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HomeMy WebLinkAboutMiscellaneous - 32 CIDERPRESS WAY 4/30/2018 sz- Date TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .�' has permission to perform . .i,�1 .P. �? . . .� .(?!�. . . . . . . . . . . . . . . . wiring in the building of at . . . . .�.. . �.c. ?�l�X Q . . . J , North Andover, Mas Fee Cr Lic. No. . . . . . . . . . . --k .P�- ELECTRICAL INSPECTOR t Check# T '1 '� 2 Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. --7Y -. Occupancy and Fee Checked „ BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/071 (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code q 7�d-o 527 C 12.00 (PLEASE PRINT WINK ORTYPEALLWFORMATIOA9 Date: /off ,`— City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number)___J. �`�-erral�sS oi Owner or Tenant fir, r 1-4o,5f,.vc�.,ez lTelephone No. Owner's Address Is this permit in conjunction with a building permit? Yes No F1 (check Appropriate Box) Purpose of Building i�`e 71771 17 7(t] Utility Authorization No. - Existing Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters r Number of Feeders and Ampacity e Location and Nature of Proposed Electrical Work: tom_ Ori Completion of thefollowin table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Cell:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- ❑ N—o.IoTEmergency.Lighting rnd. grnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones No.of Switches No.of Gas Burners No.of Detection and Initiatin Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons No.of Waste Disposers Heat Puumb mp Ner Tons KW No.of Self-Contained Totals: - "" """"'""' ..."".....''""' Detection/Alertin Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal Connection El Other No.of Dryers Heating Appliances KW Security Systems:* No.of Water No.of No.of No.of Devices or Equivalent KW Ballasts Data Wiring: Heaters Signs No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or E uivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of ElectIcal Work: (When required by municipal policy.) Work to Start: /a /)-- Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE C RAGE: Unless waived by the owner,no permit 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 coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: 1NSURA_NCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify,under t pains and penalties o erjury,that the inform tion on this application is true and complete, /� FIRM NAME: . C /� c a (� C 2 LIC.NO.: / ' R Licensee: M k..0 e, L Signature LTC.NO.: 7 (Ifapplicable,enter "exempt"in the licens aimber line.) Bus.Tel.No. d 3 Address: _ ,s.p, 1 Sb.�lzf_ ��5� �t� Alt.Tel.No.• *Per M.G.L c. 1 57-61, ecurity work requires Department of Public Safety"S"License: Lic.No. � OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent. Owner/Agent PERMIT FEE.$ Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the provisions of M.G.L.c. 143,§3L,the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166,§32,an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L.c.143,§3L. Permits shall.be limited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012. ❑ Rule 8—Permit/Date Closed: ***Note:Reapply for new permit ❑ ❑Permit Extension Act—Permit/Date Closed: Trench Inspection Pass 0 Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass n Failed Re-Inspection Required($.) ❑ Inspectors Comments: . Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass F?1 Failed M Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: ROUGH SPECTION: Pass ? Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: i FINAL INSPECTION: Pass M Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: f 2 - 2? - Inspectors Signature: v Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 ,Y www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): 1nly C Y G C of Address: ( ; T q City/State/Zip: Phone#: .,Q3 Are you an employer?C t propriate box: Type of project(required): 1 I am a employer witi, N 4. ❑ I am a general contractor and I 6. ❑New construction employees(full an4r�part-tim .* have hired the sub-contractors2.❑ I am a sole proprietor listed on the attached sheet.l ?• ❑Remodeling silip and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.E]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.]i employees. [No workers' comp.insurance required.] 13.❑ Other :Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. 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. am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site formation isurance Company Name: I olicy#or Self-ins.Lic.#: Expiration Date: )b Site Address: City/State/Zip: .ttach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). a.ilure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ne 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 up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of tvestigations of the DIA for insurance coverage verification. do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. gnature: Date: lone#: 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 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 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." r 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 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 N 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 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 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 evised 5-26-05 Fax#617-727-7749 www.mass.gov/dia ' N2 9 7 c Date.)z y.1 1-L-. NORTH TOWN OF NORTH ANDOVER C� ♦N° ,�1ti PERMIT FOR PLUMBING ,SSACMUS� �t 1 C kol?This certifies that . . . . . . . . . . . . . . Q . . . . . . . . . . . . . . . . . . . has permission to perform . ". J k'! .�?��.,. . . . . . I�� } IVY- plumbing tot bI 'Idings of . . . . . .Q.� . .��a!�:�7e... . .4-��.�. . . . . 3 `, . at. . . Z. . . . � ✓.�'�I.`J. . . . . . . . . . . .. North Andover, Mass. Fee��.� -)A ��r5 )O© PLUMBING INSPECTOR Check # WHITE:Applicant CANARY: Building Dept. PINK:Treasurer I!AASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK `r CITY ...__._ IMA DATE _I PERMIT# JOBSITE ADDRESS S OWNER' NAME , u P OWNER ADDRESS TEL FAX _ TYPE OR OCCUPANCY PE COMMERCIAL EDUCATIONAL Q RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES Eq NOQ FIXTURES 7 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 P-_-_fi! ..____.____._._1IE -I(I _�___.-____-_______.►I _.._....__-_--_._._..1;i T.____-__.-___.! Qe�_(II __-____--.______.__C( ___.__.._..__-.._...!' -�.__._________._I.I( ..___„..__�._.__..____--_.�;I ____-._._-_.