HomeMy WebLinkAboutMiscellaneous - 33 MAPLE AVENUE 4/30/2018Date .7/-'L:7`/`.
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
.
This certifies that A !I -I .... 7). ..............
has permission to perform.. S., .............
plumbing in the buildings of ... 'r7 ................
at ... I.. /111 . K .............. North Andover, Mass.
Fee. Lic. No. .3 . ..... q-1.. .....
PLUMBING INSPECTOR,
Check
8'15 7
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Date 7 Z - Y_
Building Location Owners Name �1&o-tnniPermit #
Amount
Type of Occupancy
New Renovation Replacement 0 Plans Submitted Yes ❑ No ❑
(Print or type)Q % �� f Check one: Certificate
Installing Company Name (/ j 7/ ❑ Corp.
Address 0 "� /
OL-' ElPartner.
Business Telephone QFirm/Co.
Name of Licensed Plumber:
Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box:
Liability insurance policyETOther type of indemnity F-1Bond ❑
Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above
three insurance
Signature Owner ❑ Agent rl
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 State Plumbing Cod and Cha ter 1 ener 1 Laws.
By:
Signature o icense um
Type of Plumbi o License
Title
City/Town V ense um er Master ❑ Journeyman
APPROVED (OFFICE usE ONLY
WF . i ilk (
M
-M
-----MM--.--
--.--.
'• ,rJ
..----MMMMWM---
-.MMMOMM-
1 /:'
MMUMMMMMM
WWWNMMWNWMM0MMM
MMMMMWMWMMMW
MW
11'
--.----.----m-mmmm-
M---
1
--------M---M-.-M--.-----
.
--
(Print or type)Q % �� f Check one: Certificate
Installing Company Name (/ j 7/ ❑ Corp.
Address 0 "� /
OL-' ElPartner.
Business Telephone QFirm/Co.
Name of Licensed Plumber:
Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box:
Liability insurance policyETOther type of indemnity F-1Bond ❑
Insurance Waiver: I, the undersigned, have been made aware that the licensee of this application does not have any one of the above
three insurance
Signature Owner ❑ Agent rl
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 State Plumbing Cod and Cha ter 1 ener 1 Laws.
By:
Signature o icense um
Type of Plumbi o License
Title
City/Town V ense um er Master ❑ Journeyman
APPROVED (OFFICE usE ONLY
The Commanweafth of Massachusetts
Department of Industrial' Accidents
Office of Investigations
600 Nrashinonn Street
Boston, MA OZIII
www_mass gov/dia .
Workers, Compensation Iu i ance Affidavit Builders/Contractors/Eleetricians/piambers
mliicant Information
n__1 , .. .
Name (Business/Org6nizafiorL4ndividual):
P
Address:
City/,State/Zip:_
Phone #:. y % �� 235 ,
Are you an ewployerY Cheek.the appropriate box:
1. ❑ 1, am a employer with
4. ❑ 1 am a general contractor and I
employees (full and/or part-time).*
have Dred the sub -contractors
2• am.a.sole proprietor or partner.
ship and have no employees
listed on the attached sheet i
'£hese sub -contractors have
working for me in any capacity,
[No workers' comp, insurance
workers' comp. insurance.
5. ❑ We are a corporation and it
required.)
3. ❑ I am a homeowner doing
officers have exercised their
all work
right of exemption per MGL
myself. [No -workers' comp,
C. 152, § 1(4), and we have no
insurance rmquired ] .t
.employees. [No workers'
comp. irisurance uirertl
Type of project (requirep:
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demoiition
9. ❑ Building addition
l0.❑ Electrical repairs oradditions
11.❑ Plumbing repairs or additions
12.❑ Roof repairs
req 1317.Other
'Any applicant that cheeks bozo# I must also fill out the section below showing their workers' compensation policy inforrntrtron.
r Homeowners who submit this affidavit indicating they are doing all work aand then hire omaside contractors mus'submit a new affidavit iodiaetins such
tCor►hactors that check this box roust ttaeh� an add:tioas! sheet showing
the nano of the sub -cots
tractors and their works rs I cent-, palsy, infbnnMoa.
I am an employer lhai is providirwr~kers' compensation insurance or a !o
informrtlinn. f m!' m'P ye= Below is the policy and job site .
Insurance Company Name:
Policy # or Self -ins. Lie. #:
Expiration Date:
Job Site Address:
City/Statrzip:
Attach a copy of the workers' compensation policy deciaraiion page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MCiL C. 152 can lead to the imposition of criminal penalties of a
pena
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
Investigations of the DIA for insurance coverage verificati Office of
on.
