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HomeMy WebLinkAboutMiscellaneous - 349 WAVERLY ROAD 4/30/20180 n -1 -// Date.'-P�9� ............. 0 TOWN OF NORTH ANDOVER PERMIT FOR GASANSTALLATION This certifies that . Rwllofl"". ....... has permission for gas installation r;11I12MI1-4. -Y . ;�q: //. r ... in the buildings of elk: .................. a t North Andover, Mass. Fee. �W. Lic. No.. Check# 7936 J LN- GOWNER TYPE OR PRINT CLEARLY MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY MA. DATE' • / PERMITAir # r i JOBSITE ADDRESS (Q OWNER'S NAME f%/P ADDRESS: TEL: 7a�j� FAX: OCCUPANCY TYPE: COMMERCIAL ❑ EDUCATIONAL ❑ oe. NEW: ❑ RENOVATION: ❑ REPLACEMENTS PLANS SUBMITTED: YES ❑ N0jT FIXUTRES 7 FLOOR— Bsmt 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER —ROOM I SPACE HEATER ,;)OF TOP UNIT r EST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch.142 YES 0 NO ❑ If you have checked YES• please indicate the type of coverage by checking the appropriate box below. LIABILITY INSURANCE POLICY ■❑ OTHER TYPE INDEMNITY ❑ 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 ❑ AGENT ElIGNATURE 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. t LICENSE # 7-173 SIGN '� PLUMBERIGASFITTERNRME: MICHAEL HOUSE � A URE ` OMPANY NAME: MERRIMACK VALLEY CORPORATION ADDRESS: lj§ AEGEAN DRIVE, UNIT #3 CITY: I METHUEN STATE: MA ZIP: Loiw. FAX: 978 689-2206 TEL: 978-689-8312 CELL: 9707884-3427,_ , _ EMAIL: LLITTLE MVALLEYCORP.COM MASTER ❑■ JOURNEYMAN ■❑ LP INSTALLER ❑ CORPORATION N # Jam% PARTNERSHIP ❑ #= LLC ❑ # J/�o � A J . The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations kv 1 Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers Name (Business/Organization/Individual): Address: I AWMI Are you an employer? Check the appropriate box: 1.0 I am a employer with /��7" 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. employees and have workers' [Noworkers' comp. insurance required -)5.E) comp. incnrance t We are a corporation and its 3. ❑ I am a homeowner doing all work officers have exercised their myself. [No workers' comp. right of exemption per MGL insurance required.] t c. 152, § 1(4), andwe have no employees. [No workers' Type of project (required): 6. ❑ New construction 7.0 Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions ME] Plumbing repairs or additions 12.❑ Roofre� s �13.XOther C' " 43s erJ, *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy infomoation. I 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 state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. .1 am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. ` J -- / _ I l- J Insurance Company Name: Policy # Expiration Date: t,14' Job Site Address: ' ��/��� ��% - -� City/State/Zip:,/V, Ji/JK tl 1 411 el Vlt 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 ORJ5ER 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_ Official use only. Do not write in this area, to be completed by city or town officiaL City or Town: Issuing Authority (circle one): g.' Board of Health 2. Building Department 6. Other 3. City/Town Clerk' 4. Electrical Inspector 5. Plumbing Inspector Contact Person: Phone #: Date. . // ... 92'15 /b/b/ TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ............ has permission to perform �,!% . ............ plumbing in the buildings of at. r, Mass. Fe&30.. Lie. No.. Check # V �14 r ' �C—\ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK .. CITY MA. DATE /2'�i PERMIT # JOBSITE ADDRESS P OWNER'S NAME LYj� P OWNERADDRESS:j— TEL: TYPE OR PRINT OCCUPANCY TYPE: COMMERCIAL EDUCATIONAL E:1RESIDENTIALX CLEARLY NEW: ❑ RENOVATION: ❑ REPLACEMENTS PLANS SUBMITTED: YES ❑ NO j FIXUTRES Z FLOORS— Bsmt 1 2 3 1 4 1 5 6 1 7 8 9 10. 11 12 13 1 14 BATHTUB CROSS CONN DEVICE DEDICATED SPECIAL WASTE SYS DEDICATED GAS/OIL/SAND SYS DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYS DEDICATED WATER REUSE SYS DISHWASHER DRINKING FOUNTAIN FOOD WASTE GRINDER UNIT FLOOR /AREA DRAIN INTERCEPTOR INTERIOR KITCHEN SINK LAVATORY ROOF DRAIN -SHOWER STALL ERVICE / MOP SINK OILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES IN NO ❑ If you have checked YES, please indicate the type of coverage by checking the appropriate box below. LIABILITY INSURANCE POLICY 0 OTHER TYPE INDEMNITY ❑ 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 [I 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 true and accurate to the best my of Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in co I' 'th all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER NAME: MICHAEL HOUSE LICENSE # 7173 SIGNATURE MPANY NAME:MERRIMACK VALLEY CORPORATION ADDRESS: '15 AEGEAN DRIVE, UNIT 3 CITY: METHUEN STATE: MA ZIP: 01844 --I FAX: 978 689-2206 TEL: 978-689-0224 CELL:978 884-3427 EMAIL: LLITTLE@MVALLEYCORP.COM MASTER ❑Q JOURNEYMAN CORPORATION ■❑ # PARTNERSHIP El# [=LLC E]# 7 or it I r . COMMONWEALTH OF MASSACHUSETTS ~ -f LICENSED AS A MASTER PLUMBER ISSUES THIS LICENSE TO MICHAEL H HORSE 63 MARSH LN T5 R9 TWPn EBEEmEE: TWP.. _ ME -04414-;613- 7173 05/01/12 763715 L -d 6LL2996LOZ esn0H 8VN dgL:£0 LL EL deS " 9992 Date ....... TOWN OF NORTH ANDOVER PERMIT FOR WIRING —4- . De�o g This certifies that ............. J. P*4. ........ 