-_._-� -a-�BATHTUB - CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOILISAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM f ( I DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN i FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL I 1 .-- ...-� __..._._l __....I ._..___1 _X77 .__.__i ___-_) --_--_( .__._...I __-^-( t SERVICE/MOP SINK TOILET I .._ ___-_( _-__ _1 _.__.1 _ .- __. ._4 ._..___.. __,-.j URINAL ' s --_l -k --- - - -.i -i J _i .__ { . 1 ..__..! .. i ------ WASHING MACHINE CONNECTION I 1 I r , ! s WATER HEATER ALL TYPES WATER PIPING ` 1 ( I e 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 E4"' OTHER TYPE OF INDEMNITY Q BOND f 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 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 provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. J PLUMBER'S NAME _ LICENSE# _ �� __. SIGNATURE -� MP y JP 0 CORPORATION Q#PARTNERSHIP 0#[=LLC Elft .. II COMPANY NAMEf�J _L%1� .M- I ADDRESS Al -- -—- - CITY --- -._ _.__... __f STATE ZIP �p'� (aTEL (� € FAX I CELL 71MAIL k e,"Vz"jt'x_ 1M. ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# 4wi" �� ✓ ���/Z PLAN REVIEW NOTES jr r The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations kvj� 600 Washington Street Boston,MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LeLxiblv Name (Business/Organization/Individual): � Address: City/State/Zip: e 0 Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 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. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.El 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 12.0 Roof repairs insurance required.]f employees. [No workers' comp.insurance required.] 13.0 Other *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. 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. F am an employer that isproviding workers'compensation insurance for my employees. Below is thepolicy and job site %reformation. [nsurance Company Name: ?olicy#or Self-ins.Lic.#: Expiration Date: 'ob Site Address: City/State/Zip: kttach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ine 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 if up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of nvestigations of the DIA for insurance coverage verification. do hereby certify under the p ' sand enalties of pe ' t the information provided above istrueand correct. i nature: C Date: 7 hone#: 6 G �j '�/ )? 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#: 1 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 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 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 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 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 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 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax# 617-727-7749 www,mass.gov/dia r :COMMONWEALTH OF MASSACHUSETTS _ M1 PLUMBERS AND GASFITTiERS LICENSED AS A MASTER PLUMBER ISSUES THE ABOVE LICENSE TO: MICHAEL. W KELLER 20 KENNEDY DR' I� .R PE.LHAm N1 030 760-260.5 15157 � `• 1CL•tz Q�TGI.� { DateZ. -L �1�.. . . by Met.� TOWN OF NORTH ANDOVER } PERMIT FOR GAS INSTALLATION 4 � / II� . P P I This certifies that . .l. .,. . . .�.0. . .l . . 1�. . . . . . . . . . . . . . . . . . . . . . has permission for gas installation . ►n . . . . . ..`!'.'.-".-e.. . . . . . . . . in the buildings of. .�'� P P . . Y�.�;z.� L_(_... . . . . . . . . . . at . . �!)2. .C.'; �,�.p l. .`�.�. ^3 . . . . . . . . . . . North Andover, Mass. Fee . ri Lic. No. . . GASINSPECTOR Check# L] it y MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK .t` CITY ( MA /DATE PERMIT# l I JOBSITE ADDRESS OWNER'S NAME GOWNER ADDRESS _ TEL _ ___ _ _ FAX TYPE OR OCCUPANCY TYPE COMMERCIAL Q EDUCATIONAL ® RESIDENTIAL V PRINT CLEARLY NEW: RENOVATION:El REPLACEMENT: 1 PLANS SUBMITTED: YES NO E 11 APPLIANCES 1 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER 1 DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR _J : I GRILLE - --- INFRAREDHEATERI- LABORATORY COCKS L I J —_ ( — J MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT Z`cST _J( . ) _I L_-- I ._�J _ _, _I _. (, J I I. J A= UNIT HEATER NVENTED ROOM HEATER L= j I I I, J WATER HEATER I_ ( _1 1! ll r._ 1I _)I-.__,_1I-� OTHER I_ J �I — = rI —Ji INSURANCE COVERAGE - L. have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES J[�],_I NO [_I 1 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 13� OTHER TYPE INDEMNITY 0 BOND I 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 -[] AGENT 0 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 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 provision of he Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME ( LICENSE#_ / SIGNATURff — _ MPI MGF ] JP } JGF LPGI CORPORATION0# PARTNERSHIP # LLC[—]I#= COMPANY NAME: ADDRESS CITY STATE ZIPL `Z ITEL !3L_ I FAX CELL r _�3 *YAIL 12 L` 112- ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No `mow IFZ //�/� THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES AS, 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: City/State/Zip: 7 Phone#: —SB —/ f Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ElI am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. E]New construction 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet.1 7• ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.El 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.]f employees. [No workers' comp.insurance required.] 13•0 Other *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 1Contractors that check this box 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 ?reformation. assurance Company Name: ?olicy#or Self-ins.Lic.#: Expiration Date: 'ob Site Address: City/State/Zip: lttach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ine 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 ,f up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of nvestigations of the DIA for insurance coverage verification. do hereby certify under the pains and penalties of erj that the information provided above is true and correct. i nature: 2M Date: �- hone 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 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 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 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 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 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 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 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax#617-727-7749 www.mass.gov/dia ` .COMMONWEALTH.OF MASSACHUSETTS PLUMBERS AND GASFITTERS LICENSED AS A MASTER i'L`umBER ISSUES THE ABOVE LICENSE TO: MICHAEL. W KELLER 20 KENNEDY DFS: PE'LHAhf' NIS 030761 -261 T5T57 :f,41161 p