I do hereby certify under the pains and penalties of perjury that the information provided above is erste and rowed
.--�
�: 3 / 4
WIcial ass only. Do not write in lfris area, to he completed by cftj, or town. officio[
City or Town: Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town
6. Other, Clerk 4. Electrical Inspector S. Plumbing Inspector
Contact Person:
Phone #:
Information a nd Instructions '
Massachusetts General Laws chapter 152 requires all emp 3oyers 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 includirig the legal representatives of a deceased employer, or the
receiver ortnrstee of an individual, partnership, associatiori or other legal entity, employing employees. *However the
owner•of a dwelling house having not more than three apa-tments 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 appurten thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6) also states that "every state ow- local Scensing 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 t3he commonwealth nor any of its political subdivisions shall
enter irrto 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 I the workers' compensation• affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub -contractors) name(s), address(es), acid 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. Ifan 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, notthe Department of
Industrial Accidents. Should you have any Questions regarding the law or if you are requimd to obtain a workers'
oorimpertsation policy, please call the Department at the nwraiber. listed below, Self�s*Pd cranpRniPs shculd ent-- +h!^h
self-insurancelicense number on the•appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department hes 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 permitAicense 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 fitum 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'w bum leaves etc.) said person is NOT required to complete this affidavit.
The Office of investiptions 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 east 406 or 1-977-MASSAFE
Revised 5-26-05 Fax 9 617-727-7744
wwwm,-Ms.gov/dia
3? e
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, SACMUSEt�y
Date. �X' ..........
TOWN OF NORTH ANDOVER
RMIT FOR GAS IN:
I
This certifies that .....D.1.0 !. . �... 1�..!? .r� fi : ............ .
has permission for gas installation :� ...............
in the buildings of ..., F,-P.r. tii-7.......................
at ....1....?...�?,r? . !-�....... , North Andover, Mass.
Fee.. �..r Lic. No213. 5.�... .. ....�.-�
GAS INSPECTORY _
Check # -3�( y
6863
u
MASSAMUSEM UNW0RM APPLICA7MN FOR PERNII'I' To DO GAS
(Type or print)G
NORTH ANDOVER, MASSACHUSETTS
Building Loqations
�h� Owner's Name
New Renovation ' /j / Replacement
Date z �►.
Permit # �.
Amount $ 2 �-
Plans Submitted
(PI -Int or type)
Address
Name ofLicensed Plumber'or Gas Fitter
Check -one: ertificate Installing Company
Corp.
ElPartner.
FNR NCE COVERAGE
urrent liability insurance'policy or it's substantialequivalentCheck one:
e checked es please indicate the type coverage by checkin the Yes No❑insurance policy Other type of indemnitynpropriate boxBond13
nsurance Waiver i•am aware that the licensee doesdoes n°�$ve the Insurance coverage required by Ch ter1eral Laws, and that my signature on this permit application waives this requirementap 42 of the
of Owner or Owner's Agent Check one:
1 hereby certify that all of the details and information I have submitted (or entered) in er 1 aAglicationD e
best of my knowledge and that all plumbing work and installations performed under Permit Issued for thare is ie atio
compliance with all pertinent provisions of the Massachus State and accurate to the
Gas Code and Chapter .142 of the General Laws. n will be in
Flay:storeof Licensed Plumber Or Gas Fitter
lumberovvn 1:3 Master Gas Fitter Z
•
' ' ,�umoer
APPROVED coiFicE us> oN�r) [3 Journeyman
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SUB-BASEM ENT
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BASEM ENT
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1ST. FLOOR
12ND. FLOOR
3RD• FLOOR
4TH. FLOOR
5TH. FLOOR
6TH. FLOOR
7TH. FLOOR
BTH. FLOOR
(PI -Int or type)
Address
Name ofLicensed Plumber'or Gas Fitter
Check -one: ertificate Installing Company
Corp.
ElPartner.
FNR NCE COVERAGE
urrent liability insurance'policy or it's substantialequivalentCheck one:
e checked es please indicate the type coverage by checkin the Yes No❑insurance policy Other type of indemnitynpropriate boxBond13
nsurance Waiver i•am aware that the licensee doesdoes n°�$ve the Insurance coverage required by Ch ter1eral Laws, and that my signature on this permit application waives this requirementap 42 of the
of Owner or Owner's Agent Check one:
1 hereby certify that all of the details and information I have submitted (or entered) in er 1 aAglicationD e
best of my knowledge and that all plumbing work and installations performed under Permit Issued for thare is ie atio
compliance with all pertinent provisions of the Massachus State and accurate to the
Gas Code and Chapter .142 of the General Laws. n will be in
Flay:storeof Licensed Plumber Or Gas Fitter
lumberovvn 1:3 Master Gas Fitter Z
•
' ' ,�umoer
APPROVED coiFicE us> oN�r) [3 Journeyman
k,
II
"L ►-Cacrn QJMassachuset&
1fK �-� Department of Industrial Accidents
Investigafions
600 Washinjon Street
02111
w"YKV. J pz=S-, Ov/dia
Workers, Compensation Insurance Affidavit, ij
$wders/Contracfors/Eieci
�ficant Information rrictans/Piumixers
N3IIle (Business/aganizabon/Individual):
Address:
City/State/Zip:
Phone #:
Are you an employer? Check the appropriate box:
-Ell am a employer with 4- ❑ I am a
— =--neral contractor and I
have hired the sub -contractors
listed ata the attached sheet #
These sub -contractors have
workers' comp. insutsttce.
5'
ED It are a corporation and its
officers have exercised.their
right of exemption per MGL
C. 152, § 1(41 and we have no
employees. [No workers'
earn
employees (full and/or part-time).*
2. C] I am a sole proprietor or partner-
shi and have no employees
working for me in any capacity.
