPANY NAME DRESS 6 J CITY ZIP _JISTATE MAJI TEL 'A/1 FAX L �v _,=CELL EMAIL - t 0 zo (n F, LLI M Iii LU LL. The Commonwealth ofMassachusetis Department of JhdustrialAccidi�ts Office of Investigations 600 Washington Street Boston., MA 02111 www.mass.gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly NaMe (Business/Organization/Individual): Address: City/State/Zip: ":12 71".4 hone #: IM I 7_J>_1 Are you an employer? Check the appr 1. D I am a employer with 2. C�employees (full and/or part-time).* l am a sole proprietor or partner- ghip and'haveno employees working for me in any capacity. [No workers' comp. insurance required.] 3.0 1 am a homeowner doing all work myself. [No workers' comp. insurance required.] t riate box: 4. El I am a general contractor and I have hired the sub -contractors listed on the attached sheet These sub -contractors have workers' comp. insurance. 5. F1 We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. n New con struction 7. E] Remodeling 8. F] Demolition 9. F1 Building addition 1011 Electrical repairs or additions I I s?SX1umbing repairs or additions 12.E] Roof repairs 13JJ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. Al Homeowners who submit this affidavit indicating they,,fre 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 thepolicy andjob site information. Insurance Company Name:. , eN�rn ye� L c Policy # or Self -ins. Lic. 32 ExpirationDate: Z0/2,Q//4/' Job Site Address: El 2. "S ;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 hereby certtfyjq der th e pains an dpeV61es ofterjury th at th e information pro vided above is true and correct N Official use only. Do not write in this area, to he completed by c4 or town official City or Town: Permit/License # 2WJ;� 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 M, 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 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 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 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 permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one, affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in _(city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is'on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or' -permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Wasbington fteet Boston., MA 021 It TO, # 617-727"4900 ext 406 or 1-877rMASSAFE Revised 5-26-05 Fax # 617-727-7749 __WWWmaSs,goV1dia Date...... ................. TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that .... Z le- V*VI e S ....... .. .. ...... ... ... ... .............. ................................... ** ... e k,� has permission for gas installation ....... :�� ........... ................... . in the buildings of ....... Ovive.5;�4-9% .................................................................. ................... at ..... . ................................... ......................... . North Andover, Mass. Fee........... Lic. No. ml.k ............................................... GAS INSPECMR Check # 8958 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY MA DATE RMIT# tn(y- I/— A 7, PE JOBSITE ADDRESS OWNER'S NAME GOWNER ADDRESS TELF—__ . _--:]FA)(! TYPE OR -t PMT OCCU PAN CY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL Ck CLEARLY NEW -E] RENOVATION: REPLACEMENT:K PLANS SUBMITTED: YES D NOW� APPLIANCES -1 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 4 Q BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER ®r—, FIREPLACE FRYOLATOR I FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER MENTED ROOM HEATER WATER H OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL. Ch. 142 YES XNO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW - LIABILITY INSURANCE POLICY 5Z OTHER TYPE INDEMNITY [] BOND 0j 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 E] 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 complia eWlt a e ant provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME LICENSE# SI ATURE MP§4MGF;a JP% JGFKLPGI[l CORPORATION F1# =PARTNERSHIP 0#1---= LLC 0#= COMPANY NAME ADDRESS CITY STATE [MZIP TEL FAX CFI EMAIL N Cl) z 0 C.) CL VD: w LL The Commonwealth ofMassachuselts Department of IndustrialAccidints Office of Investigations 600 Washington Street Boston, MA 02111 vwwmassgov1d1a Workers' Compensation Insurance Affidavit: Buffders/Contractors/FIectriciansfPlumbers Applicant Information— Please Print LeLyib Name (Business/Orgadzation/JndiV!dual): L&N�et Address: -411 City/State/Zip: at"OA 6JJL','d)hone #: 01 Are you fin employer? Check the appropriate box: Typo of project (required): 1. F1 I am a employer with 4. El I am a general contractor and 1 6. []Now construction employees (fall and/or part-time).* 2. C& am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. : 7. [1 Remodeling ship and'havo no employees These sub -contractors have 8. E] Demolition working for me in any capacity. workers' comp. insurance. I 9. [] Building addition [No workers' comp. insurance 5. El We are a corporation and its 10.[] Electrical repairs or additions required.] 3. El I am a homeowner, doing all work officers have exercised their right of exemption per MGL I I 4kklumblng repairs or additions myself. [No workers' comp. c. 152, § 1(4), and we have no 12.Q Roof repairs insurance required.) t employees. [No workers' Un Other comp. insurance required.] 'Any applicantihat checks box#1 mustalsofill out the section below showing their workers' compensation policy information. I Homeowners who submit this affidavit indicating they ire doing all work and then hire outside contractors must submit a now affidavit indicating such. tContractors that check this b ox 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 andjob site information. f Insurance Company Name: ve5\cm, 14,vt Policy# or Sol -f -ins. Lie. #: ?,!)U— 0 U ExpirationDate: JobSiteAddress: 2,17, Ma Pity/State./Zip: 11 r -W, Wk Attach a copy of the workers' compensation -policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requireclunder Section 25A of MGL o. 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 civilpenalties 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. - 7 I do h'erihy certify under th epains Opp en alfies ofperjury th at th e information provided above is true and correct. %W 'L 0 F %. Official use only. Do not write in this area, to he co7n pleted by city or town official City or Town: Permit/License 6 Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. CitylTown Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Cmit.sr.f.'Per."m � Phone Information and Instruction' -s 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 em wkeiis 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 atim'dividual, partnership, association or other legal entity, employing employees. Howeverthe owner of a dwelling house havi ng 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 Ideal 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." Additionally, MGL chapter 15 2*: §25C(7) states "Neither the commonwealth nor any ofits political subdivisions shall enter into any contract for the performance ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting a-athority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and., if 116cessarY., 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 carry workers' compensation insurance. If anLT—C orLLP does have emPloyees,apolicyisrequired. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for confirm�ationof insurance coverage. Also be sure to sign and date'the affidavit. The affidavit should be returned to the city or town that thei 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 Eno. City or Town Officials Please be sure that the affidavit is complete and printedlegibly. 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 permithice'nse number which will be used as a reference number. In addition, an applicant that mtist submit multiple permit/license applications'Mi any given year, need only. *submit ono affidavit indicating current policy information (ifnecessary) and under "Job Site Addrese'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 Me for future permits or licenses. Anew 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 comm ercial -venture (i.e. a dog license orp" 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 Commonwalth of M-assachwetts DapaxIment offndustdal Accidents OfRoe 600 Washhagoa SftQc,�t BostonMA02111 Tel, # 617-727,4900 at 406 or- 1-877,MASSAUB Revised 5-26-05 Fax# 617-727-7749 0 Commonwealth -of Division of Regism, Board of Plumbina LAWRE 42 FORE iusetts PEABOD M s aster P11 r 159 76-M 05/01/�014 004993 Lic6r.seNb: Expiration Date. Serial No.'