HomeMy WebLinkAboutMiscellaneous - 37 GROSVENOR AVENUE 4/30/2018 (2)Date.(i`'' .../..�...��... .
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NORTH
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2` WN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
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This certifies that . .. ..... . . • . .� ................. .
has permission for gas installation ..` .. �`S ............
in the buildings of ... Q, exl.q!7... �? ✓. .
at ..�� .. �/Q !��''�� ............ . North Andov`tr, ass.
Fee. 3. LLic. No... d.? Z. ........... .......
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GAS INSPECTOR
Check # U 9 �� Y& d
7245
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MASSACHUSETTS UNWORM APPLICATON FOR PERMIT TO DO GAS FITTING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Building Locations
0 1k*,A Owner's Name
Date
Permit #
r� Amount $
0aci (f-8^G4Us t ✓1
New Renovation ❑ Replacement ❑ Plans Submitted ❑
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SUB-BASEMENT
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BASEMENT
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1ST. FLOOR
2ND. FLOOR
3RD. FLOOR
4TH. F L 0 0 R
-----I---[-
5TH. FLOOR
LOOR6TH.
6 T H .F L 0 0 R
7TH. FLOOR
8.TH. FLOOR
(Print or
Name
Name of Licensed Plumber or Gas Fitter .4-n ^-_ f l „,.t \
Corp.
Certificate Installing Company
Partner.
Firm/Co.
uv-)utcfuN L;t UVvr;xa.Ulr Check 1:3I have a current liability Insurance licy or it's substantial equivalent. Yes No
If you have checked res, please' dicate the type coverage by checking the appropriate box.
Liability insurance policy Other type of indemnity ❑ Bond ❑
Owner's Insurance Waiver: I am aware that the.licensee does not have the Insurance coverage required by Chapter 142 of the
Mass. General Laws, and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's Agent Owner ❑ Agent
1 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 StaWGas Code and Chapter 142 of the General Laws.
Title
City/Town
(OFFICE USE ONLY)
Signature of Licensed Plumber Or Gas Fitter
❑ Plumber _ L,- P %y a �
❑ Gas Fitter License Number
❑ Master
Journeyin
7 14n -
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
-L_, www.mas&gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
a a�.aaG J
Name (Business/Organiza6on/Individual):
Address:
City/State/Zip: Phone #:
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).*
2. ❑ I am a sole
have hired the sub -contractors
listed
proprietor or partner-
on the attached sheet. $
ship and have no employees
These sub -contractors have
working for me in any capacity.
[No workers' comp. insurance
workers' comp. insurance.
5. ❑ We are a corporation and its
required.]
3. ❑ I 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 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
I3.❑ Other
t:"-;, Wort -1 compensation policy i.^.fo ma ion.
t
Homeowners who submit this must attached
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.
I am an employer that is providing workers' compensation insurance for my employees. Below is the police 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 expirationiate).
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 of perjury that the information provided above is true and correct
Signature:
Date.:
Phone #:
F
ial use only. Do not write in this area, to be completed by city or town official
City or Town:
P ermit/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 an d 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 it 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, §25CM 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 nuniber(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..retu-aed to the city or town that the application for the pernait 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
fliq must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
polity information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or
tomV." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would like to -thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call
The Department's address, telephone and fax number.
The Commonwealth. of Massachusetts
Department of Industrial Accidents
Office Gf Investigations
600 Washmgton 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
* MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or Type ,,��^^
. Mass. Date 71119 � Permit # ` l
Building Location 49/ezi Owner's Name GZAW C J/ is les
Type of Occupancy R i=51 (:i^ 11-(1 A i_
New Renovation ❑ Replacement ❑ Plans Submitted: Ye��j No,[]
installing Company Name BAY STATE CCAS (Q ( Pk0PA NF) Check one: Certificate
Address 55 M A RSTOK) ST R3 Corporation CA C�
LA lel R EtJ C - F-_ HA 01841 ❑ Partnership
Business Telephone 5 U R _ <, S ❑ Firm/Co.
Name of Licensed Plumber or Gas Fitter I*��
INSURANC COVERAGE:
have alcusrr t btlity nsou a ce policy or its substantial equivalent which meets the requirements of MGL Ch. 142,
If you have hecked yes, Vease indicate the type coverage by checking the appropriate box.
A liability insurance policy kX Other type of indemnity ElBond El
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by
Chapter 142 of the Mass. General Laws. and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's /gent Owner❑ Agent ❑
1 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 the permit issued for this application will be in compliance with all
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene ws.
gy T e of Lim •/�M ----.- ._.___... _-. ___
Plumber Signature of censelumber or Gas Fitter
Title Gasfitter
Master license Number
Aty/Town . Journeyman
O I
RON
CM
installing Company Name BAY STATE CCAS (Q ( Pk0PA NF) Check one: Certificate
Address 55 M A RSTOK) ST R3 Corporation CA C�
LA lel R EtJ C - F-_ HA 01841 ❑ Partnership
Business Telephone 5 U R _ <, S ❑ Firm/Co.