10 ............ has permission to perform ... 2'r25 wiring in the building of ........ ......................................... at .... ........ 1.el ..................... . North Andovei, Mass. Fee ... . .... Lic. No.1 ........... j a,.,: f, V�� - X4, r�,; ........... E Eemi AL INSPEe��R Check # 7cTl 2012 Massachusetts Electrical Code Amendments 527 CMR12.00 § Rule 8: in accordaucewith the provisions of M.G.L. c. 143, §. 3L, the permit application form to provide notice of installation of wiring sh . all 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 U CTJ, c. 166, § 32, an electrical permit shall be issued to the person, ffi�n 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 shalLbe limited as to the time of ongoing construction activity, and maybe�deemed-by-theJnspector-of-Wires abandoned.and-invalidme— or she has detem-iined 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. El The Permit Extension Act was created by S ection. 173 of CjiaMt r 240 of th,e Acts of 2010 and extended by S eations.74 and 75 of Chapter 2-3 8 of the Acts of 2012. The purpose of this act is to promote7jobi'growth dad long-term economic recovery and the Permit Extension Act finthers 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 quialifying Tiod beginning on August 15,2008.and extendinjEfthrough August 15,2012. 8 — PermitfRate Closed: /X//i— Z4-z *** Note:)Reapply for new permU 0 Permit Extension Act — Permit[Date Closed: L "Commonwealth of Massachusetts Department of Fire Services „ BOARD OF FIRE PREVENTION REGULATIONS Permit No. Official Use Only Occupancy and Fee Checked [Rev. 1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code NEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date:- City ate:_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) ->q Owner or Tenant Owner's Address L —p Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building tavF t� Utility Authorization No. Existing Service J `J Amps /Jr / s-4) Volts Overhead ® Und rd g ❑ No. of Meters New Service Amps / Volts Overhead ❑ Und rd g ❑ No. of Meters Number of Feeders and Ampacity Location /and Nature of Proposed Electrical Work: (-) (n.J � 1 �' i h'� S('e.<) No. of Recessed Luminaires No. of Luminaire Outlets I/ No. of Luminaires No, of Receptacle Outlets No. of Switches No. of Ranges No. of Waste Disposers No. of Dishwashers No. of Dryers ivo. of Water II f Heaters [No. Hydromassage Bathtubs OTHER: No. of Cell: Susp. (Paddle); Fans No. of Hot Tubs Swimming Pool Above ❑ In- -- 2rnd grad 0 No. of Oil Burners No. of Gas Burners No. of Air Cond. Total- Space/Area Heating KW Heating Appliances KW No. of No. of Signs Ballasts No. of Motors Total HP table may be waived by the Inspector of Wires No. of Total Transformers KVA Generators KVA ALARMS JNo. of Zones of Alerting Devices o. :al ❑ inumcipat El other Connection :urrty Systems:* No. of Devices or Equivalent to Wiring: ` No. of Devices or Equivalent ecommumcations Wiring: No. of Devices or Eauivatent Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: () (When required by municipal policy.) Work to start: ' 0_.23-11 Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCECOVERAGE: 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: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify, cinder the pains and penalties of perjury, that the information on tl:is application is true and complete. FIRM NAME: l C, b-( . v t t< LTC. NO.: %L Licensee:�v�� ��+(� Signatur (If applicable, enter "exempt 'in the li e e nuger line.) LIC. NO.C-:�p3 � S Address: ` `fi 01 --� Bus. Tel. No., *Per M.G.L c. 147, s. 57-61, security, ecuri work re wires „ „ Alt. Tel. No.:, ' ` 7 �)� r of �3 h' q partment of Public Safety S License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware t at 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 —0 owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE. $ ELECTRICAL PERMIT NO. INSPECTION REPORT:' ELECTRICAL INSPECTOR - DOUG SMALL 3. UNDERGROUND INSPECTION: Passed — [ ] Failed [ Inspectors' comments: kj-u�kGuwrb- oignature -no ii f INSPECTION — SERVICE: ATE CALLED NATIONAL GRID:ssed — [ j Failed — [spectors' comments: o.0 L inspectors' comments: fallen — Date NAME: no initials) Date -no ection required ($50.00) - Date DOOR TAGS ARE TO BE FILLED OUT AND LEFT ONSITE I�++' TOE AREA TO BE INSPECTED IS NOT ACCESSIBLE AND A RE -INSPECTION OF $50.00 IS TO BE CHARGED. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, AM 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organizationdndividual):) �fj U �� , , ILI, '7, L - Address: City/State/Zip: e;, i Phone #: 7t%-7vt,--Ut 3 Type of project (required): 6. 4 New construction 7. El Remodeling 8. El Demolition 9. E] Building addition 10-ElElectricalrepairs or additions 11.❑ Plumbing repairs or additions 12.0 Roof repairs 13. ❑ Other e ow s owing 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, tContractors 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 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. I do hereby certify under the pains and penalties ofperjury 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: Issuing Authority (circle one): 1. Board of Health 2. Building Department 6. Other Permit/License # 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector Contact Person: Phone #: Are you an employer? Check the appropriate box: L ❑ I am a employer with 4. El am a general contractor and I employees (full and/or part-time).