HomeMy WebLinkAboutMiscellaneous - 31 ROYAL CREST DRIVE 4/30/2018 — — — — __ J31 2���1 Gel ➢z .
BUILDING ELLE
v
i
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Date... ............
TOWN OF NORTH ANDOVER
0
PERMIT FOR WIRING
CHU
This certifies that .
has permission to perform .... ....A�j......... . S f V-10 0-1 x lv-�Alz C>-
........... ............................................................................
wiringin the buildin ofA
...........✓V.yv�.A............................................................................
at ..................t................ ....C��Vgk.. . .....Z N rth Andover,Mass.
Fee Lic.No.2.G.;�.c A .......................................
ELECTRICAL INSPECTOR
Check#
13 3
ammanwea[1Ji o�///ueaac�rueaf ()fficitd Ilse Only
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`..��spcxrtmRrr�o�.}due�ca�rdcr,e . - --
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Itev. 1/07] (Icnvetilank.)
APPLICATION FOR PERMIT TO PERFORMELECTRICAL WORK
All work to be pertbrined in accordance with the Massachuwtiy Electrical C'odo(MGC),527 CMR 12.00
(PLEASE PRINT•I•NINK OR TYPE ALL INTORMA..PIO.N) Date: _
City or Town of: PQ`t . Astia V To the Inspector of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described bellow.
Location(Street&Number)^ gyeCk\, Cf�S[, )i1J� @ > SmU106, ---
Owner or Tenant k,—tk b _ 1'elepbone No. -6-Bg 605-A
Owner's Address 60 L -y-s-r ' Twe..._MgLN hekw 1[
Is this permit in conjunction with a building permit? Yes ❑ No (Check;Appropriate Box)
Purpose of Building wh!b�. int}'� Utility Authori7Atinn No.
Existing Service Amps / Volts Overhead El Undgrd❑ No.of Meters
New Service _ Amps VoltsOverhead Undgrd❑ No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
�iu?,�P � r.���^4+'rnM �'cuc�--To Q,P. .<,.tt. 4.�. l�l"r Da`C ..,.,�i�Va►,CFtr�a.�t"_�!"a taAl\ OCCU.r try uL�ASS
4 C:'ow letion n Ylre nllowin table wnv be waived by the lns eNor or wins.�.15CQR
No.of Recessed Luminaires No.of Ccil.-Sus . Paddle Fans r o Total
p (Paddle) Transformers NAVA
No.of Luminalre Outlets W No.of Hot Tubs _.. Genernt:ors ICVA
No.of Luminaires Swimming Pool Above ® tib ❑ o.aTEmergency ig tag
rad. rad. Ratter Llnilw
No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones
No.of Switches No.of Gas burners Nnitiatin m o.o Detection D ane
Devices
No.of Ranges No.of Air Cond. otal Tons No.of Alerting Devices
No.of Wnat.c Disposers eat um um er .,fans 1CAV o.o Sell-C:ontnme
p Totals ........ .. betectionlAlerting Devices
" No.of Dishwashers Space/Area Heating IOW Local❑ .unicipnl 7 011ier
_ Onlslection
No.of Dryers Heating Appliahces Kms, � Security Systems!"
No.of Devices or E guivollent
o,o Watcr KWNo.of o.o' Data Wiring:
Waters Signs Ballasts No.of Devices or F uivnlent
No.Hydromassage Ontlitubs No.of Motors 'Total HP c No of De ices o s �rmgg:
y No.ofDevices or E alvalcltt
OTHER:
Attach additlonal defe l i/clesirnd,or en required by the Inspector rnf YC Tres.
URtimated Value of Electrical Work: 1 -) (When required by municipal policy.)
Work to Start: I; Inspections to be requested in accordance with NIEC:•Rule 10,and upon completion.
INSURANCE COVERAGE: Unless waived by the owner,no pernliit for the performance of electrical work may imuc unless
the licensee provides proofof liability insurance including"completed operation"coverage or its substantial equivalent. The
undersigned certifies that such coverage is in fotec,and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE Ox BOND ❑ OTHER ❑ (Specify:)
I certify,under the pains and penalties gf pet;jurf,,that the information on this application is tried and conwlete:
FiRM NAME: Newport Eloctric LiC.NO.: A20803
Licensee: David McMullen Signature LIC.NO.: 1960813
(Ifapplieahle,enter "exempt"in the license•number line;) Bus.Tel.No.:_A01.-263_0527_
Address: 2-00.Nlginl Ave. Portsmouth,.Rf_02871 _ Alt.'i'el.No.:...a1.7-806 h1.93
*Per M,G.I_.c. 147,s.57-G1,security work requires Department of public Safbty"S"License: Lic,No.
