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HomeMy WebLinkAboutMiscellaneous - 37 STONINGTON STREET 4/30/2018 (2)Date. TOWN OF NORTH ANDOVER .PERMIT FOR WIRING This certifies that ... - tc .................. . has permission to perform wi 'ng in the buil ng of .... 0 �, --� • • • • • � ......... .� ............ North Andover, ass. s % = Fee .13.� ... L,ic. No�� i ... ..... ... . ELECTRICAL INSPEC R Check #VJ �_ 0 9 3 3 Conunonuraa[ti l 1/lamac Vlu IULL v .. __j �j c7� Permit No. otJeparimmt ol.jitB S wicad occupancy and Fee Checked BOARD OE FIRE PREVENTION REGULATIONS Fsv: 1/071 eaveblank APPLICATION_ FOR PERMIT TO PERFORM ELECTRIC AL -WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT )7VINK OR TYPE L INFO T 11� Date: City. or. Town of To the Inspector of Wires:' By this application the undersign ves notice of s or her intentio to perform the e ectrical work described below. Location (Street & Number -7S f Owner or Tenant r - Telephone No. Owner's Address Is this permit in conjnncti^on with a buildm permit' Yes No ❑ (Check Appropriate Box) Purpose of Building GA — Utility Authorization No. ? Existing Service Amps / Ovolts Overhead Undgrd ❑ No. of Meters J New Service Amps / Volts Overhead-❑ Undgrd- ❑ No. of Meters Number of Feeders and Ampacity / Location and Nature of Electrical Work: �� I 0.141 fntlnw:ne table maybe warred by the Inspector of Wires 1-1- Attach additional detail ifdesire4 or as required by the Inspector of Wires - Estimated Valu of El cal Work_ LLO-66 (When required by municipal policy.) Work to Start: NECInspections to be requested in accordance with Rule 10, and upon completion. INSURANCE C RAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "compleroed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of " Pe> issuing office. /. CHECK ONE: INSURANCE§ffBOND ❑ OTHER ❑ (Specify:) 1 I certify, under the pains and es of ptajury, that the information on this app ' is true and complete ` FIRM NAME: LIC. NO. - Licensee: Q, Sigiiatare LIC. NO.: _ . Bus. TeL No. LL Q — �0? 13 (If applicable, to mpt1' '� 1, .+?se 't1e� Ait. TeL No.• l ` ��L'S Address: U% *Per M.G.L. c. 147, s. 57-61, securi 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 ar,Tent. Owner/Agent Telephone No. PERMIT FEE S V Signature ' --- No. of CeiL-Susp. (Paddle) Fans o. of Total Transformers KVA No. of Recessed Luminaires No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool ffnd. ❑ _ d. ❑Butte No. o mergency g Units No. of Receptacle Outlets �y No. of Oil Burners FIRE ALARMS No. of Zones o. 01 Imection and No. of Switches I No. of Gas Burners initiatin Devices No. of Ranges No. of Air Cond. Tuns No. of Alerting Devices Heat Number Tons KW No. of Self -Contained Detection/Alertin Devices No. of Waste Disposers S Heating KW Local ❑ Conncecption ❑ Other No. of Dishwashers � ce/Area Pa g No. of Dryers Heating Appliances KW . Systems: eroNontyof Devices or Equivalent No. of WaterNo. ICV of No. o Signs Ballasts Data Wiring: No. of Devices or Equivalent Heaters HP TeleeommumZations Wiringg-.- No. Hydromassage Bathtubs No. of Motors Total No. of Devices orEguivatent nrvt, a. 1-1- Attach additional detail ifdesire4 or as required by the Inspector of Wires - Estimated Valu of El cal Work_ LLO-66 (When required by municipal policy.) Work to Start: NECInspections to be requested in accordance with Rule 10, and upon completion. INSURANCE C RAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "compleroed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of " Pe> issuing office. /. CHECK ONE: INSURANCE§ffBOND ❑ OTHER ❑ (Specify:) 1 I certify, under the pains and es of ptajury, that the information on this app ' is true and complete ` FIRM NAME: LIC. NO. - Licensee: Q, Sigiiatare LIC. NO.: _ . Bus. TeL No. LL Q — �0? 13 (If applicable, to mpt1' '� 1, .+?se 't1e� Ait. TeL No.