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Home My WebLink AboutMiscellaneous - 29 ROCK ROAD 4/30/201890 0 0 Locationz7 No. M Date 0 z 7- / TOWN OF NORTH ANDOVER Certificate of Occupancy $- Building/Frame Permit Fee $ Foundation Permit Fee Other Permit Fee �;#T,4ir7z- s, TOTAL $- Check# 6151-49 v IV W-fbt- Commonwealth of Massachusetts mi-i-ni Permit Permit # Date Estimated Job Cost: Permit Fee: Plans Submitted: YES NO Plans Reviewed: YES NO Business License Applicant Licens6 -Business Information: Property owner / Job Location Information: 4WY 7�(MAlcr-e—1 Name: Name: a Street: 4 S7— Street: -a -2-f I(Y-J�?2* 1 4) Val: City/Town: I City/To e -ph =-. Telephone: p one: 2 ZS-) v� NO Photo I.D. required Copy of Photo I.D. attached: YES Building Type: Residential: / 1_2 family Multi-fu3ily Condo / Townhouses Commercial: Office Retail - Industrial Educational Institutional Building Cubic Footage: under 35,000 cu. ft. -V/" over 35,000 cu. ft. Sheet metal work to be completed: New Work: Renovation: HVAC —Z. Metal Roofing _ KitchenExhaust System Chimney Vents Provide brief description of work to be done: AAh5 -7;Z _,, / / e j4 e S-e-� i I H AV INSURANCE COVERAGE: I have a current liability Insurance policy Rr Its equivalent which meets the requirements of M.G.L. Ch. 112 YesUr'No[l If you have checked Yes, Indicate the type of coverage by checking the appropriate box below: A liability Insurance policy Other type of Indemnity F1 Bond El OWNEFVS INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by Chapter 112 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only Owner Agent Signature of Owner or Owner's Agent By checking this boxE], 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 sheet metal work and Installations performed under the permit Issued for this application will be In compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws. Progress Inspections Date Comments Date Final Inspection Comments Type of License: By, D Master Title El Master -Restricted Cltyfrown njourneyperson Permlt E]Joumeyperson-Restricted Fee Inspector Signature of Permit Approval Signature of Licensee License Number: Check at www.mass.govldpl V, 4 Sheet Metal Residential Guidelines / Inspection Checklist No N/A 'description Detailed and sketch of sheet metal system to be installed has been provided . All -workers performing sheet metal work onsite, has'valid Massach usetts sheet metal license All sheet m6W work being performed with properjourneyp6rson-io- apprentice ratios Equipment sized per heating / cooling load calculations Duct work sized per manual "D" calculations Bath / shower rooms contain mechanical exhaust fan vented outdoors Electric dryer -exhaust properly installed maximum total nin 35'-0", maximuin flexible run 8'-0" Flexible duct rufis installed 14'-0" maximiim length Wiume dampers installed for 6achs'upply air branch duct Ductwork installed using proper gauges and hangers Ductwork / plenum connections scaled substantially airtight Ductwork insulated 'by means of external covering or internal lining Now/clean - properly sized filter installed (final inspection) Testing and Dalancing report complete (final sig*n-off) 47 Sheet Metal Commercial Guidelines / Life Safety / 01fical Systems Lmspectiort Checklist Yes No NIA I's Set of stamped engineering documents and,detailed description of mechanical system to be installed has been provided All work�rs performing sheet metal work onsite has valid Massachusetts sheet metal license M sheet -metal work being performed with properjoumeyperson-to-apprentice ratios Fire dampers with access door properly installed and checked for operation Smoke and combination fire / smoke daimpefs with access doors properly installed - actuator checked for proper operation (May also be verified by fire department during fire.alarm testing) Duct smoke detectors with access doors properly located (May also be verified by fire dopgtment during.fire alarm testing) Smoke / atrium exhaust systems installed and operation verified (May also be verified by fire department during fire alarm testing) Stair pressurization systems installed (where required) and operation verified (May also be verified by fire departmefit during fire alarm testing) Grease / kitchen hood exhaust system installed with all scams and connections welded airtight with properly located cleanouts. Proper cledances, fire rated enclosures and pressure testing required,. installed i'4Wd*r'6qjgred oil eqjhp'-mentand dub, ory Duct penetrations in fire'rdte4 wall.