Loading...
HomeMy WebLinkAboutMiscellaneous - 30 UNION STREET 4/30/20181 Date.J TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ... ........... � ` �` ....................M �..................................... has permission for gas installation .....G ... a.u1.Q:,�2........................................ in the buildings of ......I& 4P. Q.............................................................................. It at ..........�--�.U......� .... ! ........ ........ North Andover, Mass. Fee ..�, ."'..... Lic. No. .� ?? 7 .................................................... � i Q GAS INSPECTOR Check # { U � p rj1'A 9 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITYLAf - A i7D W� II MA DATE ILS > PERMIT # v — - JOBSITE ADDRESS., Un )0-1 s ' OWNER'S NAME GOWNER ADDRESS _ �'�r 011 J1 TE 5- - 9S7 -' Z7i7 FAX _ TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ® RESIDENTIAL4t PRINT CLEARLY NEW - E] RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES F---jj Ncd APPLIANCES 7 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER .._._ _ Z: J E::. - L:j L:. _ L:D 1__...1. ,. -1- _ _1 . BOOSTER ED -- - E::- --- CONVERSION BURNER COOK STOVE I DIRECT VENT HEATER I IAV �J -_- :. _ TI I -y _rA --J- DRYER FIREPLACE FRYOLATOR FURNACE _ T, �J .J L _ L- = 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 1- . J - _ -- f — -- L.. L— ._ OTHER - - - - - INSURANCE COVERAGE 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 [� OTHER TYPE 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. CHECK ONE ONLY: OWNER Q 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 curate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliith al e e pr vision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME lenk1 { �_ A?3_IC5= LICENSEtIGNATURE MPl� MGF El JP ® JGF Q LPGI CORPORATION [j# PARTNERSHIP 0#= LLC COMPANY NAME: ADDRESS r A2 CITY _ _� STATE 1-8—Wi�-- ZIP 3C TEL �o� �i� IoSJ FAX CELL �3/`�_�3 EMAIL rj1'A 9 H O H U a w � o z O �El W �- � W 4 w O a w 5 cn o. w O �+ w w c a w occ a a E., a a s w I-- LL H °z 0 H U w cocin C7 x x a V 0 Aw The Commonwealth of Massachusetts - Department of lndustdglAccidents Office of Investigations 600 Washington Street Boston, MA. 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information �j Please Print Lep-ibly Name (Business/Organization/lndividual): Address: City/State/Zip: �e6 t Phone #• -3 `-17S_ d Are you an employer? Check the appropriate box: - Type of project (required): 1. ❑ I am a employer with 4. El am a general contractor and I 6. ❑ New construction employees (full and/or part-time).* have hired the sub -contractors �• E] Remodeling 2'" pI am a sole proprietor or partner- ship and'have no employees listed on the attached sheet. These sub -contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance,g ❑ Bg addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions required.] 3. ❑ I am a homeowner doing all work officers have exercised their right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, § 1(4), and we have no 12. ❑ Roof repairs required.] insurance . re uired employees. [No workers' 13.❑ Other comp. insurance required.] --------------- xAny applicant that checks box41 must also fill out the section below showing their workers' compensation policy information. T Homeowners who submit this affidavit indicating they ire doing all work and then hire outside contractors must submit anew 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. X am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Policy # or Self -ins. Lie. Expiration Date: Job Site Address: 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 requiredunder Section 25A of MGL o.152 can lead to the imposition of criminal penalties of a flue 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 maybe forwarded to the Office of investigations of the DIA for insurance coverage verification. X do hereby certr r the stns p na[ 'es o perjury that the in.Tormauon proviaeu uouve :3 rue u.tu L 119 C �G l�z- Phone #: Official use only. Do not write in this area, to be completed by city or'town official City or Town: Permit0cense 0 Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - - ('nntart PerSnn: Phone 0• Information and Instructions 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 employei 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 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 ofpublic 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 LL C 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 retumed 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. 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 Min the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications "Many given year, need only -'submit one affidavit indicating current Policy information (ifnecessary) 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. 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 burn 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 Gommouwealth of Massae usPtts Departmeat of Zadustdal .Accidents oface ofI11yestigatiom 644 Wasb.Ytagto>u Street Roston} MA 42111 Tel, # 617-727-4940 eyt 446 or 1-877,MASSA'E Revised 5-26-05 Fax # 617"727-7749 ,0 PLUMBERS AND GASFITTERS $.;SUZ,$.:,,THE FOLLOW INGLICENSE' Lt:CENSE'D AS . -:-,:A MASTER PLUMBE Q Safety Insurance Form of Notice of Casualty Loss to Building Under MASS. GEN. LAWS, Ch. 139, Sec. 3B To: Building Commissioner or Board of Health or Inspector of Buildings Board of Selectman City Hall City Hall N ANDOVER, MA 001845- N ANDOVER, MA 00 1845- RE-.- Insured: KEVIN M BREEN and HOLLY BREEN Property Address: 30 UNION ST, N ANDOVER, MA Policy Number: HMA 0114420 Claim Number: BOS00043966 Date of Loss: 7/3/2014 Company: Safety Indemnity Insurance Company Claim has been made involving loss, damage or destruction of the above -captioned property, which may either exceed $1,000.00 or cause Mass. Gen. Laws, Chapter 143, Section 6 to be applicable. If any notice under Mass. Gen. Laws, Chapter 139, Section 313 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 number. Daniel Olsen Claim Examiner Safety Insurance Company Homeowners Claims Unit P. O. Box 55098 Boston, MA 02205-5098 Phone: (617) 951-0600 EXT 3323 Fax: (617) 531-2762 Email: Danie101sen@Safetylnsurance.com 7/8/2014