[No workers' comp. insurance
required.]
3. ❑ Iam a homeowner doing all work
myself. [No. workers' comp.
insurance required.] t
Type of project (required):
6•. ❑New constr•uctian
7. ❑ RemodeIing
8- ❑ Demolition
9. ❑ Building addition
10 ❑ Electrical repairs or additions
11.❑ Plumbing repairs or additions
Roof repairs
p. Insurance required) 13 ❑ Other
Any appficaet.that checks box # I .most also f"' our the section below showing their workers co
' RomcownerF who sobniit•oris afirdavit indreatirtg &tei, are doir: , lit .v- H . , mpensation poircy mmrmatton.
�Contnactots Ihal c},c1, this box.must attacked an additional sheet showi jl f �'�` hire outside ooniraziuri; mus(suomii a nc,
the nerve of. the sab-e- affidavit indicMM; such.
I am Errs. enrplo}�er MX is providing work-=' car,–,Ve� tractors and their workers' romp. policy information.
4i ormafio2 �r' insfprrcnce for n9' e
mPLOYe-s. Below is the policy andjob site
Insurance Company Name:
Policy # or Self .ins. Lic. #:
Expiration Date:
JobSite. Address.
Attacb a copy of the workers' compensationCity!/statecip:
policy tlecEaration Q
Failure to secure coverage as required under Section 25A of pace (san el the policy number and expiration date)
fine up to $1,500.00 and/or one -Year imprisonment,MGL c. I52 can lead to the imposition of criminal penalties of a
Of up to .5250.00 a da g y as well as civil penalties in the form of a STOP WORK pRDER and a fine
y against i the violator. Be advised that a copy of this statement may be forward --d to the 'Office, of
investigations of the DIA for insiusnct coverage verification.
I do hrrnfn, 1107WAi,
r � aha penattter oJperjur3� that the informafion provided above is true and correct
Official use onip. Do not write in this area, to be corrrpleted'bl' city or town offeci¢(
City or Town:
Issuing Authority Permitll,icense #
Issuing ritJ (circle one):
1. Board of Healtb 2. Building Department 3. CitylTowc6. Other Clerk 4. Electri�l Inspector r S. Plumbiao
b Inspector
Contact Person:
Phone fi:
iuivi marLivu cXJLI l MSL UMURS
Massachusetts General.Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute; an employee is defined. as ".. :ver -y person in the service of another under any contract of h ire,
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 inclutiiYrg the legal representatives of. a deceased employer, or the
receiver or trustee of an individual, partnership, associate on or other legal entity, employing employees. However the
owner of a dwelling house.having not more than .three ap, arre
tments and who sides therein, or the occupant of the
dwelling house of another who employs persons to do m21im,-nance, 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 o r local licensing agency shall withhold the issuance or
renewal of a license or permit to operate s business or- to construct buildings
in the commonwealth for any
applicant who has not produced acceptable evidence of compiiance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7) states "Neither -tire commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public worts until acceptable evidence_ of compliance with the insmmce
requirements of -this chapter have been presented to the c< rTftra.eting
authority.",
Applicants
Please fill out the workers' compensation affidavit com?Vetely, by checking the boxes that apply to yore situation and, if
necessary, supply sub-c6nt wtor(s) naim(s),. address(es) and phone number(s) along with their certificates) of
insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the
members or. partners, are not required to caary.workers' compensation insurance. rf an LLC or LLP does have ..
employees, a policy is required_ Be advised that this affic$a.vit maybe submitted to the Departrnent of. Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the. affidavit. Theafiidavitsbouid
be returned to the city or town that the application for the 'Permit or license is being requested, not the Department of
Industrial Ac=cidents, Should you.have any questions M-raLrdirg ilte-law or if you are mquir„d to obtain a workers'
.compensation policy, please call the Department at the ntL bcr:lis+.ed belovr. Self insured companies should enter their
self=insurance license number on the appropriate line.
Cite or Town Oiucials
P}ease be sun a fat the aft rdavit .is complete and printed }eartily, The Department has provided a space at the bottom
of the affidavit foryou to fill out in the event the Office of- nvestigations has to contact you regarding the applicant
Please be sure to fill in the permiMicense number which will be used as a reference number. In addition, an applicant
that must submit multiple permitliicense applications in arty given year, need only submit one affidavit indicatinge current
poiicy information (if necessary) and under "Job Site Address" the applicant should write "all locations in d (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 Iicenses. A new affidavit must be filled out each
year. VA= a home owne=r or chit -n is obtaining a Iicens� or p•not related to any business or commercial venture
(i.e. a. dog license or permit to burnleaves etc.) said perrson 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 far, numbs:
The Commonwealth of Massachusetts
Department of Lmdtstrial Accidsnts
Qffice of Eavestigatitons
600 WaShLington Street
Boston; MA G21 I I
TeL 4 617-727-4900 ea_ -t 406 or 1-877 MASSAFE
Revised 5-26=05 Pax 4 61 7-72.7-7749
�1.mass.gOV/dFa