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Home My WebLink AboutMiscellaneous - 34 CIDERPRESS WAY 4/30/2018fb 3 Date ..� _ 3v - /Z TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ....... .............. ...................... C�ytDv cJ1vr� has permission to perform .......... ....... ............. . wiring in the buildi of .�'� '.� ... ! «. ( ........ . 3U Cy�D�c1�F �- � �� t • • • ! • • • • ...... • • • . .... ,VortAndover, Nlss. Fee .?`...... Lic. No. �....., ....... ..:�h ` r` * . ELECTRICAL INSPECTOR Check # ' i Ii J 3 2 N Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. 1 / L).5- Z - Occupancy and Fee Checked [Rev. 1/071 leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: �d ?ja `/ (-L-- 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 Lf Owner or Tenant /''`,FAL 1 .✓ iT N, c> SC l Owner's Address 11.1-, C -,k --t 0v� V- 1 Is this permit in conjunction with a building permit? Yes Telephone No. i-4� 7 -Z.46 3S- -,- c7J C k- A A1,e4 No ❑ (Check Appropriate Box) Purpose of Building •4't Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ New Service Amps / Volts Overhead ❑ Undgrd ❑ Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Wc„ te: cz , -o No. of Meters No. of Meters Completion of the followin table maybe waived by the Ins ector of Wires. No. of Recessed Luminaires No. of Ceil: 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- Elo. rnd. rnd. o mergency Lighting 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 Initiating Devices No. of Ranges g No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers p Heat Pump Totals: � Number Tons KW ......... No. of Self -Contained iDetection/Alerting Devices No. of Dishwashers S ace/Area Heating KW P g Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Sectio. oyf Devic s or Equivalent No. of Water Heaters KW No. of No. of Signs Ballasts Data Wiring: No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications No. of Devices or Equivalent OTHER: JD Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value or Electrical Work: (l ®. (When required by municipal policy.) Work to Start: 1. 'L� Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: 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 cove age is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) I certify, under thepains andpenalties ofperjury, that the information on this application is true and complete. FIRM NAME: _ 6-k,L M SEG c LIC. NO.: �L Licensee:ignature LIC. NO.: �27 kph (If applicable ent "exempt in the licen�g number line.) Bus. Tel. No.: �A3 ��Z-%79 y Address: Uw 5 60 ." f �� -• ti 1�-� Alt. Tel. No.: 1: ? 7,S 0g� Z— *Per M.G.L c. 147, s. 57-61, sec rity 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. • ��►�+�LT��j�j.(A��-{(,��'.f•��]+('jf3��'(�y��'�i'®,P•��{,ya{{'Tv/'�p`Q�{� ,�i�'��T�'�?�7[: �ssec�• rgveaq I e-ulspeetioz� ec�uzxet ($�O.OU) � j . �ns,�ectoxs' c 7mxnte�u �� . • (Xnspectaxstizgaaiuxe�xtouiiiaTs) Slate .6/. A!-L'IL3.R-I.fLl�i i=tCil��1Yf �.'asse$•- • T`ailec�--(� � �te�nspectionxequixec� ($0.00)-• j � . �'n5�iectox-s' c4 enfs; (Irispectaxs' uzgnafuze • no ztiaTs} date 3, tTMNRGROM mgRX( TION.- �'assed�-j' � �'azIec�--[ � 7�2e�isls�eetzo�aeguirec�(�50.Q0)�j ] i'ns.pectozs, comments: (.tn.s�ectoxs�Signatuxe•-�o?nifiaTsj ]ate . � ' Rr + CAL L8f -0 NAT+ON's 0101:10: H'AME; . Esser --[ ailet3• j Pe-bspeedon required ($50.00)- j - s�iecto�rs9 eo�nm.ep�fs; (�Cuspectoxs',�iguatuz'e��aoznitiais} date seaf•-- jailer- j ]. Renspectioxtretuixea� ($50.00} - j - ?P,doxal comments; ' s ' fsp ectoJrs'zguatuxe xto xnifia7s} date • 0 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations kv 600 Washington Street Boston, MA 02111 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: 3 tP`u-S'S��-G City/State/Zip: D?il Phone #:_ 9; -?'s 7 5`0 &,6 Are plan employer? Check the appropriate box: Type of e*6ct (required): 1. (� I am a employer with �� 4. ❑ I am a general contractor and I 6. Tew construction employees (full and/or part -tune).* have hired the sub -contractors 2. El am a sole proprietor or partner- listed on the attached sheet, # ❑Remodeling ship and'have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. E]Building addition [No workers' comp. insurance 5. ElWe are a corporation and its 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.[i Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. T Homeowners who submit this affidavit indicating they aie doing all work and then hire outside contractors must submit anew 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 am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. J CV�_ t_ arS . Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: G- / Eh 5 w City/State/Zip: alb,- Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Ol� Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certlo(under the pains and penalties of perjury that the information provided above is true and correct. Phone #:Z�-- Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # � 1 -37-1 1 1 'Z.—_ 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 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 -contractors) 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 TeX. # 617-727-4900 ext; 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass,govldza Date .. ... Il. �..I.... . i1 TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ... '.....�r':.. �� .... ................. . has permission for gd`s �'nsta at'on 1`�!P. /�'�..��n--.......... . in the buildings of . i..I.. ?.. .`........V.V\P at .. 0 t AD P.SS .......... North Andover, Mass. Fee. .... Lic. No. IG! 5.7 .... C` D ...................... GAS INSPECTOR Check # 19 3 Zr 93,10 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY _ MA DATE PERMIT # JOBSITE ADDRESS OWNER'S NAME F GOWNER ADDRESS TE _ _ _ FAX TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL CLEARLY NEW: "' RENOVATION: EJ] REPLACEMENT: ® PLANS SUBMITTED: YESF—] NO APPLIANCES 7 FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER ( I ( 1 ! I BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE T FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT _._ T—_ I_ .. -- f OVEN :- _._..