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Home My WebLink AboutMiscellaneous - 30 MATHEWS WAY 4/30/2018 (2)1�3 14 149 C� Q\1 Date ... 2-J.q.1 ...... J .... .. ...................... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION k'kkli I- CP Id 6is certifies that ............................................ elcwl� has permission for gas installation ��.& ...... inthe buildings of ...... ....................................................................... at .... ��5Li ........ . North Andover, Mass. Fee ... Lic. No. JL'�W) .. ... GAS INSPECMR Check# 1 0440 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK C I TY "Z/,b MA DATE[ 9- PER'Ml # JOBSITEADDRESSI-->>b W *dOWNER'SNAME -V-crVef GOWNER ADDRESS FAX TYPE OR PRINT OCCUPANCYTYPE COMMERCIAL EDUCATIONAL RESIDENTIAL 13 CLEARLY NEW: 03"'o' RENOVATION: D REPLACEMENT: 13 PLANS SUBMITTED: YES Fj NOD APPLIANCES'l FLOORS- BSM' 1. 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/ SPACE HEATER — - - ------- . . . . . . . . . ROOF TOP UNIT TEST UNIT HEATER ILINVENTED ROOM HEATER I WATER HEATER dT —HE R F ..... . .............. ........ . . . . . . . . . . . . INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL. Ch. 142 YES NO El I IF�OU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAPE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY M' OTHER TYPE INDEMNITY E] B 0 N D Eil 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 0J 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 com ' nce with af rtinent pr ision of e Massachusetts State Plumbing Code and Chapter 142 of the General Lam. PLUMBER-GASFITTER NAME -fferz,0 LICENSE SIGNATURE IMP Eff"'MGF Ej JP D JGF LPGI CORPORATION []# = PARTNERSHIP 0#= LLC [J# COMPANY NAME:1— W -U �� "�L ADDRESSE /,Z <-6C-tj 16� CITY I -') -, 6 ALI 2 STAT4V ZIP ]TEL FAX CELkkAZ4S7/4 AEMAILL_ 'A V) 4 A 0 El LU M LLJ 00 U) < LLI C0 CL LU w Cf) z 0 CL EL LU LL CIO 0 u un IV a r M 0 I Al 11619 Date -2-01. �. ............ TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ........................................................................................ ................ �\.& ....................................................... has Permission to perform ...... V-Y\o W, L -- plumbing inj�e bu#ings of ............................................................................................. —5 ........................ North Andover, Mass. at ..... Fee....... �X` ........ Lic. No . ..................... ................................................................................. PLUMBING INSPECTOR Check 4 LAVATORY ROOF DRAIN SHOWER STALL SERVICE I MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YESF �1 N 0 n-1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE Box BELOW LIABILITY INSURANCE POLICY Z OTHER TYPE OF INDEMNITY Ell BOND 0 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 JEO 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 b and that all plumbing work and installations performed under the permit issued for this application will be in c pliance with all Pertinent Massachusetts State Plumbing Code and Chapter 142 of the General Laws. Z_45r ioe�4 PLUMBER'S NAME �)OLICENSE# SIGNATURE MPE, JPEJ CORPORATION FJ # PARTNERSHIP P-1 # LLC D� COMPANY NAME J)0 -e— 'POBq 'f-�qtgl ADDRESS led --- C., — CITY 7Z X STATE ZIP FAX CEL��MAIL of my knowledge ision of the, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY MA DATE I P— PERMIT JOBSITE ADDRESS 1,,VrjteyJs—e��'I OWNER'S NAME L POWNER ADDRESS L j TELF,927,3466zJ gjFAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: fff RENOVATION: REPLACEMENT: Ell PLANS SUBMITTED: YES NoE]j FIXTURES I FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB I 1= --'- —.1 = = CROSS CONNECTION DEVICE -.--I __j DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM ------ J --.