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Miscellaneous - 32 BANNAN DRIVE 4/30/2018 (2)
32 BANNAN DRIVE 210/038.0-0109-0000.0 Location dj Iri K Date { 1 ! . • TOWN OF NORTH ANDOVER . D '. �.r Certificate of Occupancy $ Building/Frame Permit Fee a Foundation Permit Fee Other Permit Fee $ TOTAL �$ Check. 27518# Building Inspector TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: � � Date Received Date Issued: r 2-1 IMPORTANT: Applicant must complete all items on this page LOCATION - ' -- --- . PROPERTY OWNER__ r_. y C-Q' � _ r� YD - - -- Print 100 Year Old Structure yes: MAF NO: . __ PARCEL:__ _ ZONING DiSTRICT _-_ !Historic District yes ono Machine Shop Village yes no TYPE OF IMPROVEMENT. PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other Septic. ❑Well ❑ Floodplain y ❑Wetlands ❑ Watershed District p'Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: oa'�(— Y2����/'t�t. C,..b 1,tJ S�U-J �� S\1� W l Xh V\ ��`j� � �p�,D L� V\�•�� � S6!�((� Identif cation Please Type or Print Clearly) OWNER: Name: _�os Phone: —� ��31.� w Address: CONTRACTOR Name: ._.ho e:_ Supervisor's Construction Licensees Exp. :Date: _- _ _ Home 1mpCovemenf;License: ZZExp_. Date: -- - - - . ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED O $125.00 PER S.F. Total Project Cost. $ ��� � FEE: $ OL 1 r Check No.: Receipt No.: FaC NOTE: Persons contracting with unregistered contractors do not have ac ss to the guaranty fund g...3�. : { � S� nature o ;;Signatufe�of Agent/Ownei. fcontractorY a- -' Plans Submitted FE Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ i !, i '� t -- - - - -� . I Plans-Submitted ❑ Plans=Waived ❑ :Certified Plot Plan ❑ Stamped Plans ❑ -TYPE-OF-SE W ERAGE DI SP:OSAL" Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑- Tobacco.Sales 0 . .,Food Packaging/Sales ❑ Private(septic tank,etc:_ ❑.. _ Permanent Dempster on Site ❑ THE..FOLLOWING SECTIONS FOR'OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM -DATE REJECTED DATE:APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS CONSERVATION Reviewed on Si nature i COMMENTS i HEALTH Reviewed on _ Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes . Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit DPW'Tmdv;: Engineer: Signature: Located 384 Osgood Street FIRE DEPARTwnT Temp Dump§t& on site . yes no Located at;124,Mair Street Fire Depa`rtme �tsignature/date CM M.ENTS NORT11 Town of Andover h ver, Mass, � �A CoCNICNI WICK�Vot• �d �AATED S U BOARD OF HEALTH Food/Kitchen PERM1, T L D Septic System THIS CERTIFIES THAT � :�,. . . BUILDING INSPECTOR ....................... ....... . .................... ... ....... ............................................ has permission to erect buildings on Foundation ,.. . Rough �- t0 be OCCUpled as --' Chimney ......... ... ..... provided that the person accepting this pe hall in every respect con rm to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 0 THELECTRICAL INSPECTOR UNLESS CONSTRUC 0 S A S Rough Service :. .... ... :. :.............................. Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. BETTER HOMES WINDOW AND SIDING THE EXCLUSIVE WINDOW AND SIDING CONTRACTOR 978-372-6385 TOLL FREE 1-800-668-3505 MASS REGISTRATION #122318 DATE -2 57 SOURCE � �'"�'� CONSULTANT HOME TEL. WORK TEL. MR./MRS. THIS AGREEMENT, made and entered into between BETTER HOMES WINDOWS AND SIDING hereafter referred to as a contractor ANDi ADDRESS/STREET 13 7Z- -0 CITY 11 STATE ZIP hereafter referred to as owner. THE SAID CONTRACTOR hereby agrees that it will furnish all labor and materials necessary to install the following described work at premises located at: JOB ADDRESS 5Al—,('t CONTRACTOR agrees to start described work on/or about _ weeks after final measure and complete described work in about I-A z- working days. In addition to manufacturer's warranty, Better Homes Window and Siding guarantees our workmanship for ten years. ALL HOME IMPROVEMENT CONTRACTORS AND SUBCONTRACTORS SHALL BE REGISTERED IN MA. INQUIRIES RELATING TO A REGISTRATION SHOULD BE MADE TO:DIRECTOR,HOME IMPROVEMENT CONTRACTOR REGISTRATION.ONE ASHBURTON PLACE,ROOM 1301,BOSTON.MA 02108,TEL.617-727-8598. We hereby submit specifications and estimates for: Q�lMri ►�� v Dbbli= C�yQ moi'f'� li.,l OK �'�C �St*,j � (SCS, ? `A �� \ L- 14vc✓��-1rn as `' �i�'.