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Home My WebLink AboutMiscellaneous - 30 ALCOTT WAY 4/30/2018N) 6/30/2016 Date: June 30, 2016 20775 This is an e -permit. To learn more, scan this barcode or visit northandoverma.viewpointcloud.comt4/records120775 TOWN OF NORTH ANDOVER I LIM. 0. 91 PERMIT FOR GAS INSTALLATION This certifies that William L Desantis has permission for gas installation Gas Fireplace insert with Piping (Hearth & Glow Direct Vent) in the buildings of Ronald Wells at 30 ALCOTT WAY 30Y, North Andover, Mass. Lic. No. 10768 In Ic N I � ---------- --------- - ---- - ------ — -------- — -------- ------ -- --- ----- ---- ---- ------- h— I oWn of North Andover, IVA Q 20775 'G� Permit - Ren—tion(AfterationiAddition IC—mercial or Residential NG'F in conjunction with a Building Pernift) TIMFLIAFE S.b.t,�itm reloi,.d Your request is in progress j- 29,2m 6 o 10.48— we -11 let you k— of any pd tes via —il. FeM free to check the --- - ------ -- sx�w5 atanytime by curningbackto this page. Gal Ponnit RaA.. 0 P—Sc—%1—%C0MDE\1R[0)H c- Ke" I Esc Rocky DeSantis m AL( -OTT WAY F:, NORTH AN DOVE R, MA D— Ronald Wells Pitachments 15 -0'3WYQIDO I F�Wed_jun_29_2016_14:59;.PI)F Primary Contractor search for your contractor using the search bar below. Either the Firm's Name or license. # Is required. 5j !129t CT -3 Wednesday, Jun 29, 2016 10:59 AM The Commonwealth ofMassa chusetts Department of IndustrialAccidents I Congress Street, Suite 100 Boston, AM 02114-2017 www.mass.gov1d1a 'Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. NaMe (.Business/Organization/Individual): Address: /,t, 6 Phone Are you an employer? Check &e appiiopriate box: I.[] I arnaemployer with . — � employees (full and/or part-time).* 2.[Rfam a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3.F_J 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 onmy property. lwill ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5. F1 I arA a general contractor and I have hired the sub -contractors listed on the attached sheet. Thes'e s�b-contractors' ba�e enployees and have workers' comp. insurance.1 6. F1 We are a corporation and its, office rs.havc exercised their right of 'exemption per MGL c. 152, § 1(4), and wehave no empl6yees, [No workers' comp. insurance required.] Type of project (required): 7. El New construction 8. Remodeling El Demolition 10 E] Building addition 11. Electrical repairs or additions 12. [_JPlumbing repairs or additions 13.E] Roof repairs 14. n other_6�_�_ *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. I Homeowners who submit Us affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating suctL tContractors that check this box must -attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. if the sub-cofilraciors hav'e employees, ley' must pro.vide their workers' comp. policy number. I am an employer that ispiovidhig workers' compensation insurancefor my emplbyees.'Below is thepolicy andjob site information. Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: 116 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 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 ification. coverage ven I do h ereby certify u n der & e ofperju ry th at M e information pro vided ah ove is tru e an d correct. Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # =3W__MR1M= 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 thek employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contrdbt Ullie, expres's 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 tru�tee 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 of its political subdivisions shall. enter into any contract for tlfe performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Pleise 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 Depattment of ffidustrial Accidents foiconfimation'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 reiqi�red to obtain a workers' compensatiou'policy, please call the Department at the number listed below. Self-iiisured companies sh,ould'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 Ell 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 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 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 perrijit to bum leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number: The Commonwealtb of Massacbusetts Department of Industrial Accidents I Congress Street, Suite 100 Boston, NIA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia L 4 's