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HomeMy WebLinkAboutMiscellaneous - 3 WALKER ROAD 4/30/2018N) I 1001'.115 f If I Date/Z //3... . TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ..... has permission to perform _ ......... . d • . ,J plumbing in the buildings of ... � .. z .�,,C!'� .... • ....... _ ... . • ... • • ..... . , North Andocr-fMass. Fee .VIr.S .. Lic.I xf, PLUMBING INSPECTOR Check # , e F,? MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY 07-(4evcTe MA DATE JIPERMIT# JOBSITE ADDRESS OWNER'S NAME 7, POWNER ADDRESS T 2 JI TEL�--FAX a_zkEDUCATIONAL SCM TYPE OR OCCUPANCY TYP ERCIAL Q RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT:R PLANS SUBMITTED: YES NO FIXTURES'l 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 GAS/OIL/SAND SYSTEM=I—JI DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM_.__.__( _.__._! _( _____( DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER _( E FLOOR I AREA DRAIN _._ _.__-E .____ ___J ____1 A J _. ._ ( ( ( J (._------ J INTERCEPTOR INTERIOR KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK ILET 1 . _f __J __._ L___j URINAL WASHING MACHINE CONNECTION _ 4J .__.__(_ __.._1 WATER HEATER ALL TYPES i i I I I ( I ...___.._+ J _..–J I _ J I r` WATER PIPING a OTHER INSURANCE COVERAGE: 1 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 TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY J�f OTHER TYPE OF INDEMNITY Q 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: OWNERE-1 AGENT SIGNATURE OF OWNER OR AGENT 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 myknowledge and that all plumbing work and installations performed under the permit issued for this application will be in complian th e ' nt ro '6, ' n of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. r PLUMBER'S NAME L w GLS % 11 LICENSE # ei'�d�-`� SIGNATURE MPz JP P_( CORPORATION #=PARTNERSHIP D#=LLC [( COMPANY NAME ADDRESS CITY `� _. _. ._..... i STATE ZIP:! TEL FAX - CELL EMAIL H °z 0 H U a w o❑ z a Z U., _ O Q w 5 a W U)LLI W u w a O zz W F= L) J 0- IL a � w z w F- w H z° 0 H U a z as a a c�7 ' a The Commonwealth of liPassachusettsINY - Department o f1ndustr1g1 Accid&ts Office of Investigations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/EIectricians/.Plumbers Applicant Information Please Print Legibly Name (Business/OrganizatiorAndividual):- __eo-42i rt?f— Address: 1 -7 A&A2.//y,-/ /W City/State/Zip: a?� hone #:_ 075—= y7p -,912- Are ,9%2 Type. of project (required): 6. [] New oonstruction r 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.[] Electrical repairs or additions I 1 .10 Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other •Any applicant that checks box#1 must also fill out the section below showingtheir workers' compensation policy information. T Homeowners who submit this affidavit indicating they tie doing all work and then hire outside contractors must submit anew affidavit indicating such. :Contractors that check this box must attached an additional sheet showingthe name of the sub -contractors and their workers' comp, policy information. I am an employer that ispYoviding woYkers' compensation insurance for my employees Below is the policy andjob site information. Insurance Company Name / ,%Rc A �6/0 Policy # or Self --ins. Lic. #: - B�/� ��5�� i� 2 1- Expiration Date: Job Site Address: -/it- 21 l,6ltj(� LI�/ AV 2, , _ City/State/Zip: Attach a. copy of the workers' compensation policy ileclaration 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. Ido hereby certify under ti pains and enalties ury that the information provided above is true and correct, - signature: / Date: Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit[License ff Issuing Authority (circle one): I. Board of Health 2. Building Department 3. City]Town Clerk 4. Electrical Inspector 5. PIumbing Inspector 6. Other - - - Contact Person: Phone #: Are von an employer? Check the appropriate box: 1. I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time,).* have Hired the sub -contractors 2111 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 3. ❑ I 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 worke& comp. insurance required.] Type. of project (required): 6. [] New oonstruction r 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.