((t-i,�<< ,C > tri, n 1 TZw• kt% -6 ksi W Ly WE PROPOSE HEREBY TO FURNISH TOTAL INVESTMENT MATERIAL AND LABOR (IF SPECIFIED) - h DEPOSIT ..Sy, ti COMPLETE IN FULL ACCORDANCE WITH -3 7j,76 ,T ABOVE SPECIFICATIONS FOR THE SUM OF: BALANCE UPON COMPLETION 1 f i ,333, ANY WORK NOT LISTED ON THIS CONTRACT WILL BE AT ADDITIONAL CHARGE.BETTER HOMES WINDOW AND SIDING DOES NOT INCLUDE PAINTING OR STAINING ON ANY PROJECT UNLESS SPECIFIED ON THIS CONTRACT. You may cancel this agreement if it has been signed by a party thereto at a place other than the address of the seller, provided that you notify the seller in writing at 18 Bates Road, Haverhill, MA 01832, by ordinary mail posted, by telegram sent, or by delivery, not later than midnight of the third business day following the signing of this agreement. ALL MATERIAL IS GUARANTEED TO BE AS SPECIFIED.ALL WORK TO BE COMPLETED IN A WORKMANLIKE MANNER ACCORDING TO STANDARD PRACTICES.ANY ALTERATIONS OR DEVIATION FROM THE ABOVE SPECIFICATIONS INVOLVINGEXTRA COS S NVILL BE EXECUTED ONLY UPON WRITTEN WORK ORDER AND WILL BECOME AN EXTRA CHARGE OVER AND ABOVE THE ESTIMATE.THIS IS TO INCLUDE,BUT I OT LIMITED TO,HIDDEN DAMAGES THAT ARE UNCOVERED DURING THE COURSE OF THE JOB AND ADDITIONAL WORK REQUIRED BY LOCAL BUILDING INSPECO�ALLELENIENTS OF THIS AGREEMENT ARE CONTINGENT UPON STRIKES,ACCIDENTS,OR DELAYS BEYOND OUR CONTROL. NOTE,THIS PROPOSAL MAY BE WITHDRAWN BY CONTRACTOR IF NOT ACCEPTED WITHIN DAYS. AUTHORIZED SIGNATURE DATE ACCEPTANCE: THE ABOVE PRICES,SPECIFICATIONS,AND CONDITIONS ARE SATISFACTORY AND ARE HEREBY ACCEPTED.YOU ARE AUTHORIZED TO DO THE WORK AS SPECIFIED.PAYMENT WILL BE MADE AS OUTLINED ABOVE. AN INTEREST CHARGE OF 1.1/2%PER MONTH(18%PER YEAR)WILL BE ADDED TO ANY AN40UNT UNPAID AFTER 30 DAYS FROM INVOICE DATE. //- - DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES SIGNA DATE SIGNATURE DATE The Commonwealth of Massachusetts , - Depalrtment of Industrial Accielents Office ofluvestigations 600 Washington.Street Boston,MA 02111 www.mass gov/rtia Workers' Compensation Insurance Af�a.davit:Builders/Conti°actors/Blectricians/Plumbers Applicant Information Please Print Le0b Name(Businessiorgani'zation&(Rvidual): kGv\ v Address: City/State/Zip: �AA5a-e ` 1 Phone#• 1$— 72 (,, 385' Are yo n employer?Check the appropriate box: Type of project(required): 1. 1 am a employer with 4• ❑ 1 am a general contractor and 1 6, ❑New construction employees(full and/or part-time).* have ned the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7• E]Remodeling ship and'havano.employees These sub-contractors have 8. ❑Demolition working forme in any capacity. workers'comp.insurance. y. F1iuilding addition [No workers' comp.insurance 5. ❑ We are a corporation and its 10.[]Electrical repairs or additions required.] officers have exercised their 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.❑Roofrepairs ( � k '.s eo worersU)lv SDI insuran.cerequired.]t em to ep y 13.❑Other comp.insurance required.] 1 ny applicantthat checks box#1 must also fill outthe section below showingtheirworkers'compensationpolicy information. 7-Homeowners who submit this affidavit indicating they tie doing all work and then hire outside contractors must submit a new affidavit indicating such. t'Contractors that cheekthis boar must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name;. � Policy#or Self ins.LIC.#: Expiration Date: y 1 2ct L, lob Site Address:, 3 2 Dk—` 4�_ City/State/Zip: �t(A(3Ua 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 ofMGL o.152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or ones-year imprisonment,as well as civil penalties in the form of a STOP W ORIS ORDER and a En.e 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. f do liereby rto under the pains and penalties ofperjury that the information provided above is true and correct. - Signature: Date: 'I ci I Phone#• �" _ L 3 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 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 their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract ofhire,• 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 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 lie-ening 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 acceptable evidence of compliance with the insurance requirements of this chapterhave beenpresentedto the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if iiecegsary,supply sub-contractors)name(s),address(es)andphonenumber(s)alongwiththeir 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. IfanLLC orLLP does have employees,a policy is required. Be advised that thisaffidavit may besubmitted tothe Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. !'he affidavit should be retumod 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 fill in the permit/license number,whichwill 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'an 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 orpermit 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 shQuid you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: Tho CQ onw.DalthofN-Tassachusetts Depat`Gxuent offudustrial,A,ccidonts Office ofJAVestigaftow 600 Wasbiugtm Strut Boston,MA.021.11 TOA.