• l ` ��L'S Address: U% *Per M.G.L. c. 147, s. 57-61, securi 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 ar,Tent. Owner/Agent Telephone No. PERMIT FEE S V Signature ' 'Vb 7::7-7 1 -6, - ()-L Py, d The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations quo 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/Organization/Individual): r\ j CA V .e,4- eil COU K, a63!3City/State/Zip: S C, 4 GLcc)Thone 11: Cl% % 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 maybe 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 Iavestigatlons 600 Washington Street Boston., MA. 021 It Tel. # 617-72.7-4900 ext 406 or 1-877�,MASSAFE Revised 5-26-05 Fax # 617-727-7749 wvvw.znass.govldia Date. (P. 17.%.1x-...... . ° TOWN OF NORTH ANDOVER A PERMIT FOR GAS INSTALLATION This certifies that ..jo � ... 61CAJUr.. ..... ........... . has permission for gas iinst 11 tion Z .: ! rl f . / - 1. I in the buildings of .. `..:.1 :A .............................. at ... NZ,.1 North jA/rid ver, Mass., Fee. Lic. No.. GAS INSPECTOR Check # Z 3-71- 8225 71- 8225 \M-1) MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK a _ CITY I'o&tk MA DATE�� . _. PERMIT# JOBSITE ADDRESS 3---_' — OWNER'S NAME OWNER ADDRESS TE FAX TYPE OR PRINT _ _ OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL E] RESIDENTIAL CLEARLY NEW: [l RENOVATION: D REPLACEMENT: FJ PLANS SUBMITTED: YES F-711 NO R APPLIANCES Z FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER , `: _f 1::J BOOSTER) CONVERSION BURNER COOK STOVE -- _.... DIRECT VENT HEATER DRYER — T FIREPLACE-- FRYOLATOR FURNACE GENERATOR GRILLE ... INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATERI—r1[- WATER HEATER OTHER FY INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES ,910 El 1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY 0 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 Q 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 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. PLUMB ER-GASFITTE R NAME �h . "�jf�►� _ _ _ ( LICENSE # l SIGNATURE MP, MGF JP JGF LPGI(] CORPORATION Q# -- PARTNERSHIP [# LLC #�.-___-11 COMPANY NAME: __DL_�GfyfG�3__ -_.ADDRESS CITY STATE MZIP --f 4 TEL FAX -----_-� CELL EMAIL \M-1) W� W °z z 0 U W a a� d w N � T Z � ❑ W '�r CL ftZ co aW 5 co a �i > z ® w @ o a d a a � U J a too: a � w X: w LL W H °z z O H U W C7 C�7 W °a i;l ' The Commonwealth of Massachusetts Department ofIndustrialAccidents Office of Investigations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le0bly Name (Business/Organization/Individual): �DL S1 U i `c e Address: $Q ",%X City/State/Zip: mp- 0f 6a Phone #: 11S - S~3(, • 7,7s ? Are you an employer? Check the appropriate box: 1.0 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.] r 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 ILEI 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 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 policy and job site information. ) I Insurance Company Name:. /-1 4 f tfQr� � Policy # or Self -ins. Lic. #: Q 9' ,)c- c- 15 6 7 Expiration Date: T V / 12 Job Site Address:? - 39 S H r, ', d!G City/State/Zip:. 0. Aoioy 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. 1 do hereby certify under the pains andpenalties ofperjury that the information provided above is true and correct. Signature: 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 c 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 TeX. # 617-7274900 ext 406 or 1-877:MASSAFF, Revised 5-26-05 Fax # 617-727;7749 wwwinass,gov/dia 9461 Date.�.�.1i2' TOWN OF NORTH ANDOVER ' PERMIT FOR PLUMBING 'SSACMUS� This certifies that ... �� ...'!. G C. Q ........ �• � has permission to perform plumbing in the buildin sof � at .... ..... ..........{. !. `. .` .,� .. /' . , No - Andover, Mass. Fee./2/`V.Lic. No.JIP4!... ��........ PLUMBING INSPECTOR Check # Z37Z'' MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY MA DATE _ PERMIT # ---� • 0�� JOBSITE ADDRESS Sct� OWNER'S NAME P zj OWNER ADDRESS _ TEL —FAXX j TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIALLU PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: Ell PLANS SUBMITTED: YES E( NOR FIXTURES -1 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM __-....