OWNER'S INSURANCE WAIVER: I am aware that the Licensee does nol have the liability insurance coverage normally
tequired,by law. By my signaturc below,i hereby waive this requirement, I n,n the(check on x owner El owner's agent,
Owner/Agent
Signature Telephone No._-_----_ PER.M/T rEE, $ a5-
Date.
.............
OF NORTN,�
TOWN OF NORTH ANDOVER
0
PERMIT FOR WIRING
Tt,is certifies that ................................................................................................. ............
has permission to perform)4..... ........................S•
wiringin the building of.... .1
....... Vy (I(
V.
........... .
at . .........................'North Andover,Mass.
Fee... .....Lic.No.C2.P.w5.....................................ELECTRIC'A*L'KS'PECTOR'********'*"*"""***
Checko
133n ?
ammoncuaaGl�x 4///ueeachudal C)frGal Use Only
Permit No.
�t3�tt.M6mRIN,O��6+R�wrrricmfl
Occt.,pancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS (liev. 1/07) (lenveblank)
APPLICATION FOR PERMIT TO PERFORM 'ELECTRICAL WORD
All work to be pertbrmcd in accordance with the Massachusetts Electrical C'odo(MEC),527 CMR 12.00
(PLE,4SE,PRINT IN INK OR TYPE ALL INFORMATION) Date: �`?-f J_
City or'T'own of: P010%%%% AcW"e�c To the Inveclor of Wires:
By this application the undersigned gives notice of his or her intention to perform the electrical jwork described below.
,
Location(Street&Number) 9,0 a ._ C [ y'ke t 1` -�tw� er ,�1 U106,
- e
Owilcror'Y'enant ��'�Cb I'dp hone No.
Owner's Address E0._ p l L t-rP-S-T DyNt f g nLhI„ ►4.`c NrA�__�
Is this permit in conjunction with a building permit? Ves F1 No (Check Appropriate boat)
Purpose of Building—z—J,)WN�h UIiy1T i;ltility Authorizat.inn No.
Existing Service Amps / Volts Overhend El Undgrd❑ No.of Meters
New Service -- Amps / Volts , Overhead 0 Undgrd❑ No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
`` p
Ck �1(
C.',om letfon a the/i�llrnvin sable srav be waived by the bas ectm,or wires.1.155 Q�
No.of Recessed Luminaires No.of Ccil.-Sus Ea (Paddle)Dans r t1 Total
_ TrKVA,
No.of Luminaire Outlets No.of Hot Tubs __. Generators ICVA
v No.of LuminairesSwitptt�ing Pool Alcove 0-�n�-_ ❑ o.off'Emergencyl-g mg
rnd. nasi. Battery UniLw
No.of Receptacle Outlets No.of Oil Burners f IRE ALARMS No.of Zones
No.of Switches No,of Gas Burners - o.o Initiating ng D an
Dev1Ce9
No.of Ranges No.of Air Cond. otal Tons No.of Alerting Devices
ettt um um .Cr 'funs 14�►V o.o'Self C:ontnme
No.4f Waste Disposers Totala Detectlon/Alertin Devices
No.of Dishwashers Space/Arent Henting KW Local❑ .Municipal te Otlier
Connection
Pleating A alialnce9 KW T Security Systems:.
No.of Dryers pl No.of Devices or E guivallent
Mo-.-WW atcr �, No.of o.of Dnta Wiring:
1 Heaters Signs Ballasts No.of Devices or T uivalent
No.Hydromassage Bathtubs No.of Motors I'ntrl HPc eCommun entins rrm :
No,of Devices ornE uivalent
F OTHER:
A ltach addfflonal r.lrF71 71-Tv—ire.,Y or as required Iry lite lntrecror,�f RC fres.
Estimated Value of Electrical Work: 1 CQ0 (When required by municipal policy.)
Work to Start: i; inspections to be requested in accordance with MEC:Rule 10,and upon completion.
INSURANCE COVERAGE: Unless waived by the owner,no pcl'mit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The
undersigned certifies that such covcragc is in force,and has exhibited prool'of same to the permit issuing office.