[] Electrical repairs or additions I 1 .10 Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other •Any applicant that checks box#1 must also fill out the section below showingtheir workers' compensation policy information. T Homeowners who submit this affidavit indicating they tie doing all work and then hire outside contractors must submit anew affidavit indicating such. :Contractors that check this box must attached an additional sheet showingthe name of the sub -contractors and their workers' comp, policy information. I am an employer that ispYoviding woYkers' compensation insurance for my employees Below is the policy andjob site information. Insurance Company Name / ,%Rc A �6/0 Policy # or Self --ins. Lic. #: - B�/� ��5�� i� 2 1- Expiration Date: Job Site Address: -/it- 21 l,6ltj(� LI�/ AV 2, , _ City/State/Zip: Attach a. copy of the workers' compensation policy ileclaration 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. Ido hereby certify under ti pains and enalties ury that the information provided above is true and correct, - signature: / Date: Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit[License ff Issuing Authority (circle one): I. Board of Health 2. Building Department 3. City]Town Clerk 4. Electrical Inspector 5. PIumbing Inspector 6. Other - - - Contact Person: Phone #: Information 2nd fII111structions 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 ormore 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 compliance with the insurance coverage required" Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any ofits 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 -contractors) 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 an LLC or LLP does have employees, a policy is required. Be advised that this affidavit maybe 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. f City or Town Officials -Please be sure that the affidavit is -complete -andprinted legibly:The D eparimerit 11as provided a space of the botiom 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 Min 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 maybe provided to the applicant as proof that a valid affidavit is on file for fixture 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 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 iassach-Voits Dop.aftent ofJadustdal Accldopts Office oHAVesligatons 600 WasbbgtQja &=,t Boston, U&02111, T01, # 617-727-4900 cxt 406 ox- 1-877,MASSAFF, Revised 5-26-05 Fa.Y, # 617-727-7749 1 LU CO) co m co I—CL co CO LU LL w w ma " SENDER: y • Complete items 1 and/or 2 for additional services. I also wish to receive the IV • Complete items 3, and 4a & b. following services (for an extra V • Print your name and address on the reverse of this form so that we can fee): > d return this card to you. > • Attach this form to the front of the mailpiece, or on the back if space 1. ❑ Addressees Address N does not permit. L • Write "Return Receipt Requested" on the mailpiece below the article number. 2. ❑ Restricted Delivery a " • The Return Receipt will show to whom the article was delivered and the date c delivered. Consult postmaster for fee. N 3. Article Addressed to: WAI�I/�iC 4a Article Number ?IV //--�� I`i �t J 4 —010h So n W 4b. Service Type 0 P� D ❑ Registered ❑ Insured • ^ry y 1.., Certified El os E W LU_(�<�<'. n ,�_ A _., -,I ❑ Express Mail E] Return Receipt for 0 �`+ Merchandise 7. Date of Delivery o �- 5. Signat a (Addressee) �" 8. Addressee's Address (Only if requested Y y�� 4� ©7 � and fee is paid) LU 6. Signature (Agent) 0 PS Form 3811, December 1991 *U.S.GPO: 1993-352.714 DOMESTIC RETURN RECEIPT UNITED STATES POSTAL SERVVM- INI Official Business PENALTY'rOR-PRIVATE' USE T.QAVOtD-PMENT- OF POSTAGE -$300.__ Print your name, address and ZIP Code here PATRICK J. DONOVAN ASSOCIATES, INC. elaim and ROSS ./adjustments P. O. BOR 110 WAKEFIELD, MA 01880 (617) 245.5540 — FAX (617) 245-7016. June 03, 1997 Building Commissioner City or Town Hall North Andover, MA 01845 Insured Property Address Insurer Policy Number Type of Loss Date of Loss Paul alker Road, Unit #2 North n a 845 Providence Mutual : H538-70118 : Water : 05/30/97 ' 9 `gg� �� Claim has been made involving loss, damage or destruction of the above -captioned property, which may either exceed $1,000 or cause Mass. Gen. Laws, Chapter 143, Section 6, to be applicable. If any notice under Mass. Gen. 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 file number. 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. hn Spano ASSOCIATION OF INDEPENDENT INSURANCE ADJUSTERS AMU,p„ of Massachusetts A _ D