-�. --_ POOL HEATER ( 1 ROOM /SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER I r -TJ I INSURANCE COVERAGE MOL. Ch.142 YES eNNOD 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of 1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Ball", OTHER TYPE INDEMNITY E] 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 E] AGENT SIGNATURE OF OWNER OR AGENT 1 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 e Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME LICENSE # / ` -3- _ SIGNATURE - -i _C.,__ MPMGF JP EjJ JGF Q LPGI Fj CORPORATION Q# [= PARTNERSHIP 0# LLC [3# COMPANY NAME: &-___.-.-_ - .______..__.-. -__--- -----.___...__I ADDRESS CITY �%l/r _ r._.I STATE ZIP - TEL FAX ]J CELL !IEMAIL _ The Commonwealth of Massachusetts Department of IndustriqlAccidints 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/OrganizatiorAndividual): (� l Address:— City/State/Zip: ddress:City/State/Zip: �c� 0 % Phone #: 5 - 1 Are you an employer? Check the appropriate box: 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 2. ❑ I am a sole proprietor or partner- listed on the attached sheet ship and'have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11. ❑ Plumbing repairs or additions 12. ❑ Roof repairs 13.❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. T Homeowners who submit this affidavit indicating they aie 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 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: 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 requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one=year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certto under the pains and penalties of perjury that the information provided above is true and correct. 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 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 -contractors) 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 permittlicense number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)" A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to 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, # 61.7-727-4900 ext 406 or 1-877:M.ASSAFE Revised 5-26-05 Fax # 61.7-727-7749 vvw.miass,gov1dia Date . 'O/.3 /� :. ` _ 9563 MORTM TOWN OF NORTH ANDOVER Oen„'D '•1b0 o PERMIT FOR PLUMBING * , r +O+•r,° �^�4� {fes^/ ,SSACNUS ��.CT 1 � � 1 1 This certifies that .... W .. ,-,Q ... ........................ . has permission to perform p r.....!.....-....... .......... . plumbin in thebuildingsof ..�� P? .'� �'! r. �Ac,�,l I at ...... .......... North Andover, Mass. Fee?-�(P.-.` Lic. No.65 1. ......................... 2 PLUMBING INSPECTOR Check w 19 JL DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR /AREA DRAIN INTERCEPTOR (INTEF KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER I I INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES ['NNO DI IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Er OTHER TYPE OF INDEMNITY Q 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 0 AGENT 10 SIGNATURE OF OWNER OR AGENT I 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 complia�allt prov' je h4assachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME__ _ _ ?LICENSE # . SIGNATURE mpg, JP D CORPORATION 0# _ r PARTNERSHIP_(# LLC # F— „. COMPANY NAMEW ; ADDRESS L 56 CITY _ _STATE ZIP Q �Q �_ TEL FAX �_ _—� CELL �— EMAIL MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY L_ M_ .__ Jr� _ _� MA DAPERMIT # - JOBSITE ADDRESS ('� OWNER'S NAME MdG __yam_ fC, P OWNER ADDRESS 11 TEL _ FAX TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL PRINT CLEARLY NEW: _.RENOVATION: El REPLACEMENT: O PLANS SUBMITTED: YES 0 NO FIXTURES'l FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE m,•_„_I -_TM_I I. _.._.._I. -...._ ...._,_....i D _...__..__! __.___.� ._..__,.,I .____,I ._. . ( �� I _ I i DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM I 1 _ i _J11- _ ___.I ___..� i _ __,__ __.,__1 .__ _1 .____I .___...__I _E —11 —J DEDICATED GREASE SYSTEM 1 ....___..I �. I _i ___..._.1 .._.._.._...( I .._____..._I i 1 _..._._..I ( I DEDICATED GRAY WATER SYSTEM I __ ___I DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR /AREA DRAIN INTERCEPTOR (INTEF KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER I I INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES ['NNO DI IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY Er OTHER TYPE OF INDEMNITY Q 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 0 AGENT 10 SIGNATURE OF OWNER OR AGENT I 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 complia�allt prov' je h4assachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME__ _ _ ?LICENSE # . SIGNATURE mpg, JP D CORPORATION 0# _ r PARTNERSHIP_(# LLC # F— „. COMPANY NAMEW ; ADDRESS L 56 CITY _ _STATE ZIP Q �Q �_ TEL FAX �_ _—� CELL �— EMAIL z ❑, z W Lij LU The Commonwealth of Massachusetts Department of Industrial Accidents Office of Invesdgations 600 Washington Street Boston, MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/PIumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: C�_ City/State/Zip: 1% ! nDi�vh p 3 Phone #: G'3 — C13 — /3 S Are you an employer? Check the appropriate box: 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 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. t ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other `Any applicant that checks box 41 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. ram an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site reformation. nsurance Company Name: 'olicy # or Self -ins. Lic. #: ob Site Address Expiration Date: City/State/Zip: attach 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 C 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 tinder the pains and penalties of perjury that the information provided above is trice and correct. mature: Date - 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 pennit/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 I.ndustrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-7274900 ext 406 or 1-877-MASSAFE evised 5-26-05 Fax # 617-727-7749 www,mass,gov/dia