CHECK ONE: rNSURANC E ❑ BOND ❑ (OTHER ❑ (Specify:)
I certify,under the pains and penalties gf perjtuy,that the information ort this application is tr'ise and complete
FIRM NAME: Newport Eloctrlc LiC.NO.: A20803
Licensee: David McMullen? Signature � JAC.NO.: 116088
(1fapplicable,enter "exentpi"in the license number fine) � -- Bus.Tel.No.:441.-263_0527
Address: 20U.High oint Ave. Portsmouth,RI02871 -_ -- Alt.'rel.No.: 617-908-4193
*Per M,G.L.c. 147,s.57-61,security work requires Department of public Safety"S"License: Lic.No.
OWNER'$INSURANCE WAIVER: I am aware that the Licensee does not have,the liability insurance coverage normally
required.by law. By my signa.turc below,I hereby waive this requirement, f not the(check otic)[x owner 0 owner's agent,
Owner/Agent
Signature Telephone No.___��-� �. _ PL'0"T I'EE: $ �S
� �
� �
r
Date A gA\4.............
,\
i
' i, &ORTN
a°.•' ��om TOWN OF NORTH ANDOVER
o !
PERMIT FOR WIRING t
y "..T.,,.''�g
sSgcHus� ,
�, �IThis certifies that .1�.1�,�v1�.....��-P,c�t..e �� H e�U
has permission to perform CD.....&.Ae6ac> .....S...................................................
wiring in the building of.,.' . .......m- C
................................................................................
at ... t : .In.�...1.. �? ..u �. ...1.��!Z-..n orthAndover,Mass.
Fee....�5 . ........Lic.Nof: ....1....!4........
//l/�. .1. /f.l!!
UECTRICAL&SPECTOR�
check#
r
Commonwealth of MassachusettsFii/99)
otRcial UUse oni —
Department of Flre Services
BOARD OF FIRE PREVENTION REGULATIONS d pee Chocked
(leave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.
(PLEASE PRINT IN INK OR o0
TYPE AL,�INTO �{A TION) Date;
City or Town of: �dY 1 �.
By this application NRc�I�V�'�(' T
- r%
PP on the undersigned gives notice o is or er intention to perform hlnspector of fres:
Location(Street& Number) �O p e electrical work described below.
� G1-05 i
Owner or TenantA t-r�Ca ~�� I"�``� � ` N ck, d 1 ty CJ
Owner'SAddress --0 Cres Telephone No, g7fr 6r-" 7a 0C
Is this permit in conjunction with a building permit? Yes No �gl"_
Q $ L
' ❑
Purpose of Building Dw etc (Check Appropriate Box)
Existing Service Utility Authorization No.
Amps / Volts
�, v -------______ Overhead❑ Undgrd❑ No. of Meters
m er ice _ _i Amps / _Volts Overhead
Number of Feeders and Ampacity Undgrd ❑ No.of Meters
Location and Nature of Proposed Elec
tricxl Work.,
1!N ��2 �, TS IN g.in,► _ � V�.11l\�\V�. 1 �
arae,v'e- 0im. a (k �r
t�lU 0.5
lesion a 'the ollowin table ma be waived 6 t
No.of Recessed Fixtures he Ins e t
No,of Cell.-Sus c or o Wires.
p. addle Fa o,o
(Puddle) ns o a
No.of Lighting OutletsTransformers K
VA
No.
Of Hot Tubs
l ubs Ge
< No,of Lighting Fixtures
nerators KVA
Swim eve n.
ming Pool ❑
rno.o mergency ri
d. ❑
No,of Receptacle Outlets rnd. Bette Unitg s
No.of Switches g
No.of Oil Burners FIRE ALARMS No,of Zones
No.of Gas Burners
0. 0 etee ori an
No,of Ranges ea otal evices
Initiatln D
No.of Air Cond'
No,of Waste DisposersTons No,of Alerting Devices
ump , um er Un9
Totals:
No,of Dishwashers Space/Area Heating KW Detection/Alertin nDevices
Local
❑ unic a tion 11 Other
0.0 ater KW
No,of Dryers Heating appliances onnecpecur ys
Renters KW . 010 010 No,of Devices or E uivalent
Data Wiring:
Sl ns Ballasts No, f Devices or E uivalent
No.hydromassage Bathtubs No.of Motors a ecommun cat ons r pg;
Total HP
5V-hRtnWNT OTHER; 6 No.of Devices or Equivalent
L___.- Glc C Yi �ja � �rd }ec�T�1,i
ItiN 1\'S tjGll .�Nl "1�-�Qy Mo STc1��
INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless
fttach addidonat delait!J'destred,or os required by the Inspector of Wires,
the licensee provides proof of liability insurance including`bompleted operation"coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office.
a CHECK ONE; INSURANCE
°[ ' BOND ❑ OTHER ❑ (Specify; _
Estimated Value of Electrical Wor
Work to Start;
(When required by municipal policy.) (Expiration Date)
Inspections t�,be requested in accordance with MEC Rule 10,and upon completion.