Name of Licensed Plumber or Gas Fitter I*��
INSURANC COVERAGE:
have alcusrr t btlity nsou a ce policy or its substantial equivalent which meets the requirements of MGL Ch. 142,
If you have hecked yes, Vease indicate the type coverage by checking the appropriate box.
A liability insurance policy kX Other type of indemnity ElBond El
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by
Chapter 142 of the Mass. General Laws. and that my signature on this permit application waives this requirement.
Check one:
Signature of Owner or Owner's /gent Owner❑ Agent ❑
1 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 the permit issued for this application will be in compliance with all
pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the Gene ws.
gy T e of Lim •/�M ----.- ._.___... _-. ___
Plumber Signature of censelumber or Gas Fitter
Title Gasfitter
Master license Number
Aty/Town . Journeyman
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NORTH .TQWN OF NORTH ANDOVER
0�tt a op : PEMIT FOR GAS INSTALLATION
This certifies that.., .. .• ! .. r .. .....�j.
has permissi6ri`for gas installation . � . f . �F:' . ;► c!� -..... .
in the buildings of .. Gtr 11.r. �� U I -t. _ ......... . .
at . ? 7.. �-� !�..'�. Yr t .'�� ... �% :.. , North Andover, Mass.
Fee. .... . Lic.
GAS INSPECTOR,
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: File
_rvoIASSAriHr Type)
(Print a TType) S UNIE:ORM APPLICATION FOR PERMIT TO DO GASFITTING
)
qi NORTH ANDOVER, , Mass. Date
Building /'
Locatlot (�-i 6 �w,�� Permit *—I, 5
Owner's
Name
New p Renovation d Replacement p Plans Submitted: Yes ❑ No p
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81111—ss MT.
SA8E1r1EHT
1ST FLOOR
21410. FLOOR
311D FLOOR
4TH FLOOR
8TH FLOOR
STH FLOOR
?TH FLOOR
STH FLOOR
Check one:
Installing Company Name��o�
Address Q G 5i Q Corp.
El Partnership
O Firm/Co.
Business Telephone ---313 - n' /
Name of Licensed Plumber or Gas Fitter
INSURANCE COVERAGE: Check open
have a current IlabMfty Insurance policy or its substantial equivalent. Yes Gr No EI
If you have checked yes, pleaseIndicatethe type coverage by checking the Appropriate box.
A liability Insurance policyQ' ;
Other type o! Indemnity O Bond D
Certificate
OWNER'S INSURANCE WAIVER: I am aware that the licensee dace not have the Insurance coverage required by
Chapter 142 of the Mass. General La*s, and that my signature on this permit appllcatlo aloes this requirement.
Ch one:
nature • wner'
owner or Os en Owner Agent ■
I hereby certify that an 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 an plumbing work and Installations performed under the permtl Issued for this application will be In compliance with all
perlrnent provisions or the Massachusetts Stale Gee Uod nd of
City/Town
APPROVED (OFFICE USE ONLY)
.0 Chapter 142 the Genal Laws.
TVDA of License: -
Plumber gna nse um er or as ter
Gasntter r, _
Master License Number
D Joumeyman 2�d Q 6
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Installing Company Name��o�
Address Q G 5i Q Corp.
El Partnership
O Firm/Co.
Business Telephone ---313 - n' /
Name of Licensed Plumber or Gas Fitter
INSURANCE COVERAGE: Check open
have a current IlabMfty Insurance policy or its substantial equivalent. Yes Gr No EI
If you have checked yes, pleaseIndicatethe type coverage by checking the Appropriate box.
A liability Insurance policyQ' ;
Other type o! Indemnity O Bond D
Certificate
OWNER'S INSURANCE WAIVER: I am aware that the licensee dace not have the Insurance coverage required by
Chapter 142 of the Mass. General La*s, and that my signature on this permit appllcatlo aloes this requirement.
Ch one:
nature • wner'
owner or Os en Owner Agent ■
I hereby certify that an 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 an plumbing work and Installations performed under the permtl Issued for this application will be In compliance with all
perlrnent provisions or the Massachusetts Stale Gee Uod nd of
City/Town
APPROVED (OFFICE USE ONLY)
.0 Chapter 142 the Genal Laws.
TVDA of License: -
Plumber gna nse um er or as ter
Gasntter r, _
Master License Number
D Joumeyman 2�d Q 6
Date... % .............
Eesti TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that(- ;C'-. rr r.. ?. ..... ................... .
has permission for gas installation`.' . !'.7 ..........:.. . . .. . . . . . .
in the buildings of . r -. `. . .
at,� . /.�� . 5.k, ....: r' ... ?.....,
... North Andover, Mass.
Fee .�, . f .. Lic. No.�. ! )..:.. :...................
GASINSPECTOR
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: File