#61.7-227,4900 QA 406 or Z-877-MA.SSAFI E Revised 5-26-05 Fax 0 617"727-7749 ' �w.roass.gov�cb`a. - imension Number of Stories: Total square feet of floor area, based on Exterior dimensions._ .Total land area; sq. ft.: ELECTRICAL: -Movement:of.Meter location, trust-or service drop requires approval of Electrical Inspector Yes No DANGERZONE LITERATURE: . -Yes No MGL.Chapter166.Section 21A--F and G min.$100=$1000.fine NOTES and DATA— For department use Y&— rorrr ttLLa OV D Notified for pickup - Date E ! I Doc.Building Permit Revised 2010 I Building Department the foh wing isa list of;the required:forms to be filled out for the appropriate.permit to be obtained. Roofirg, Siding, Interior Rehabilitation Permits a - 0% Building Permit Application o Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C'.S.'L.- Licenses o Copy of Contract o Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire-Department prior to issuance of Bldg Permit Addition Or Decks o Building Permit Application o Certified Surveyed Plot Plan a Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o Mass check Energy Compliance Report (If Applicable) o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) o Building Permit Application o Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit L3 Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o Copy of Contract o Mass check Energy Compliance Report o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the apn,al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submJted with the building application Doc: Doc.Bui1.ding Permit Revised 2012 . Date.. .4/!/../.Z. . .... .. pORTN 3j TOWN OF NORTH ANDOVER O D t - PERMIT FOR GAS INSTALLATION y �9SSAf HUSEtt This certifies that . . . . . . .�./j . . . . . . . . . . . . GCe has permission for gas installati . . /orf in the buildings .. . . ./.:a w. . . . . . . . . . . . . . . . . . . . . . . . . . . . . at . . . . . . Q124a.h . . . . . . . . . . . . . North Andover,,,,Mass. Fee. ??:vU. Lic. No..*3 GASINSPECTOR Check# 4 8185 r MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK s - CITY Lao- M' . "._ vim^-- _ _ MA DATE I PERMIT# JOBSITE ADDRESS 13L A 1✓ IL _. OWNER'S NAME =0 2 c, GOWNER ADDRESS S - e _ TEL[- _____ IFAXE TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL CLEARLY NEW:F-1 RENOVATION: REPLACEMENT: PLANS SUBMITTED: YESFII NO Q APPLIANCES Z FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTERS CONVERSION BURNER - .J COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR -- - -- FURNACE _ .aJ GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS . . ... z! MAKEUP AIR UNIT OVEN - - - -- ---! --- I--- J POOL HEATER I _ (�- . . J _ _ I _ ROOM/SPACE HEATER _ —..=-I ---__ --- -. -._ = L (_ ! _ - -! ROOF TOP UNIT 7-771 TEST UNIT HEATER L ._n) I UNVENTED ROOM HEATER __ I_ ! _ 1 ( _.I WATER HEATER OTHER F. J�F �__-F--I ---I I = _J __._.I. --- -- - --- -----LL---- -- INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES JB NO 13 1 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY ER" OTHER TYPE INDEMNITY [j 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 'r AGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are tru nd ccurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in co li cith all ertine prov' on of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. - PLUMBER-GASFITTER NAME /11J.� ✓� �o��w --�-_ LICENSE# v SIGNATURE MP 0 MGF E! JP D JGF 0 LPGI CORPORATION(�'# 3 3 © PARTNERSHIP # =LLC 01#= COMPANY NAME: -� -e . ADDRESS _jya-_d_X-__ S .___.----_...___.-___•---------.--------___.� _ _._ zr CITY a,-A _a- _ _I STATE ZIP a �� TEL -6 T___... NFAX CELQ._ .7..3_ MAIL . - - --- - -- ---- ✓ r ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES " Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES '27,12—a I A--S �v�1 The Commonwealth of Massachusetts Department of.£ndustrial Accidents Office of1nvestigations ..600 Washington Street Boston, MA 02.711 www.mass gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lebly Name(Business/Organization/Individual): --Address: City/State/Zip.' Phone#: [2. re you an employer?Check the appropriate boa: " ❑ T am a employer with 4. ❑ I am a general contractor and I TyEN f project(required):employees(full and/or part-time).