—I --1L=—(= L DISHWASHER ----I —J DRINKING FOUNTAIN ---- ----- ------- FOOD DISPOSER FLOOR / AREA DRAIN ------- INTERCEPTOR (INTERIOR) ViTrPPKI I III -I I--- J I- IIL--J LAVATORY ROOF DRAIN SHOWER STALL SERVICE I MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YESF �1 N 0 n-1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE Box BELOW LIABILITY INSURANCE POLICY Z OTHER TYPE OF INDEMNITY Ell BOND 0 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 JEO 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 b and that all plumbing work and installations performed under the permit issued for this application will be in c pliance with all Pertinent Massachusetts State Plumbing Code and Chapter 142 of the General Laws. Z_45r ioe�4 PLUMBER'S NAME �)OLICENSE# SIGNATURE MPE, JPEJ CORPORATION FJ # PARTNERSHIP P-1 # LLC D� COMPANY NAME J)0 -e— 'POBq 'f-�qtgl ADDRESS led --- C., — CITY 7Z X STATE ZIP FAX CEL��MAIL of my knowledge ision of the, 0 zo U) F-1 CL 4 Lij LU LL The Commonwealth of Massachusetts Department of IndustrialAccidents I Congress Street, Suite 100 Boston, AM 02114-2017 www.mass.gov1dia Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH TRE PERNHTTING AUTHORITY. Applicant Information Please Print Le Name (Business/Organization/Individual): Address: Ll A)c_6 City/State/Zip: Xle�,OIUJ �4VI, A/ 31?S 7 Phone #: Are you an employer? Check the appropriate box: I 1. n I am a employer with - .,.,! employees (full and/or part-time).* -2. ZI am a sole proprietor or partnership and have no employees workirig for me in any capacity. [No workers' comp. insurance required.] 3. rJ I am a homeowner doing all work myself [No workers' comp. insurance required.) t 4. F1 I am a homeowner and will be hiring contractors to conduct A work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5.FJ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. Thes'e sub -contractor . s , have employees and have wo I rkers' comp. msurance.t 6. n We are a corporation and its officers have exercised their right of 'exemption per MGL c. 152, § 1(4), and we have noemployees. [No workers' comp. insurance required.] Type of project (Tpquired): 7. New construction 8. Remodeling El Demolition 10 F1 Building addition 11. F] Electrical repairs or additions 1�. Ptlumbing repairs or additions 13. E] Roof repairs 14. F1 Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t it a new affidavit indicating such. I Homeowners who submif Us affidavit indicating they are doing all work and then hire outside contractors must submi tContractors that check this , box must-affached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. if the sub-c6fitractors have employees, 1hey must provide their workers' comp. policy number. I a m� an employer th at is providing workers' compensation insuran cefor my employees.' Below is th e policy an d)ob site information. Insurance Company Policy # or Self -ins. Lie. #: Expiration Date: 3 P_t- G City/State/Zip: Job Site Address: n Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby , certalu under thepai andpenalfies ofperjury that the information provided above is true and correct. Date: Official use only. Do not write in this area, to he completed by city or town official City or Town: Permit/License Issuing Authority (circle one): i 1. 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. Pursua ' rit to this statute, an employee is defined as "...every person in the service of another under any contra'A'o'i h� ire,. express or implied, oral or written." An employer is defined as "an individual, partners�ip, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint 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 empl6yees. 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 covera ! g , e 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 Plea'se fill out the workers' compensation affidavit 6ompletely, 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 Depaltment of Industrial Accidents fb� 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 Dep' artment of Industrial Accidents. Should you have any questions regarding the law o*r if you*are re'qw'ired' to obtain a Workers' compensatioft'policy, please call the Department at the number listed below.* Self-iiisur6d' 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 permitilicense 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. I The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street, Suite 100 Boston, AM 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia Date.. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ........................................................................................................ has permission to perform ....... 0/ ............................... . X.—.2 ?�� wiring in the building of.. at .................................................. , North Andover, Mass. Fee .. / (2 Lic. No. ............... ........................................................ . ........... . ...... I ...... ELECTRICAL INSPECTOR Check # 1-3036-/ Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. Occupancy and Fee Checked [Rev. 1/071 eave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be perfornied in accordance with the Massachusetts Elect Coda WC 527 CMR 12.00 (PLEA SE PR TNT M NK OR Y YPE A LL ) NFOR MA TION) Date: 4 111 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-�r - Owner or Tenant 7-t1r —t( -Z Owner's Address Telephone No. Is this permit in conjunction with a building permit? Yes ff No [:1 (Check A p . ate Box) Purpose of Building kq��- aK--,,y-b A-� Utility Authorization No. t I I _� Existing Service Amps Volts Overhead Undgrd [:] No. of Meters New Service 7,00 Amps CLO/ ZqQ- Volts Overhead Undgrd i2r No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: (,,,7 (1�) COA1 Completion of the -following table maybe waived by the Inspector of Wires. No. of Recessed Luminaires No. of Cell.-Susp. (Paddle) Fans No. o Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above o In- Ei grnd. grnd. No. of Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FM ALARMS I N*o. of Zones No. of Switches No. of Gas Burners No. of Detection nud- Initiating Pevices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers HeatPump Totals: JNM!��K]J�A� J.KW ........... No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local D Municip�l El Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of Water KW No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Eauivalent OTHER: OD Attach additional detail ifdesired, or as required by the Inspector oJ Mres- Estimated Value f Electrical Work: (When required by municipal policy.) Work to Start: 1 1 q � i' " Inspecti�ns to be requested in accordance with MEC Rule 10, and upon completion. 1NSURANCf—C6VERAGE: 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! I coverage or its substantial equivalent. The undersigned certifies that such cove ge is in force, and has exhibited proof of same to the permit issuing office. g' CIIECK ONE: INSURANCE E?tOND n OTHER n (Specify:) I certify, under thgains andpenalties ofperjury, thatthe information on this application is true and complete. FJERMNAME:. LIC. NO.: MICI5, C-, Licensee: SiLynature LTC. No- (Ifapplicable enter "exempt" in the license number line) Bus. Tel. No.- A-3rk-wCrP)Z-- Address: P,()- h 17yk A-,", iAAVe,-7014�t�- A� 018'3,5 Alt. Tel. No.. *Per M.G.Mc. 147, s. 51 -61, -Security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIWR: I am aware that the Licensee does not have the liability insurance coverage non-nally required by law. By my signature below, I hereby waive this requirement. I am the (che one) E] owner E] owner's agent. Owner/Agent Signature Telephone No. PERWTFEE.- $�/l 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the#rovisionj 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 20 10 and extended by Sections 74 and 75 of Chapter 23 8 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 Insuction Pass M V Failed Re- Inspection Required ($.) 0 Inspectors Comments: 4 AW Inspectors Signature: t1l Date: SERVICE INSPECTION: Pass M Failed Re- Inspection Required 0 Inspectors Comments: . Inspectors Signature: Date: PARTLU ROIX-H INSPEWION: Pass M 1Z , 6 Failed Re- Inspection Required 0 Inspectors CommenJs1_ r-:?— V 4 .10; Inspectors Signature: Date: ROUGH INSPECTION: Pass Failed Re- Inspection Required 0 Inspectors Comments: Inspectors Signature: Date: FINAL INSPE19-PfLON: Pass bV*-/ Fai'ledl-fl on Re� Inspecy6n Required El Inspectors Comments: Inspectors Signature: Date: DEBWEINHOLD ... TOWN OF MERRIMAC, MA . ....... dweinhold@townofmerrimac.com . —WT—M-L1, ONk The Commonwealth ofHassachusetts Department of industrialAccidents I Congress Street, S�ite 100 Boston, MA 02114-2017 www.mass-gov1dia er�/Contr-,ictors/F,Ieqtricians/Pl'g�Mbers. Compensation hsurane6 AfrId'vit' Bad TOBEYMED W1T)aT)aEpFW&TTINGAUTiI0 RITY- Name (Business/Oigal"zat'ongnd'v'aual): Address: CitylState/Zip: Vk Are you an employer? Check tbe app�opriate box: 1. Va, , emp loyer with ---�Mploye es (fLIU and/or p art -time) 2.F] I am a sole proprietor or partnership and have no employm working for me in any capacity. (No workers' comp, insurance required-] 3.[] 1 am a homeowner doing all work mYselt [go -workers' comp. insurance required-] 4.n I am a homeowner and will be hiring contractors to conduct a work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole withno,Q proprietors Was. d sheet. d I have hired the sub-colitraotors listed on the attache 5.FJ I am a general contractgra,u, t These sub-contract�r� haV6 einployees and have workers' comp. insurance. per MGL c. its. offic6rs have exercised their right of bxeroption 6.n We are a corporatao.ii.and �s LNo workers' comp. insurance required.] --A',-,eh bfioemPld Type of, project (Tequired); 7. j;J<dVdo.-nstr66f1on 8. kemodellhk 9. Demolition 10 E] Building addition ll.EJ Electrical repArs or additims repairs or addition$ lZZ Prwn5ing l3-.E]Rb6fre&ir§ 14. Other I D4, vi��,J, ,lowsh,wi,gth, "boi #1 piti�t ils,6, fjil out the section i, workers, compensation policy information *A,y applicant that chdrk§ all work and then lure outside -1 Homeowner, who A��ii,thi��aWavlt indicating they are doing , contractors must submit a now affidavit indicating surb- 1� �uu�i attached iin additional sheet showing the name,of the sub -contractors and statp wh�ther or Pot faOse,pntiges, have tCoutractors that check 1his �'o comp. policy number- ' . 1 1. -ve employees, they must provide their workers emnlovees. If the sub-cotractors ha a m an emp Joy er th a t is P To V 1 d1ug -W 0 rkers' compensation insuraneefOr my enTlbyees' �Uelow is epoiley an information. Insurance CompanY NaMO-IUIV—�� p licy A or Self- S. Lic. 9: Expiration Date; U/ City/State/Zip: -4(;o A JobSiteAddress: 13 �Iicryd�ecla ation page (Showing the policy number and iration date). Attach a copy of the wo-rkers' COMPePsat'on Pon at�� qui ed under MGL c. 152, §25A is a criminal violation punishable by a fulb up to $1.,5 00.00 Failure to secure coverage as re u as civil penalties in the form of a STOP WORK ORDER and a fma of up to $250.00 a and/or one-year imprisonment, as well n uran .1 -,--+ +ke, violator. copy of this statement maybe forwarded to the Office of Investig6tions of the DIA for i s. ce ay a6 Coverage verification. - - ftnder thepains andpenallies Ofterjury that the information PrOVided above trpe and correct I do hereby certift fty VV Phone Z, -05 ly. Do not -write in this area, to be completed by citY or to,,ft of ficial. Permft/License City or Town: issuing Authority (circle Onp* I . Plumbing inspector 1. Board of Health 2. Building M-partment 3. City/Town Clerk 4. Electrical Inspector 5 6. Other Phone#: Contact Person: Ot oil I z, Information and Instrnetions Massachusetts General Laws chapter 152 require� all employers to provide workers' compensation for theg pmployY-s- * ' ' . I Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of Wo, express or finplied, oral or written." An employer is'deffied as "an individual, partnership, association, corporation or other legal entitL or alry two or more of the foregoing engaged in a joint enf6rprise, and including the legal representatives of a deceased employer, or the receivef6k trust6d 6 fan individual, partnership, association or other legal entity, employing emplOyAes�. -However the owner of a dwelling house having not more than three apartments and who resides thereiin� or the occup:iiiii o'fthd 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 b6 deemed to be an employer!� MGL c , hapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to opdrate a business or to construct buildings in the commonwealth for any al)Plicaiit,who has not produced -acceptable evidence of compliance with the insurance coverage ie ,quired Additionally, MGL chapter 152, §25C(l) states "Neither the commonwealth nor any of its political subdivisions shall enter intp any cont ract for the performance ofpublic work until accep'table evidence of compliance with the in requirements of thi I s chapter have been presented to the contracting authority." surance Applicants Pleasb fill out the Workers, compensation affidavit completely, by checking the boxes that apply to your situation and, if nec6sary, supply sub"contractor(s) name(s), address(es) and phone number(s) along with their certificate('s) of insurance. Limited -)�iability 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 auLLC o'rLLP d66s have employees, a policy is required. 1�e 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 affiddvit should be returned to the city ' or town that the application for the permit or license is being requ�steq, not the Dep* artment of IndustrialAccidents. Should you have an y* questions regarding the law or if you are req*ed to obtain aw"o'kkers' compensatiod policy, please call the Department at the number listed below. Self-insured companies s�odild enter their self-insurah-ce 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 �pplicant thai 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 proofthat a valid affidavit is on file for future permits or licenses. A now 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 burn leaves etc) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-A/IASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia MIT U. The Commonwealth of Massa. ch usetts Department ofIndustrialAceidents I Congress Street, Suite 100 Boston, M4 02114-2017 www.mass.gov1d1a Workers' Compensation Insurance Affidavit: Builders/Contractors/Elq�tricians/plu.mbers. TO BE FILED WITH TBE PERARTTING AUTHORITY. Applicant Information Please Print Legibb Name (Business/Organization/Individiial): IL.)6 KAV,*,h-A 01, 8,�_- Address: Ll A),=_6 Llj Gty/State/Zlp:,.#ve ZA--) r 6 9X A/ b 31�� Phone #: 6 & -3 a, ?Q- 7 Are you an employer? Ch'eck th e appropriate box: Type of project (T�quired): LFJ I am a employer with___,_ employees (Ul and/or part-time).* 7. New construction �l am*a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity. No workers' comp. insurance required.] §. Demolition 3.F1 I am a homeowner doing all work myself [No workers' comp. insurance required.] t 4.Fj I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 F] Building addition ensure that all contractors either have workers' compensation insurance or are sole 11 Electrical repairs or additions propnetorswith no employees. 1�. 2"Plumbing repairs or additions S. n I am a general co4tra.9tqr and I have hired t - he sub -contractors listed on the attached sheet. 1�.-E] Roof repairs Thes'e s�ib-contractors'�a�� e�iployees and have workers' comp. msurance.1 14. E:1 Other 6. n We are a corporation and its, officers have exercised their right of 'exemption per MGL c. l52,§l(4),an4WphaKerjoen oy es. fNo workers' comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit )Ns affidavit indicating they are doing all work and then hire outside contractors must s4bmit a new affidavit indicating such. 'fContractors that check this box must attached an additional sheet showing th� name of the sub -contractors and state whether or not those entities have A employees. ifthesubco'fi666� aveemployees, ey must provide their workeis'comp. policy number.' 1a,m: an employer thaiispiovidlhgwork�rsl compensation insurancefor my emplbyees.'Below is thepolicy andjoh site information. Insurance Company N Policy # or Self -ins, Lie. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaraVon page (showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK OPPER and a fine of up to $250.00 a day against the violator. A copy of this statement may be forwarded to the Office of Investi ations of the DIA for insurance 19 coverage verification. Ido hereby certifs under thepal andpenalfies ofperjury that the information provided above is true and correct. 