%, and fib"66" sealbd Metal roofing systems installed watertightasing proper materials and fasteners . Flexible dactruns installed 6'-0" maximum length Ductvvork installed using proper hanger spacing, hanger stock, threaded rod and angle iron Ductwork / planum connections scaled substantially airtight Ductwork insulated by means of external covering or internal lining Volume dampers installed for each supply air branch duct New/clean - properly sized filters installed (final inspection) Testing and Balancing report complete (final sign--oM `4 Ali, The Commonwealth of Massachusetts fu Department of Industrial Accidents WN Office of Investigations 600 Washington Street Boston, MA 02111 wNw.mass.govIdia Workers' 6mpensaflon Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organizafio0ndividual): Maffei Plumbing and HVAC LLC Address: 383 Main Street City/State/Zip: Rowley,. MA 0 1969 Phone #:- 978-312-6268 Are you an employer? Check the appropriate box: 1. [9 1 am a employer with 9 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 t 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 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. E] New construction 7. Remodeling 8. Demolition 9. Building addition 10.El Electrical repairs or additions I Lgg Plumbing repairs or additions 12.E] Roof repairs 11M Other Any applicant that checks box# 1 must also fill out the section below showing their workers' compensation policy information. 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 of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers'compensadon insurancefor my employees.* Below is the policy andiob site information. insurance Company Name: The Hartford Policy # or Self -ins. Lic. #: 76WEGPY2413 Expiration Date: 10/22/2017 Job Site Address: Citv/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 insurance coverage verification. I do her�b y cWy under t4e pqins andpenallies ofpeiyury that the information provided above is true and correct. Phone #: 978-312-6268 Official use only. Do not write in this area, to be conrlded by cio, or town official City or Town: PermittLicense # 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 The Commonwealth of Massachusetts lu Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 w%w.mass.gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Avylicant Information . Please Print Legibly Name (Business/Organizafionnndividual): Maffei Plumbing and HVAC LLC Address: 383 Main Street City/State/Zip: Rowley, MA 01969 Phone #: 978-312-6268 Are you an employer? Check the appropriate box: 1. E@ I am a employer with 9 4. [11 am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2.11 1 am a sole proprietor or partner- fisted on the attached sheet. t ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. F1 We are a corporation and its required.] officers have exercised their 3.0 1 am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required-] employees. [No workers' comp. insurance required.] Type of project (required): 6. E] New construction 7. E] Remodeling 8. Demolition 9. Building addition I0.E1 Electrical repairs or additions I I. N Plumbing repairs or additions 12.M Roof repairs 13.0 Other *Any applicant that checks box # I must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they we 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 of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers'compensadon insurancefor my employees.' Below is thepolicy andjob site information - Insurance Company Name: The Hartford Policy # or Self -ins. Lic. #: 76WEGPY2413 Job Site Address: Expiration Date: 10/22/2017 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 insurance coverage verification. I do herOy ce�* under t4epqins andpenalties ofpeilury that the information provided above is true and correct. ,tl _r � ,t� -2,317 Phone#: 978-312-62618 Official 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: Phone #: TH OF M CHusETTS WEAL ASSA COMMONWEALTH 1MINUSETTS 17 Comm 0 0 BOARP OF PLUMBERS G SHEET METAL WORKERS AN ASFITTERS ��J��jt VC ISSUES THE�FOLLOWING LICENSE ISSUES THE FOLLOWING LICENSE MASTER -UNRESTRICTED LICENSED ASA MASTERPLUMSE�w GREGORY K MAFFEI SR GREGORY K MAFFEI.SR 1183 HAVERHILL ST 183 HAVERHILL ST ROWLEY, MA 011969-21120 ROWLEYNA 01969-2120 6822 1012812018 `173954�k 10069 05/01/2018. 47"'744 WWI: "11[s]MOTAIN 4. COMMONWEALTH OF MASSACHUSMS Commonwealth of Massachusetts Department of Public Safety, MUM BOARD OF License: PM -296552 PLUMBEASANbGASFITTERS. Pipefitter Master PP ISSUE STHE FOLLOWING LICENSE LICENSED AS A JOURNEYMEN PLUMBER GREGORY K MAFFEI 183 HAVERHILL ST GREGORY K MAFFEI-Sit ROWLEY MA 01969 118THAVERHILL ST ROWLEY,- MA:OTM9.21.20, r"jZCK- Expiration: 19296 '05101120.18 47767 Commissioner 10126/2018 w4a ETTV 1101MOT.N 1:1 State of New HampShire State of New HaMpShire MECHANICAL IDENTIFICATION MECHANICAL IDENTIFICATION NAME: GREGORY MAFFEI SR NAME: GREGORY MAFFEISR UCENSEIREGISTRATION UCENS&REGISTRATION GAS SERVICE GFE0804636 PLU MASTER 4407 -COMMONWEALTH OF MOSSACHUSIMS, Pm I BOARD OF PLUMBERS AND GASFITTERS ISSUES THE FOLLOWING LICENSE REGISTERED AS A PLUMBING C16RP GREGORY K MAFFEI SR MAFFEI PLUMBING & HVAC LLC 183 HAVERHILL STREET ROWLEY, MA 01938-1084 3451 0610112018 47611 1 0 00-0 -41 =r --q �-jo. o - 0 w x 0 cr CA AE4 U) :5. 0 0 m o 5 0 (D C.) m la Z5 0 CL C) = 5,5 x z 0 0 S -h tv 0 C: 0 0 CL :3 m -,h 5; w w m CD 133 0 (n 0 CD '10 - (D CD SU CD = 0 0 CL = (1),� E 0 0 0 — Er CD (D 0 m rpplpk o = -V (D 0 0 jo r.L C.) r� m * :5. m 0 0 Cl) 0 r.L a cn 0 j3 rr 0 = =;;:. = . o m o - I > = 0=: 0- 0 SL: cc cr) — S. 0 CL ='. 1. (n CD ;a rL < (D = - o M (n M SU.) ( .0 ;5 <D CL Z3 cn CD cr 2) CD cn 5� co) 0 (n CD (o 0 CO) CD CD CD CD 0 75- Z - (D W Z 0 M: 0 0 M --i: = ct: 0 0 CL ro 0 fD (D z 0 (D zs (D m a m -n 0 (M > (A M m 0 -n rD C) (M rri r- m m -n 0 C: Go =r c tp 2 cl m 0 m M 0 C? 0 w tz 0 co z G) z m 0 Ln CD _0 Ul l< 4 3 -n 0 0 =r (D 0 dew s .zl 10817 Date �01?.:;;A, A.�.l ........ TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that��eix-p::�� has permission to perfo, ........................................................................ plumbing in the buildings of ... e�?,p J. at ........ ......... ................... North Andover, Mass. Fee.!�q ....... C. No. Hf� . . ............................ I ................................ PLUMBING INSPECTOR Check #2 Zs 1� 0" MASSACHUSETTS UNIFORM APPLICATION FOR A PERMI PERFORM PLUMBING WORK CITY j North Andover MA DATE L1Q-?1-2L0.j4 _------'PERMIT# JOBSITE ADDRESS 29 Rock Road OWNER'S NAME; Gail Wilkes OWNER ADDRESS 129 Rock Road TEL 808-4314418 FAXL_----: TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL f —I RESIDENTIAL P1 PRiNT CLEARLY NEW: RENOVATION:' REPLACEMENT: PLANS SUBMITTED: YES NOFT FIXTURES -1 FLOOR— B SM 1 2 1 3 4 5 6 7 8 1 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR / AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET --- URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER I I I INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES'i NO L IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY iz OTHER TYPE OF INDEMNITY 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. CHIECKONEONLY: OWNER AGENTJ 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 y and that all plumbing work and installations performed under the permit issued for this application will be in COMO 91ce with all Partin i a Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME -Gregory- K Maffei Sr LICENSE # 1, 10059 TG9AT`URt---- MP Li ip Lj CORPORATIOND#'—'— -'PARTNERSHIP[ —,C —�LLCLL#73*451C COMP��Y NAME: Maffei Plumbing and HVAC LLC ADDRESS: 89 Turnpike Rd CITY jpswich STATE L Ma__j ZIP L�1938 TEL L!78432-1128 FAX, CELL,, 978417-9264 EMAIL gmaffei@maffeiservices.com m 40 CA > CA m m ;o ic EJCD (0 E z V!4 Date...... ..... ....... . ... ....... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that P.S.ty....J.1.411ii.1 ..Aff� ...... �.P/.A.Uvo NJ .1 has permission for gas . stallation.)�..C.b��.�..-.k . ................................. in the buildings of at ...... 271 ...... North Andover, Mass. Fee... P . . ..... Lic. No. .... ..................................................................... GASINSPECTOR Check 9617 W-11 IWAIR �aN- MASSAC1HU1SETT§zdNIFORM APPLICATION FOR A PERMIT Itc/PERFORM GAS FITTING WORK CITY North Andover MA DATE 10-21-2014 PERMIT# JOBSITE ADDRESS 29 Rock Road OWNER'S NAME Gail Wilkes GOWNER ADDRESS 29 Rock Road TEL 808-431-4418 FAX TYPE J-RINT OCCUPANCYTYPE COMMERCIAL EDUCATIONAL RESIDENTIAL CLEARLY NEW: RENOVATION: REPLACEMENT: v PLANS SUBMITTED: YES NO APPLIANCES -1 FLOORS— B8M 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 UNVENTED ROOM HEATER WATER HEATER OTHER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES v NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY v OTHER TYPE INDEMNITY BONDI 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 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 com 9@nce with all Pertinent pproAsi p4 Massachusetts State Plumbing Code and Chapter 142 of the General Laws. Z, & �/— �%7/1z— PLUMBER-GASFITTER NAME Gregory K Maffei Sr LICENSE # 10059 SIGNAT6Rb( MID MG� jp JGF LPGI CORPORATION --# PARTNERSHIP # LLC v # 3451C COMPANY NAME: Maffei Plumbing and HVAC LLC ADDRESS 89 Turnpike Road CITY Ipswich STATE MA ZIP 01938 TEL 978-312-6268 FAX CELL 978-417-9264 ;'EMAIL gmaffei@Maffeiservices.com x CO) > -0 CA m m (1) > CA co -4 m M. m ;a ic ECD El o -Ilk 01le Cornmonwealth qf'Mas,�A�huseQ_, Departnte'tif q n S fIndustrialAccide' t Qf .fice q Investigations I Congress Sti-eet, Suite, 100 Boston, A,1A 02114-2017 jvww.,inass.got,1dia Wqrkers' Compensation Insurance Affidavit: Bu' i I'd ersto tit racto rs/Electri c ian s/Plu mb e rs -,Xpplicant In formation Please Print Le(,Yiblv Maffei Plumbing and, HVAC LLC. Name -(Bus invss/organ izati onl/ind ivid ua h: I i I , Ad&_Cs�'s: 89 Turn�iike'Road city/stkc/zip: 1p9wich, MA 01938 Ph6ne #: 978-312-6268 Are you an employer?, Check the, �ppropriate box: I'vpc of project (required): AE -11 I ain a employer with 9 4. 1 ani a gencral contractor and I I I L'. 6. New construc'tion employees (full arld/or part-tirne),�- 2. 0 1 ain a sole Proprietor or partner- have hired the sub ' -co ' ntractors, fisted oil the attached slice(. 7. R�rno'dcling' silip and-havc no eniployces; Tlicsc sub -contractors havc 8, Demolition working for ine in any capacity. employees and have workers' 9, Building addition t� [No workers' conip. insurance I . -1 k I i� collip. insuranceJ 1 -5. F-1 We are a corporation -and its Electrical repairs oF additions I required.] 3.7 l ain a lionicownel"Uoing all work officers have e)<crcjsed their .10.7 . I I . C73 Plumbing repairs oi- additions myself. J'No worke rs' c6fiip. right of exemption Pei- N4Gl_ R'Obf repairs , insurance required'.] c. 15", § 1(4), and we have no 131� Other employees. [No workers* conip. insui -ancc required.] *Any applicant itiat ch I ecks box #1�11111sl illso fill 0111 111c -section below showing ilicir workcr.,;7 corripensatibn policy hiforimition. + I I ornco%vnc�s who submi i th is� affidavit i rid icating they :ire doi rig cill work and dien hi re outside contractors must subm it it new a Ffidavit i nd icat ing such. *C'ont racions that clieck thi s box must moched an additional sliect showin g the narile of flie sub -contractors and stac whether or not thosc entities have eniployees. If the sub -contractors ha�'e employees, thCy 111LISt provi I de their workcr�' comp. policy nurrilier. I am an einpliqer that is pro viding workers' compensation insurancefin- 11�1, employees. Beloit, is thepo lic.y andjob site infin-mation. Insurance Company Narne:The Hartford Pol icy# or Self -ins. Lic. g: 76WEGPY2413 '10/22/2015 Expirati,on Date: . I - Job Site Address: C ?U_q.