* 2.V I am a sole have hired the sub -contractors listed proprietor or partner- on the attached sh%et. 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.] 3. ❑ 1 am a homeowner doing all work officers have exercised their 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 iequired.] *Any applicant that checks box #I must also fill out the section bel h Type of project (required): 6. 4 New construction 7. El Remodeling 8. El Demolition 9. E] Building addition 10-ElElectricalrepairs or additions 11.❑ Plumbing repairs or additions 12.0 Roof repairs 13. ❑ Other e ow s owing 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, tContractors 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 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. I do hereby certify under the pains and penalties ofperjury 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: Issuing Authority (circle one): 1. Board of Health 2. Building Department 6. Other Permit/License # 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 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 -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 Tel. # 617-727-4900 ext 406 or 1-877-NIASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia Ad Date. 88'/ 8 TOWN OF NORTH AND6VER dL 0 PERMIT FOR e�ZMBING SACHUS This certifies that ............................ has permission to perform ........... plumbing in the buildinis of ./7,0(y t ................... at. ."-If ...... h Andover, Mass. YP Fee. Lic. No.) ........ ....... PLUMBING INSPECtOR Check 'Y 2 Tr MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING City/Town:-1,),v`���� , MA. Date:Perm it# _ Building Location: t � ,Owners Name: Type of Occupancy: C ypommercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential M New: Kj Alteration: ❑ Renovation: ❑ Replacement: ❑ Plans Submitted Yes ❑ No ❑ FIXTURES DEDICATED w z SYSTEMS r. z w Y v D z Ln o h a z z_ H Y a N U r-- owe Z Z Q W 2 W Z F, N Z W W H 2 y to NLn Q H Z C Q Z W Z O a LL S J Q 3Q ClU. W W U H' H C p F' U C7 Q a Z Z N F- F- W O Q �W" 1' _ C3 H W NQ a m m o o LL °s� 3 3 3 o a SUB BSMT. BASEMENT 1sT FLOOR 2ND FLOOR 3RD FLOOR 4T" FLOOR ST" FLOOR 6T" FLOOR 7T" FLOOR 8T" FLOOR Installing Company Name: Y _ Check One Only Certificate # I)An��^ Corporation Address:A 4t City/Town: State: ❑ Partnership Business Tel:ug ` I 4 I Fax: ❑ Firm/Company Name of Licensed Plumber: INSURANCE COVERAGE: I have 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 of coverage by checking the appropriate box below. A liability insurance policy v� 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 Massachusetts General Laws, and that my signature on this permit application waives this requirement. Check One Only Signature of Owner or Owner's Agent Owner E] Agent E] I hereby certify that all of the details and information 1 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. By Type of License: 4Siga4UiCe Title ®, Plumber Plu ber ®, Master Cit APPROVED APPROVED (OFFICE USE ONLY) ❑Journeyman License Number: /0N The Commonwealth of Massachusetts r Department oflndustrial Accidents g i Ii Office of Investigations listed on the attached sheet. # 600 Washington Street These sub -contractors have Boston, MA 02111 r ,,'" www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please PrinfLegibly Name (Business/Organization/Individual): I \ Y_ Address: City/State/Zip: Phone ##: US 151L • l Are you an employer? Check the appropriate box: L ❑ I am a employer with 4. ❑ I am a general contractor and I einployees (full and/or part-time).* have hired the sub -contractors 2. ❑ I aim 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 ain a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] 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 1119 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 Homeowner's 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 acid 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 N Policy # or Self -ins. Lie. #: 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 maybe forwarded to the Office of Investigations of the DIA for insurance' coverage verification. I do hereby cert* under the pains andpenaldes ofpeijury 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 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 numbers) 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 cant' 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. AIso be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the pen -nit 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 pen-nit/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 pen -nit 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 Tnvestiptions 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-1VIASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia a IMPORTANT NOTICE PERMITS FOR PLUMBING AND GAS FITTING INSTALLATIONS ON STATE OWNED OR USED FACILITIES MUST BE FILED AT THE OFFICE OF THE STATE BOARD.