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Home My WebLink AboutMiscellaneous - 28 BEACON HILL BOULEVARD 4/30/2018o,., o �' ao m ao � 0 0 �� g m o � 0 0 AII This certifies -that h'As permission for gas installation in the buildings of... M elv, �- ...................................... at ...... North Andover, Mass. Fee2p DD Lie. No. ................... ... GASINSPECTOR Check # I (P �I V I- I � IT,;, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK 1 0!4 CITY MA DATE PERMITMI� & JOBSITE ADDRESS 7 --::]OWNER'S NAME I - GOWNER _,_k ADDRESS . . . . . . . TE FAX�� TYPE OR PRINT OCCUPANCYTYPE COMMERCIALE] EDUCATIONAL RESIDENTIA $ CLEARLY NEWT -1 RENOVATION: L3 REPLACEMENT: PLANS SUBMITTED: YES —71 NOW, 7 Y02 - APPLIANCES -1 FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOKSTOVE j DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR I LL� FURNACE ......... - - - - - - - - - L . . . . . . . . . . ---j - - - - - - GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM I SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER J== OTIIER T - INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL. Ch. 142 YES XNO D I IF YOU CHECKED YES -,-PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY BONDED 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 [:1- AGENT E-11 SIGNATURE OF OWNER OR AGENT I hereby cerlify 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 pliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. f. L CENS PLUMBER-GASFITTER NAME [2�p§M LICENSE SIGNATURE MP MGF LPGI E] JP JGFE CORPORATION�4# PARTNERSHIP Ej#= LLC Fjl#= COMPANY NAME: ADDRESSL CITY STATE[ TEL FAX Lop Lt. L, EMAILF- L= -1 CELL .k A V I- I � IT,;, k 0 El z 0 co < co 0 w co z 2 Un 0 u k um The Commonwealth ofMassachusetts Department of Industrial Accidints Office of Investigations 600 Washington Street Boston, MA 02111 Uf www.mass.gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/FIectricians/Plumbers Applicant Information Please Print Legibly - Name (Bi Address: gq5flhone 171 !Z City/State/Zip 4–Offil — Are on an employer? Check the appropriate box: 1 1 n a employer with 2_ 4. El I am a general contractor and I e:ployees (fall and/or part-time).* have hired the sub -contractors listed on the attached sheet. 2 0 1 am a sole proprietor or partner- ship and'have no employees These sub -contractors have . working for me in any capacity. workers' comp. insurance. 5. El We are a corporation and its [No workers' comp. insurance officers have exercised their required.) 3. El I am a homeowner doing all. work right of exeraption per MGL myself. [No workers' comp. c. 152, § 1(4), and wehave no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. E]New construction 7. [] Remodeling 8. E] Demolition 9. Building addition 10. Electrical repairs or additions 1 Q�&Iumbing repairs or additions 12. Q Roof repairs 13F] Other *Any applicant that checks box #I must also fill out the section below showing their workers' compensation policy inforrration. I Homeowners who submit this affidavit indicating they are 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 eMp 10Yees. Below is thepolley andjoh Site information. fl— Insurance Company Name:. C --,UM I tJ Policy # or Self -ins. Lic. # - Expiration Date: 17 91 6t, ti City/State/Zip: V�n,. A,.&a�, rA. o sqt-- Job Site Address:_C—C Attach a copy of the workers' compensation -policy declaration page (stowing 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 $1,500M 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. 111at t1i in rm 1 1 1 & rrect. I do flereby ceLfify under thepains andpenalfies ofperjury e fo a ion prov ded above s ue and co A 10,42, Official use ontv. 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. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: 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 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 inaintenance, 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 statep 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 6oinpanies (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 of 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 affldavit should be retained 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 numb on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed'I.-gibly. The Department has provided a space at the bottom of the affidavii 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 �car, ne�cd only submitone 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 i4on 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 Mass.achu�etts Department of Industrial Accidents Office of Investigations 6 00 Washington Sixi�et Boston, MA 02111 Tel. 9 617-727-4900 oxt 406 or 1-877rMASSAFE Revised 5-26-05 Fax# 617-727-7749 __WWWMass.goV1dia *,l OF MASSACHUSE S A ) �A- AS A MASTER PLUMBER� OVE LiCENSE TO: ISSUES THE AB P OBERT B B.LANCIIET TE r BOX 728 -0728 NORTH ANDOVER MA 01865 m 859 05/01/14 147813