*' have hired the sub-contractors6 ew construction ❑ I am a sole proprietor or partner- listed on the attached sheet.f 7• ❑kemodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. [No workers'comp.insurance 5. 9. EJ Building addition p ❑ We are a corporation and its required.) officers have exercised their 10•❑Electrical repairs or additions 3-0.1 am a homeowner doing all work right of exemption per MGL .1 Ln Plumbing repairs or additions myself. [No workers'comp, c. 152,§1(4),and we have no 12,0 koof repairs insurance required.]t employees. [No workers' comp.insurance required.) 13.❑Other *�-u3'EpaL;cant that chee`�s bo x#1 must also fill out the section begot=,showing+, __ _ T Homeowners who submation it this affidavit indicating they are doing all work and then hire outside contractors must submitinf 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. lam an employer that isproviding workers'compensation information. insurance for my employees. Below is the policy and job site Insurance Compiny 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. X do hereby certify under the pains and penalties ofperjuu that the information provided above is true and correct Sienature: Date: Phone#: Official use only. Do not write in this area, to be completed by city or town official City or Town• Permit/I,icense# Is Authority(circle one): 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 their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of lure, express 6r 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 br 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 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 certificafe(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 anLLC 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 nlE.FBt T'vd t0 trtaP�City or toCM1�n th t t"O&pa liGaieon-for the pars it-oma license is being roqu*estt d,not the D=part enit o7 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 fill in the permit/lice'nse 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 nbt-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.0211.1 Tel. 617-72.7-4900 ext 406 or 1-8.77-M.ASSA_FE Revised 5-26-05 Fax 4 6.17-727-7749 Date. . . . . . ... .. f NORT1y 1 a TOWN OF NORTH ANDOVER • PERMIT FOR GAS INSTALLATION ACHUSE� 6 &q, This certifies that . . . . . . . . . . . . . . . . . . . . . . . has permission for gas 'nstallation .�� %.. N�. .?`�. . . . . . in the buildings of `.�% -. (5 .. . . . . . . . . . . . . . at . u) . . . . . . . . . . . . . . .�. . ., North Andover, Mass, Feer! :G.. Lic. No. -�?.. . .. I GAS INSPECTOR �f Check# i! 5154 MASSACHUSETTS UNIFORM APPLICATIO FOR PERMIT TO DO GASFITTING (Print or Type) Mass. Date Permit # r � Building Location- � N j\j 13R_ Owner's Name Type of Occupancy k F-S l D F O T 1 -L- New New ❑ Renovation ❑ placement Plans Submitted: Yes[] No ❑ N N ¢ W N NNCC V) cc M V Z ¢ N z 0 W W Cc O x r m x n z o u h UJ a CC Z 0 o r w ¢ m N h y W O O h 1 N ¢ W W fa Z OL) W rn W < ¢ O > . CW C7 F.. Z J f- Z W W O O > LL at W t- V J W 1' Q W a C h !- N m Z O Z a O Z 6 W ¢ W Z. < ¢ Q ¢ '.X O tl Y U. 3 C tl J V ¢ y D a F O SUB—BSMT. BASEMENT !ST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR STH FLOOR 6TH FLOOR 7TH FLOOR STH FLOOR I I Ij Installing Company Name BAY STATE GAS COMPANY Check one: Certificate # Address 55 MARSTON STREET �❑ Corporation 1862 LAWRENCE, MA 01840 ❑ Partnership Business Telephone -68,7-1105 ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter Francis X. Corkery . INSURANCE COVERAGE: 1 Pave a current liability insurance policy or Its substantial equivalent which meets the requirements of MGL Ch. 142. Yes No ❑ If you have checked yes, please Indicate the type coverage by checking the appropriate box. A 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 ❑ I hereby certify that all of the details and information I have submitted(or entered)in&aWcation are true and accxi�te to the best of my knowledge and that all plumbing work and installations performed under the permit Iapplication will n mpliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Ge (/ i By Type of License: Plumber Signature of Vicensed Plumber or Gas Title Gasliitter Master License Number 3-145 City/Town gJourneyman O IC SE ONLY y i. BELOW FOR OFFICE USE ONLY FINAL INSPECTION SKETCHES PROGRESS INSPECTION FEE N0. J� APPLICATION FOR PERMIT TO DO GASFITTING NAME TYPE OF BUILDING LOCATION OF BUILDING PLUMBER OR GASFITTER LIG NO. i PERMIT GRANTED DATE X19 { GASINSPECTOR