1? Date: Ofj1cial use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License #. 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: I — Phone #: i 3 12 Ot 21 a Jet - 7 A- -3 A A� c)- vn— 3 It, //,�- /0 ,2 4�J /7 e-),— 12-1th- 0257 c,261 -311,111., c>? f12-311,5 c;2, . � "11618 Date;�..J.�iji,�e .......... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ......... ) ... ...... k ...... x ....................... � . ............................ ....... ......... ........... tas permission to perform ...... ..................................................... plumbing in the b f .................................................. at 2_..'k .......... qX.. ................................... ....... North Andover, Mass. -Fee ....... Lic. No. . ................................ ................................................ PLUMBING INSPECTOR C e k h c # V,, MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ourClW MA DATE PERMIT# JOBSITE ADDRESS OWNER'S NAME 'S k's,2z L ff-1-" POWNER ADDRESS TEL ____JjFA<� TYPE OR OCCUPANCYTYPE COMMERCIAL EDUCATIONAL RESIDENTIAL 0�r PRINT CLEARLY NEW: 2111' RENOVATION: REPLACEMENT: Ell PLANS SUBMITTED: YESE11 NOD 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 GASIOIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM I DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/ AREA DRAIN .-D ----j --J===== INTERCEPTOR (INTERIOR) L --j KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET URINAL WASHING MACHINE CONNECTION J WATER HEATER ALL TYPES WATER PIPING 5THER F i I Ill i F—f I 1--i F—i I- -1 F--7- IIF ---fl F-7 INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES NO IF YOU CHECKED YES, PLEASE INDICATE THE E OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 7 OTHER TYPE OF INDEMNITY D B 0 N D [--Jj 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 Ej 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 Vill be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. --71 PLUMBER'S NAME Wsf I __aICENSE # SIGNATURE M P i P CORPORATION n] # PARTNERSHIPD# LLC D� COMPANY NAME ADDRESS 1, -0 Kc( CITY -b STATE ZIP TEL ."M111 FAX CEL6 EMAIL V 0 zo LLI CL Cd Lij LL hto................... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ...... )"� .............................................................................................................. has permission for gas installation ...... �.rqme . ................ in the b'uildings of ............ Svy-'t-).A.J.-� .................................................................... .................... .... . ..... at 2X pv�,- -> ....................................................... U�.) .......... . North Andover, Mass. FeelLic. No. 1 .................................................................... GASINSPECTOR Check # 15)-1 L4 0 4 3 9 �-1 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY MIT# j MA DATE =c2 PER JOBSITE ADDRESS I �:OWNER'SNAME ,G OWNER ADDRESS TE FAX TYPE OR PRINT OCCUPANCY TYPE COMMERCIALF-] EDUCATIONAL RESIDENTIAL CLEARLY NEW: 011' RENOVATION:E] REPLACEMENT: [3 PLANSSUBMITTED: YESD,1N6Fj APPLIANCES I FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13, 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOFTOP UNIT TEST L UNIT HEATER UNVENTED ROOM HEATER WATER HEATER dT- H —ER F ------- . . . . . . . .... ... ....... ............. . ...... . ... ..... . ...... .. .... ....... . ... . .. . ..... -7:1 FE ji INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL. Ch. 142 YES NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ER00'j OTHER TYPE INDEMNITY Ej B 0 N D Cil 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 compli ce with all Pplinentprov' 'ion of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. P 00 PLUMBER-GASFITTER NAME llp- 0----b4LICENSE# SIGNATURE MP 09'OMGF El JP [I JGF LPG1 [I CORPORATION []# = PARTNERSHIP 0# LLC E]# COMPANY NAME: FLB ADDRESS I C-&4.00rj )<,4 CITY 1 Ivefi-r—ex) TEL 5- 7 STATE�ZIP __j -IV FAX CELL$ff-471-,-J,-)?J]EMAIL ' �j �-1 I? 0 F] z 43) El LU u LU 3: F - GO CD 4 < LU Cf) LU LU z 0 0 CL IL < LLJ LL z z 0 u w p6q