I certify,under the pains and penalties o u p
FIRM NAME: fp r`that the informative on this crppitealton is true and compl8te,
Licensee: ---= LTC.
(Ifs applicable r. • Signatur c
pA enter exon
ipt"in the 11c Te number line,) LIC,NO.: (�,d
Address: D Bus.Tel.No.• a5
��
OWNER'S INSURAN E WAIVER: I am aware that the licensee does noha�e�t�1 liability insurance c
required by law, B Alt,Tel, co 3
Owner/Agent y my signature below, I hereby waive this requirement. I am the check one overage no�mally
q ( owner
Signature owner s a ens.
Telephone No.
I
l pie t.�r�trttct,�M�etxltli of',1{�nsstaelrzcsettsimam=
,Department of IlIdrrstrial Accidents
Office o,fXnvestigations
I Cottgress Street,Suite 100
BvstOjf , MA 02114-2017
wwwanass gov/dia
Worker's' Cor;<apensatxon Jusurance,Affidavit: Builders/Contractors/FIectri;cians/Plumbe>r s
Anntic.,eint Tnfor-unlatxo>a
lease Pr;>�nt Lir >ibX
Name(Business/organization/Individual): ( r4-
A.ddress:��,1�j
City/State/flip: a 1'1'adt4 .. "� 'hone #: •., , , �, -
Arfyou an employer?Cheep the appropriate box-
I.A I all,a employer with 4. D I am a.general contractor and I Type of project(required):
employees(full and/or part-time).* have hired the sub-contractors G. ❑New construction
2,❑ 1,am a'sole proprietor or partner- listed on the attacher) sheet, 7. 0 Remodeling
ship and have no employees These sub-contractors have
working, for me in any capacity. employees and have workers' S• ❑Demolition ns
[No workers' comp, insurance comp. insurance.[ 9. [Iuilding addition ir���
3.❑ required.] 5. ❑ We are a corporation and its 1056E,lectrical repairs or additions
lam a homeowner doing all wor1� of'f'icers have exercised their
myself [No workers' comp. right of exemption per MG.tr I 1.❑ Plumbing repairs or additions
insurance required.]t C. 152, §1(4),and we have no 12-❑Roof repairs
employees. (No workers' 13-❑ Other
comp, insurance required.]
*Any applicant that ehccks box 61 must aiso fill out tltc section below sirowing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside cohtractors must submit a new affidavit indicating such,
tGontraCtors thslt cheolc this box must attadhcd an odditional sheet showing the name of the sub-contractors and state whether or not those cntitiea have
employccs. If the sub-contractors have employees,t)tr:y must provide their workers,comp,policy number,
I am an ettrployer that is providing M,orker•s I comp I ensation insurance for rrry errrployees. Below is the policy anal job site
in fOrMation.
Insurance Company Name:�y � z
Policy#or Self-ins.Lic.#:
� Expiration Dale: 0!
Job Site Address:1_1�6d�/�/�
City/State/Zip: yfr
Attach a cagy of the workers., compensation Polley declaration page(showing the policy number and expiration date),
Failure to secure coverage as required,under Section 25A of MCrL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1.,500.00 and/or one-year imprisotimen.t,as well xs civil penalties in the form of a STOP WORK OltT�1:R and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do h.ereG cerci t,rrrrtler tlr ar.rr rid penalfies U 'ter•itry iftat the in ortraativrt provided accrue is tare and correct i
Si nature:
17
.Pho
F
only. Do not write in dais area,to be completed by city or town official,
n: Permit/License#
horlt:y(circle one):
Health 2,Building IUepartment 3.Cii°y/Town Clerk 4,Electrical Inspector 5.Plumbing Inspectorrson:
Phone#:
�.' OMMONWEALTH OFtiMkSSAHUS ._
C1 EGTRI:C I A1�i _ K f,
ISSUES THE FO.LLOWlNG Iw1fNSE
REGISTERED MAS TERj,ELEC."-Rll
NE1<IPORT 'ELECTR!C .CORPORAT`"lbt�Ck
DA b �q F1Ct�ULLEN:
19 BUR 15 S'
� 1 01.
f.
1I WELL 1 A 01852 02t;
: .20803- a < 07%31 . 6 1;11039 f
O MONWEIXLTH"'OFlog
IIA �iAl✓tiISETT .:..
• • • ' • •
LT121 Cl ANS
155UE5 THE FOLLUWttG1 CENSE
qS A I#1:G` JOURNEYMAB ELECTRI'C.1 AM ¢`
DrAY#U A i MULLEN x 4 a R a
6 KI ,P. [CLIP T EET; ,
P�3�TS#1ouTH _ f#► 02$jl 5802
:
AC R NEWPO13 OP ID: LS
�.---� CERTIFICATE OF LIABILITY INSURANCE DATE
a THIS CERTIFICATE 13 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON 01�0$�2014
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED TE THE POLI C
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING EINSURER7S AUH HOLDER. THIS
I REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IES
IMPORTANT: if the certificate holder Is an ADDITIONAL INSURED,the policy(les) must be endorsed. If SUBROGATION IS WA VED subject
the terms and conditions of.the policy,certain policies may require an endorsement A statement on this certificate does not confer rights t
certificate holder in Ile"of such endorsement s, ito to
PRooL�aR 9 he
30 Dwyer Agency D,F. Dwyer Insurance Agency
N Bellevue Avenue P �-•----___
Newport,RI 02840 _401 84g�96Y.9 —�-W9,_N
Daniel F.Dwyer tit aooResa•dfd dfd --I-�.C.�Nu.1L401.846.9629
wyer,com
--------------
INSURE S AFFORDING COVERAGE
NAIC N
INSURED Newport Electric Constructlony INsuRERa:Foremost
Corp INSURERS:Scottsdale Insurance Com an • _
200 High Point Ave,Suite B6 INSURERC:Beacon Mutual Insurance �- 41287
ortsmouth, RI 02871 — __._......
INSURER D; ........_._....__.... __�_._..
INSURER E: _COVERAGES CERTIFICATE NUMBER: INSURER F
THIS 13 TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE•BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
REVISION N MBER:
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY 8E ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
TYPE o INBURANCe _.._._.....-----._.._..
GENERAL LIABILITY POLICY NUMBER
LIMITS
s 1,000,00
CLAIMS-MADE X�OCCUR 12/30/2013 12/30/2014 SES(E --
sILr�BsaL s _300,00
MED EXP An one anon $ 10,00
PERSONAL&ADV INJURY $ 1,000,00
GEML AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE
$ 2,000,QO
POLICY PRO- LOC PRODUCTS-COMPIOP AGG S 2,000,00
AUTOMOBILE LIABILITY
S
A ANY AUTO 0 B NED SIN LE LI I
ALL SCP005046448 E acct en _ 1,000,00
AUTOS OWNED X SCHEDULED 12/30/2013 12/30/2014 BODILY INJURY(Per
AUTOS Person) $
HIRED AUTOS X NON-OWNED
AUTOS BODILY INJURY(Par accident)
PR PERTY D GE ----._.__
$
UMBIp„'LLA LIAB X OCCUR $
B X EXCESS uA6 CLAIMS MADE BSOO1969$ EACH OCCURRENCE $
D ETE I 12/30/2013 12/30/2014 AGGREGATE
wo►ncERs COMPENSATION a _6,000,00
AND EMPLOYERS,LIABILITY $
C ANY PROPRIETORIPARTNER/EXECUTIVE Y/NWC STATU- 0TH•
N/A
OFFICER/MEMBER EXCLUDED? 68661 01!1T
(Mandatory In NH) 8/2014 01/18/2016 E.L.EACH ACCIDENT
If yea deacrfbe under S 500,00
DE G�RIPTI NOF 0 ERATIONS below E.L.DISEASE-EA EMPLOYEE S 600,00
A Empl Prac Llab SCP005048448 12!3012013 12/30/2014 E.L.DISEASE-POLICY LIMIT S 600,00
60,00
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attaoh ACORD 101,AddWonal RenuHw BohW ula,Ii mon epaa Is nqulnd)
CERTIFICATE OLDER
CANCELLA •p
SHO
LD ANY OF
THE UEX EXPIRATION THE
DATE ABOVE
THEREOF, NOTICE POLICIES
WILL CANCELLED
CDELIE ERED IN
Insured's Copy ACCORDANCE WITH THE POLICY PROVISIONS,
AUTHORIZED REPRESENTATIVE
Daniel F. Dwyer III
ACORD 26(2010/06) The ACORD name and logo are registered ma8ks2of ACORD D CORPORATION.. All rights reserved.
a
Y
S ✓
6
7
Date. . :73.`.':�i. .