&_ City/State/zil): _,A)_o_6AA_&AbV(C 4_jLiCk C-)l4b4Y 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 uji to S 1,500.00 and/or one-year iniprisonnient.'as well as civil penalties in the tbriii of a STOP WORK . ORDER and a Fine Of LIP to S.250.00 a day agaifist tile violator. Bc,.idvi,-,cdtilatiicol)yof:tiiisstiteiilc-ntiiiaybelbrw,-ti-(tedtotlicOfFiceof' Investigations of (lie DIA for insurance coverage verification. I do herebj, certifj, under the pains and penalties ofperffi ttlieiitft)i-ittatioitpi-oi,idedabotei*stt,iteatid,cos-i-ect., -4 V- . ;l. 14 978-312-6268 Of firt .ficial use on4y. Do not wrife in this area, to be completed by ci4i oi- town o cial. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Dcp�rtmcnt 3. City./Town Clerk 4. Electrie.,11LInsputor 5. Plumbing Inspector 6. Other Contact Pei -son: Phone #: r-) a Infonaaflon. and Instrugions Massachusetts General Laws chapter 152 requires allemployers, 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 em ployer is defined as "an individual, partnership, 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 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 compUance with the misurance 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 questi ' ons 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 aDDroDnate 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 permittlicense 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 applicaiit 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 I Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext 7406 or I - 877-MASSAFE Revised 7-2013 Fax # 617-727-7749 www.mass.gov/dia Division of Professional Licensure: License Search 4IThe Official Website of the Office of Consumer Affairs and Business Regulation (OCABR) Division of Professional Licensure Mass. Gov Home State Agencies A -Z Topics Home ) Division of Professional Licensure ) I .................... I - I-- I .............. ........... ...................... .................................. ........... Check A Professional License By the Division of Professional Licensure LICENSEE Name: GREGORY K. MAFFEI SR. ROWLEY, MA NEW SEARCH **This Licensee has additional. Licenses, click here to view them.** Licensing Board: PLUMBERS Et GASFITTERS License Type: MASTER PLUMBER License Number: 10059 Status: CURRENT Expiration Date: 5/1/2016 Issue Date: 1/2/1985 Exam Date: School: This web site displays disciplinary actions dating back to 1993. This license has had no disciplinary actions taken during this time. The page above has been generated by the Division of Professional Licensure web server on Wednesday, November 12, 2014 at 12:54:21 PM. 0 2007-2011 Commonwealth of Massachusetts Page I of I Mass.Gov ONLINE SERVICES Check a License Locate a Licensed Professional Online Address Change Contact the Agency More... REFERENCES & RELATEDINFO Disclaimer Regarding Website License Searches Glossary of License Status Codes More.:. Site Policies Contact Us http://license.reg.state.ma.us/public/pubLicenseQ.asp?board code=PL&type—Class=—M&... 11/12/2014 Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS, Ch. 139, Sec. 3B To: Building Commissioner or Inspector of Buildings 1600 Osgood Street North Andover, MA 0 1845 RE: Insured: Property Address: Policy Number: Date/Cause of Loss: File or Claim Number: Gail Wikes 29 Rock Road FP5504473 2/26/2013, Pipe Burst 27776-M Claim has been made involving loss, damage or destruction of the above captioned property, which may either exceed $1,000.00 or cause MASSACHUSETTS GENERAL LAWS, CHAPTER 143, SECTION 6, to be applicable. If any notice under MASSACHUSETTS GENERAL LAWS, CHAPTER 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 or file number. Mike Peterson On this date, I caused copies of this Notice to be sent to the persons named above at the addresses indicated above by First Class Mail. Signature and Date ANDERSON ADJUSTMENT CO., INC. 50 Nashua Road, Suite 303 PO Box 1098 Londonderry, NH 03053