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Home My WebLink AboutMiscellaneous - 28 ALCOTT WAY 4/30/2018Date .............. i TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION CHU This certifies that ................................................ : . ................ . has permission for gas installation ................. I ......................................................... inthe buildings of . . . .......................................................................... ...... ....... . ... ........ at .... eZE-AJZ! b ...... . North Andover, Mass. FeesA� ...... Lic. No. ................................................................. Check #-6�7- GASINSPECTOR 'I j350 I '!L MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK C I T Y MA DATE PERMIT JOBSITE ADDRESS OWNER'S NAME j GOWNER ADDRESS A ke V, I TEL FAX TYPE OR PRINT OCCUPANC COMMERCIAL EDUCATIONAL RESIDENTIAL XVATION: CLEARLY NEW: [I REPLACEMENT:E] PLANS SUBMITTED: YES NORY," APPLIANCES'l FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 '13 14 BOILER BOOSTER CONVERSION BURNER COOKSTOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LL=j LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/ SPACE HEATER ROOFTOPUNIT TEST —F-=jF— UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHERI .. . ......... .... INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalonwhich meets the requirements of MOL Ch. 1142 YES 10 -NO 0 I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAG e CHECKING THE APPROPRIATE BOX BELOW CH LIABILITY INSURANCE POLICY 7 OTHER TYPE INDEMNITY Ej 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 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 with all Pertine rovislo of the Massachusetts State Plumbing Code. and Chapter 142 of the General Laws. PLUM TER NAME L LICENSE#�� SIGNATURE MP=175;'11' JP 0 JGFE] LPG1 [j CORPORATION D# = PARTNERSHIP D# LLC El#= COMPANY NAME: r ADDRESS CITY STATE =?YZIP[ �JTEL 15�6- -Q3 FAX I ::= EMAIL CELL V A�a 0 u ro 0 zo 4a) ;C) ` El A >- 0 LLI 1-4 IL u LU X LU co fL LLI z CC 00 ne Commonwealth ofHassachusetts Department OfffidustPialAeeldefits 'Ile 100 I Congress Street, Su Boston, pfA 02114-2017 www.mass.gov1d1a 6 Affidavit: Buflders/Contica,etors/Fie�triciaiisIPliMbers. -Workers7 compensationinsuranc THE pFRWTTING AUTJRORITY I TO BF, MED W3TH Name (BusinesslOigaA7mationf�ndivi4,,11): Address: ujx�, Are you an eTnP!0Yer2 UNION 9 3 Z) tfie appropriate box: Phone I.F] I ara,�CemployerAdth----��mPI03ees (Aill and/or part-time).* , a sole proprietor or partnership and haW no OraPlOYees working for me in any capacity. [No workers' comP. insurance lel"Yed-1 insurance required.] 3. n I am a homeowner doing all work myselt [NO workers' comp. <1 I am a homeowner and will be hiring contractors to conduct -11 work On MY property- 1 will ensure t1lat all colatractois qil�her have workers' compensation insurance or are sole proprietors with no oycos. :5.Fl I am a general c . ontract I pr a,nd I have hired the sub -contractors listed on the attached sheet. These sub -contractors hE;�e 0�n , pioyees and have workers' comp. insuranec-t 6.Fj We are a corporatioriand its, officers ' have exercised their right of *exemption per MGL 0. 1 and We , bav& no emi)18y�-,- [No workers' comP. insurance required.] Type ogproject (required)' ''I - . . 7. 0 NOW cOns"C110n 8. E] Remodellk 9. rl Demolition 10 E] Building addition ILE] Electrica,l rpRairs or 4dditipAs 12 repairs or additions. _,Qptu 13% [] R66f repairs 14.'C]. Other—,—(—!f cy inf In ti ry or a 0 *t 66 fill out the section belo) s () ing their workers' comPensat"o POE Pbo I . . - . I they are doing all work and theahire outside contractors must submit anew affidavit indicating such - t Homeowners who "A !. ' ' a�lt 9 ,t,howingt I he . name of the sub -contractors and statq whether or �ot thoso.gntities, hase fi ;.'.m:ost attaoliedan additional sh TContrartors that e S ox s, comp. policy number - employees. If th - 0 . � I have emploYr,, they must pro -vide their w 0 actors 7� . my e P16yees. Below is thepolley and Ob site I am an employer that lsprovidingworkers3 compensaflon insurancefor In information. Insurance Company policy # or SBM-iiis. Lie. Expiration 1)4te; city/state/zip.. lob Site Address' Hey declaration page (showing the policy number and expiratiou date). Attach a copy of the w9rkersl cOmPellsat'on PO o. 152, §25A is a criminal violation punishable by afifib up to $1,500-00 Failure to secure coverage as required under MGL of a STop WOPK ORDER and a fine of up to $250-00 a and/or one-year imprisonment, as well as civil penalties in the form day against the violator. A copy of this statement may be forwarded to the Office of Investigdtions of the DIA for iusurance coverage verification. the informationprovided above is true and correct e qfpejury that 1 do hereby cerFify under thepains andpe at, //— /5 Of in this area, to be completed by citY OF town Offilcial .flcial use only. Do not write perinitiLicense City or Town: issuing Authority (circle One): 1. Board of Health 2. Building Department 3. City[rown 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 Pursuant to this statute, an em . pmpkoy�es. ,ployee is defined as "...every person in the service of another under any contract of bii�? express or implied, oral or written." An ejW10yer is� deffied as "an individual, Partnership, association, corporation or other legal entity, or any two or more Of the foregoing engaged in ajoint enf6rprise, and including the legal representatives of a deceased employer, or the receivef'ok trastdo dan individual, partnership, association or other legal entity, employing emplbye.d- However the owner of a dwelling house having not more than three apartments and who resides therein, or the occ4an1'0�f the dwelling house of another who employs persons to do maintenance, construction or repairwork on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment b6 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 applicautwho has not produced -acceptable evidence of compliance with the insurance coverage required. Additionally, MGL phapier 152, §25C(l) states "Neither the commonwealth nor any of its political subdivisions shall enter intp 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 Pleas6 fill out the workersp compensation affidavit completely, by checking the boxes that apply to your situation and, if nece�sary� supply sub-'contractor(s) name(s), address(es) and phone irumber(s) along with their certificate* (s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partlierships (LLP) with no employees other than the members or partners, are not required to cany workers' compensation insurance. If an LLC or LLP do'6s have employees, a policy is required. i3e 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 affid'dvit should be returned to the city or town that the application for the permit or license is being requ�sted, not the Department of Ind-ustrialAccident's. �hould you have any questions regarding the law or if you are req*ed . to obtain a -krkers' compensatioii policy, please call the Department at the number listed below. Self-insured conipanies sl�o�ld enter their self4usuranc'e license number on the appropriate lind. 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 fnvestigations 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 thai must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "fob 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 fffled 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 Department's address, telephone and fix number: The Commonwealth of Massachusetts Deparftnent of Industrial Accidents I Congress Street, Suite 100 Boston, MA 02114-2017 Tel. 4 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia