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Home My WebLink AboutMiscellaneous - 31 STONINGTON STREET 4/30/2018 r1 31 STONNINGTON sr BUILDING FILE i .....4.—y:i'a.�4ia�y'.s'ecd.�w+^-i.'+`y,�--�^'•�-'r--++t zr ,...'.�:r-»..,..:�:'r.�...sv...r.�:..'rw+-Y...v.<..c, yw—vu w... 4..... �. Date. .tf Z%� 11 A. .... . Of HORTM 3? °` TOWN OF NORTH ANDOVER p PERMIT FOR GAS INSTALLATION 1 SgACHUSE i s , . . �. . . This certifies that . . . . . . . . . . . has permission for gas installation . . U . . . . . . . . . . . . . . C ! ` in the buildings of . . � �. . .� . . . . . . . . . . . . . . . . . . . . . . at . 3.f. . . . . . . . . . . . . .. . . . . . . . . . ., North Andover, Mass. Fee. . ''.�.�v Lic. No..,�.-3. GASINSPECTOR Check# (� 7085 MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS FITTING (Type or print) Date NORTH ANDOVER,MASSACHUSETTS Building Locations Permit# Amount$ r Owners Name / c New❑ Renovation Replacement Plans Submitted ❑ x WWz v� a � x c ] w d x z ° w x >. w w v � ¢�' x x a w � w � a F x C7 F z r w W p p > w w U z d w Q a F a z O z x � o x w � 3 c � �a ° a° > � SUB -BASEM ENT B A S E M ENT 1ST. FLOOR f 2ND . FLOOR 3RD . FLOOR 4TH . FLOOR 5TH . FLOOR 6TH . FLOOR 7TH . FLOOR _:...... .. 8TH . FI;OOR (Print or type) Check one: Certificate Installing Company Name ^l ) 5IP1,0,4 4 ( El Corp. Address �� L;' � �`� �� Partner. L9 vim. , 0 business Telephone ' ®Firm/Co. w Name of Licensed Plumber or Gas Fitter icy 0 INSURANCE COVERAGE Check one• I have a current liability Insurance policy or it's substantial equivalent. Yes No If you have checked ves,please indicate the type coverage by checking the appropriate box. Liability insurance policy �/ 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 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 0 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 instal . ' s p rmed under Permit Is ed for this application will be in compliance with all pertinent provisions of the Massa ch tate ode Chapter 1 of the G eral Laws. By: Signature of Licens Plumber Or Gas Fitter Title Q�lumber City/Town Gas Fitter Icense Number rq� Mas APPROVED(OFFICE USE ONLY) ❑ Journeyman 1 I The Commonwealth of Massachusetts Department of Industrial Accidents Office of investigations 600 Washington Street Boston, MA 02111 www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Address: li City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a ❑ I 4.with employer am a general contractor and I 6 ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet$ 7. ❑Remodeling ship and have no employees These sub-contractors have 8. Demolition working for me in any capacity. workers' comp.insurance. o workers' comp. insurance 5. 9. ❑Building addition ❑ We are a corporation an and is required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I 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 12.❑Roof repairs insurance required.] t employees. [No workers' comp.insurance required.] 13.0 Other *Any applicant that cheeks boo:#1 must also nil out the section below shot- Le;-,.,owe!compensation information. policy infoation. 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'comp.policy information. I lam an employer that isproviding workers'compensation insurance for my employees. Below is thepolicy andjob site information. ' 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. Ido hereby certify under the pains and penalties of perjury that the information provided above is true and correct Si ature: Date.: Phone#: 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 CIerk 4.Electrical Inspector 5 Plumbing 6. Other P b Inspector Contact Person: Phone#: W 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 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 not because of such employment be deemed to bean 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, §25CM 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(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 of-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 retuned to the city or town that the application for the perrnitor 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 r 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 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 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 600 Washington Street Boston,MA 0.2111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-72.7-7749 Revised 5-26-05 www.mass..gov/dia Date.. . . .. . ..... . . .. . ... . . HORTIy pf �.av ,ti0 o� TOWN OF NORTH ANDOVER f D PERMIT FOR GAS INSTALLATION • o� _ a 9SSACHUSEt This certifies that . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . has permission for gas installation . . . . . . . . . . . . . . . . . . . . . . . . . . . . in the buildings of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . at . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. North Andover, Mass. Fee. . . . . . . . . Lic. No.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . GAS INSPECTOR Check# MASSACHUSETTS UNIFORM APPUCATON FOR PERM TO DO GAS FITTING (Type or print) Date w —2 NORTH ANDOVER, MASSACHUSETTS Building Locations 7"/� rt/� f•� j�. 0 Permit#— 29 L� ; Owner's Name d ��` � �,Amount$ New Renovation Replacement Cr Plans Submitted Ua G7Wd W OU F v� az o=. O � H a u W x �, z F c a > w tW7 H z e x w a W u v, z d W d a F. v� 0 Zp Z C x o x a 3 .da a a H o SUB -BASEMENT v a > BASEM ENT 1ST. FLOOR 2ND . FLOOR 3RD . FLOOR 4TH . FLOOR 5TH . FLOOR a 6TH . FLOOR 7TH . FLOOR 8TH . FLOOR (Print or type) Check one: Certificate Installing Company Name_ /�,.1 S /�i/?2!✓1�--�_ ��f nn 0 Corp. Address /Jy `o Partner. Business Telephone phone O/ y 2--0 Firm/Co. Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE Check one: I have a current liability Insurance'policy or it's substantial equivalent. YesNo0 If you have checked Les,please indicate the type coverage by checking the appropriate box. 13— Liability insurance policy Other type of indemnity D Bond ID Owner's Insurance Waiver: 1 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 13 Agent 1 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 insta ns performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massach efts tat as Code f d Cha ere General Laws.- By: Signature of Licensed Plumber Or Gas Fitter Title Plumber D)3 b City/Town [3Gas Fitter (cense um e 13--Pvlaster APPROVED(OFFICE USE ONLY) D Journeyman L Date.... E!. .... . .... F, f NORTH '1 TOWN OF NORTH ANDOVER O p t PERMIT FOR GAS INSTALLATION o J��qh �9SSACHUSEt This certifies that *" .'y��'t L � . has permission for gas installation !�` ! c in the buildings of .�'G/t `�fja!�. . . . . . . . . . . . . . . . . . . . at . . ! ? X4 fh 4.A: . . . . . . . . . . . .. North Andover, Mass. Fee. . . . . Lic. No..��. 70 . GAS INSPECTOR Check# / 6049 MASSACHUSETTS UNIFORM APPLICATIOK FOR PERMIT TO DO GASFITTING (Print or Type) Mass. Date - _a 20 Permit# 4-oyj Building Location 3 a S� �s 1�2. Owner's Name Telephone 4i 2- Type of Occupancy 12-e,S,�. New ® Renovations' Replaceme t Plans Submitted: Yes No L � L W C y d d d ° Um 'c EZ w C O O o c IM m w p d fA C 2 ►y. (� L G1 E- 4a O V CiMdM =: N .QCO �Cd __ d i J W 2 O Z l0 U a. 6 a. Ia' O SUB-BSMT. BASEMENT 1ST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR 5TH FLOOR 6TH FLOOR 7TH FLOOR 8TH FLOOR ° Installing Company Name EnergyUSA Propane,Inc. Check one: Certificate Address 100 Myles Standish Blvd., Suite 101 R Corporation 132 C Taunton,MA 02780 ri Partnership Business Telephone (800)822-1300 X8055 Rick Rousseau C(603)231-2702 ❑ Firm/Co. Name of Licensed Plumber or Gasfitter William Kent Corson(800)822-1300 X8051 Cell (508)294-6660 INSURANCE COVERAGE: EnergyUSA Propane,Inc. has a current liability insurance policy or its substantial equivalent,which meets the requirements of MGL Ch.142. Yes XD No ❑ d If you have checked ves, please indicate the type of coverage by checking the appropriate box. A liability insurance policy X❑ Other type of indemnity 0 Bond 1-1 ti 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: Owner Agent Signature of Owner or Owner's 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 the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Code and Chapter 142 of the General Laws. Type of License: By ElPlumber Title X❑Gasfitter Signature of Licensed Plumber or Gasfitter City/Town X❑Master APPROVED(OFFICE USE ONLY) Journeyman License Number 3707 BELOW FOR OFFICE USE ONLY FINAL INSPECTION SKETCHES PROGRESS INSPECTION FEE NO. APPLICATION FOR PERMIT TO DO GASFITTING i NAME &TYPE OF BUILDING LOCATION OF BUILDING PLUMBER OR GASFITTER Ilk LIC. NO. PERMIT GRANTED f� DATE 20 GASINSPECTOR