OF '40 T
02 p TOWN OF NORTHNDOVER
' PERMIT FOR GAS INSTALLATION
CHUSE�
This certifies that . .! . . . . !.�,,. . . . . . . . . . ... . . . . . . .
L•
has permission for gas installation . -G- ..
in the buildings of . . . . . . .'... . `. . . . . . . . . .
at .uP. �. �a . �. .� /. . . . ., North Andover, Mass.
oer
Fee �. . . ic. \}: -` . . . . . . . . . . .
�• GAS INSRE-TOR
Check# �
7155
MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS FITTING
(Type or print) Date r
NORTH ANDOVER,MASSACHUSETTS
Building Locatios(�Ln N et ( C.f-e5�- 30r. N-A .
Permit#
Amount$ -b
Owner's Name
New❑ Renovation Replacement --� Plans Submitted
U a
0z x �a
z H d a C O O Z W
v~, Z. a W
CW7 F z H � x w � w � w o °w H � a
� W Q ~ � W � pOH ' w � U � F W
W > W Z Q a d d O O W O h x
x O x w 3 r a u W > o c0. F p
SUB -'BASEMENT
BASEMENT
1ST. FLOOR
2ND . FLOOR
3RD . FLOOR
4TH . FLOOR
5TH . FLOOR
6TH . FLO O R
7TH . FLOOR _.:.__. .
H . -FLOOR
(Print or type) t Check one: Certificate Installing Company
Name
El Corp.
Address El Partner.
6 01-G
usmess TelephoneZ— 3 3 ® Firm/Co.
Name of Licensed Plumber or Gas Fitter y VA\\ P
INSURANCE COVERAGE Check Me:
I have a current liability Insurance policy or it's substantial equivalent. Yes No
If you have checked yes,please in 'sate the type coverage by checking the appropriate box.
Liability insurance policy El Other type of indemnity 0 Bond
Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the
Mass.General Laws,and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner �. Agent
I hereby certify that all of the details and information I have submitted(or entered)in above application are true and accurate to the
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts S e Gas Code and Chapter 142 of the General Laws.
By: Signature of Li ensed Plumber Or Gas Fitter
Title Plumber 3
City/Town Gas Fitter License Number
Master
APPROVED(OFFICEUSEONLY) journeyman
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The Commonwealth of Massachusetts
Department of industrial Accidents
Office of Investigations
600 gZashington Street
Boston, MA 02111
www maS&gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information
Please Pr><nt Le�bly
Name(Business/Organizafion/Individual): �� )
Address:
City/State/Zip: b S � Phone#: -��/�- 3�/F
7[] 1
mployer?Check the appropriate box:
m to er with 4. Type of project(required):
P y ❑ I am a genF
l contractor and I
ees(full and/or part-time).* have hired sub-contractors 6. New construction
ole proprietor or partner- listed on thttached sheet X 2• ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers' comp.insurance.
com .insurance 5. 9 ❑Building addition
[No workers
' p ❑ We are a corporation and its
required.] officers have exercised their 10.❑Electrical repairs or additions .
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself. [No workers' comp. C. 152, §1(4),and we have no
insurance required.]t 12.❑Roof repairs
q ] employees. [No workers'
comp.insurance required.] I3.❑Other
"
Any a-yplicant that checks boxAt' must also fir,out tl e section below shote^:ng on _ _
t 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' a Ii
P policy information.
lam an employer that is providing workerscompensation insurance for
information. my employees Below is thepolicy andjob site
Insurance Company Name:
Policy#or Self-ins.Lic.#:
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 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 hereby certify under the pains and penalties of perjury that the information provided above is true and correct
Signature:
rr Date.:
Phone#: to 7
E
only. Do not write in this area, to be completed by city or town officiaL
n• Permit/License#
hority(circle one):
Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
son: Phone#:
t
n
Information as d 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 employer 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 notbecause 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 the performance of public work until acceptableevidence 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(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 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 reque-sted,not the i e-partment 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.
w
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 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 burn leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to than 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
600 Washington Street
Boston,MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Revised 5-26-05
Fax# 617-727-7749
wwu,.mass.-o ov/dia