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HomeMy WebLinkAboutMiscellaneous - 37 MILLPOND 4/30/2018N J �_ � � D� r v O Q O O Date ..... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that..1.)) 1\'V4rA .... . .............................................................. ................................ has permission for gas installa *on fiV-e.f..lftc-cL ............................ tA... ............... inthe buildings of ..............I.....!........ . .................................................................... at ......... a.. -I .......... H,Yk .... 191.-ry.j .......................... . North Andover, Mass. Fee..3).�-o ...... Lic. No. (..6.711pl.......................................................................... P40* 41(y,"") GAS INSPECTOR Check # MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY MA DATE ��� PERMIT #I Iyl� v JOBSITE ADD --� RESS �� _ OWNER S NAME GOWNER ADDRESS ,� �z )ti_ _ TEFAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ® RESIDENTIAL ®� PRINT CLEARLY NEW: RENOVATION: 0 REPLACEMENT: PLANS SUBMITTED: YES 0 NOF APPLIANCES Z FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER -- - =- --- --- --- COOK STOVE DIRECT VENT HEATER ...- _.... DRYER FIREPLACE FRYOLATOR FURNACE GENERATORi GRILLE_- INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER 1 ROOM/ SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER - INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES JE] NO 0 i IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE NECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY 0 BOND Cil OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER Q AGENT SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate the best y knowledge and that all plumbing work and installations performed under the permit issued for this application will be in co plianc76t IIPe ent p vision of Massachusetts State Plumbing Code and Chapter 142 of the General Laws. SFITTER NAME ft°lJ. '1 LICENSE# Ac'7� _� ATURE PLU7MGF MP JP JGF LPG] © COR-P�O—RATION ©# PARTNERSHIP ©# LLC E]#L� COMPANY NAME:L -- --II ADDRESS — ----�► — CITY�/9yti_ _ STATE MZIP3TEL FAX I CELL—, — i EMAIL N: w . O z 0 u U a w O❑ z O N ❑ w �- F- W WF--( z w � � � a W 5 a P4 > w W w C a a a r� U J H 0 - IL a c� ` S w F- LL 9 w N 0 z 0 H U W a L�7 C�7 1'M.. f. The Commonwealth of Massachusetts . F Department of IndustrialAccidents n.`• `''�^., r 1 Congress Sheet, Suite 100 . _ Boston, MA. 02114-2017 • ; � www.mass.gov/dia G,M SV�v`9 Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/3'lum ers. TO BE FILED WITH THE PERMITTING AUTAORIT Y• Please Print ] A ' licantlnrorma�xuu Name (Business/Oigauization/Individual): r Address: City/State/Zip: �J�///�( , WVPhone #: Are you an employer? Check the appropriate box: l.n I m a employer with employees (frill and/or part-time).* 2.I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3.E] I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contrac,ors either have workers' compensation insurance or are sole proprietors with no employees. 5. ❑I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance 6.FJ We are a corporation and its, oflicdrs have exercised their right of exemption per MGL c. 152 §1(4) and `we have no employees. [No workers' comp. insurance required.] Type of project (vecluired); 7.❑ Nevi'construction 8. n Remodeling 9. ❑ Demolition 10 [] Building addition 11.❑ Electrical repavrs or additions 12TE j.plumbing repairs or additions 13•. 0 Ro6f repairs 14.[] Other *Any applicant that checks box #i 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 liox must attached an additional sheet showing the name of the sub -contractors and state whether or not those,entities have employees. I£the sub -contractors have employees, they must provide their workers' comp. policy number. lam 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. Lic. #: Expiration Date:. ( I,G J City/State/Zip- Job Site Address: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fuie 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 ay be forwarded to the Office of Investigations of the DIA for insurance day against the violator. A copy of this statement m coverage verification. Ido liereby certify under the pal andpe lties ofperjury that the information provided above is true and correct. Date: Signature: U /j'i/��/ j/- 7Jl�nna ii• \ V �. l� J V Official use only. Do not write in tins area, to be completed by city or town official. City or Towyn: Permit/License # Issuing Authority (circle one): i 1. Board of Health 2_ Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. other Phone #: Contact Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for theiremployea. es. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hi'r`e, 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 6fan 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 applicantmho-has not produced -acceptable evidence of compliance with the insurance coverage requi'red." 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 numbers) 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 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 IndustrialAccidents. Should you have any questions regarding the law or if you are required to obtain aw"&kers' 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 thai 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��nns 'n (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 bum leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617.727-7749 Revised 02-23-15 wwwmass.gov/dia TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ............... Jja / . ..................... .............................. has permission to perform ....................... ....... wiring in the building of ............. ........... ...... .......................................... ..... . at ......... 37�ft.�... North Andover, Mass. c. No... ............... Fee .... Li . ..... Check A R -IC, -AL- -IN--SP--E-C�R 9*1 73 ommon.weaGth pp // of D .%i/1t?Va�9achu�/¢� Official Use Only (.� - - Permit No. .,LJ¢Pa�i`men.f o�.}ire �ervice� Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULA T IONS [Rev. I/07] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massae".usetts Electrical Code (MEC); 527 CMR 12.00 (PLEASE PRRIIT IN INK OR TY E AL NFORMATION) Date: I 1 U . City or Town of: / To the Inspector of Wires: By this application the undersigned gives notice of his or her intention),o-perform the electrical work described below. Location (Street & Num r U,- Owner or Tenant Telephone No. (�5.� Owner's Address Is this permit in conjunction with a building permit: Yes ❑ No (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters ,t-VeJh _ , !—I ,,.,dgr (-1 Nc of^deters New Service Amps i 'roils vvc.,,2au u �....;;_.� u . _ Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: t,n S a `r -eau rl q3 -r -o % Completion o the following table may be waived by the Inspector o bftires. 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 Swimmin Pool Above ❑ In ❑ g grnd. grind. o. o Emergency ig ttng 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 Heat Pum Totals Number Tons .KW No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW L Conn cption her No. of Dryers Heating Appliances IOW `iecurity Systems: of r quiva.ent No. of Water Heaters KW No. of No. of Signs Ballasts Data Wirin No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications No. of Devices or Equivalent (OTHER: iCl ���� Attach adciitionol detail if desired, or as required by the Inspector of Hires. Estimated Value o Electrical Work: a (When required by municipal policy.) Work to Start: inspectons 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 coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE X BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the in_(ormation on this application is trite and complete. 15 FiRM NAME: T (31tCter 1 _ LIC. NO.: Licensee: ) Signature / 7h Q a c±�......, �� LIC. NO.: (Ifapplicable, enter "esenl(t i the � t r b l�ae.j� 1//�, G Bus. Te:. No.:6_70J Address r L�3 lob f�/r! �� Alt. Tel. No.: *Per M.G.L. c. 147, s. -;7-61, security work requires Department of Public Safety "S" License: L.ic. No. SSC('_ l9/ 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, 1 hereby waive this requirement. i am the (check one) ❑ owner ❑ owner�,L2ent. Own e. int Signaturiture Telephone No. . A—M Department of P blic Safety One Ashburton Place, Rm 1301 Boston, Ma 02108-1618 License: Certificate of Clearance Number: SS CC 001975 Expires: 10/09/2011 Restricted To: 00 KENNY WONG 18 CLINTON DR HOLLIS, NH 03049 'S•CA1 0 40M-08108•DBSLIFORMCA108212008 /ce '(�arnmaiuuea.�tiz a�✓i%a�c�iucatlta + 0EPAkTME147 OF POBLIG SAFt i Certificate of Clearance Number: SS CC 001975 Expires: 10/09/2011 Tr. no: 558.0 S -License: ADT SLCURITY KENNY WONG 18 CLINTON DR HOLLIS, NH 03049 COhq4IOl41t1l;:ALTH O; MAS:;ACHU-SE t t -` -LEC' IA REGISTERED SYSTEM TECHNICIAN IS: J.b 1Ht5 ? 'SE10 . KENNY Q WDNG:: 22 FIELDSTONE DRIVE BURLINGTON MA 01803-42-13 5966 P 07/51/10 284072 p.ac~ c Tr. no: 558.0 Keep,top for receipt and change of address notification. DIG SAFE CALL CENTER: (888) 344-7233 1-- n � a