__..} DISHWASHER DRINKING FOUNTAIN1 __j ....__.J FOOD DISPOSER FLOOR/ AREA DRAIN INTERCEPTOR (INTERIOR _ I __-___P KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK ( ( .-.__J S .__..._-_ I � _._i 1 -_...___i TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER - --- — INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YESn NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLIC OTHER TYPE OF INDEMNITY E] BOND 0 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 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 c=1*ce h all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME _ _ h _. _ LICENSE # _ l; _ SIGNATURE Mpg JP CORPORATION 0# jPARTNERSHIPP# LLC i COMPANY NAME L € ADDRESS O y CITY�iQ���„�_....__.__.__..___---I STATE � ZIP 01TEL FAX CELLM- EMAIL - or] z r a El U3 CL U3* LU r The Commonwealth of Massachusetts DZ Department of IndustrialAccidints 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/Organization/Individual): Address: City/State/Zip: r ! ' � OPV Phone M c�_Y�-% -M Z`] Are you an employer? Check the appropriate box: J 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. ❑ 1 am a sole proprietor or partner- listed on the attached sheet. I 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 1011 Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 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 are 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:. �( G� C , �r4 Policy # or Self -ins. Lie. #:_ fu'*' 0C, 1 b Ej -)s Expiration Date:_ Job Site Address�� �� �J� City/State/ZipL1�►' �N\� 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. Ido hereby certify under the pains andpenalties ofperjury that the information provided above is true and correct. Signature: 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 , z 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 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 of Investigations 600 Washington Street Boston} MA. 021 1 1, , Tel, # 617-72.74900 ext 406 or I-877rMASS.A.FB Revised 5-26-05 Fax ## 617-727-7749 w .mass,govldia GBO Peabody 96 Foster Street 978-532-3796 Peabody, MA 01960 June 24, 2012 18:05:51 OT:12573 1 / 0 *************** * Pick Ticket *************** PAGE 1 OF 2 Sold To Ship To SPECIAL ORDER CASH pam cahill 978 886 0117 39 stonington st n andover, ma Shipment #: 1 ACCOUNT# --------- CUST ------------------ PO# -------------------- TERMS ORDER# ORDER DATE SLSREP INVOICE# INV DATE SPORD CASH -------- ---------- ------ SALE 198924 06/24/12 -------- HSE -------- ORDERED --------- B/0 QTY --------- SHIPPED --------- U/M ---- DESCRIPTION PRICE AMOUNT 2 0 2 EA ------------------------------- ------------- CAB CAMBRIDGE TOFFEE W1830 ------------- 100.000 200.00* CAMBRIDGE TOFFEE CABINET 5100008 4 0 4 EA CAB CAMBRIDGE TOFFEE W2430 121.000 484.00* CAMBRIDGE TOFFEE CABINET 5100012 2 0 2 EA CAB CAMBRIDGE TOFFEE W3630 161.000 322.00* CAMBRIDGE TOFFEE CABINET 5100018 2 0 2 EA CAB CAMBRIDGE TOFFEE W3015 92.000 184.00* CAMBRIDGE TOFFEE CABINET 5100020 2 0 2 EA CAB CAMBRIDGE TOFFEE 824 170.000 340.00* CAMBRIDGE TOFFEE CABINET W/DRW 5100042 2 0 2 EA CAB CAMBRIDGE TOFFEE S836 205.000 410.00* CAMBRIDGE TOFFEE CABINET 5100058 2 0 2 EA SINK SS SINGLE BOWL 9" UNDRMNT 79.000 158.00* SATIN FINISH 8037519 4 0 4 EA TOP GRANITE 72" GOLD GARNT 149.000 596.00* #GL1081B 5017038 private sale 20% off -1 0 -1 EA Shipment # 0001 taxable discount 538.800 -538.80* DISCOUNT June 24, 2012 18:05:51 OT:12573 1 / 0 *************** * Pick Ticket *************** PAGE 1 OF 2 GBO Peabody 96 Foster Street 978-532-3796 Peabody, MA 01960 Sold To Ship To SPECIAL ORDER CASH pam cahilt 978 886 0117 39 stonington st n andover, ma Shipment #: 1 ACCOUNT# CUST PO# TERMS ORDER# ORDER DATE SLSREP INVOICE# INV DATE ---------- -------------------- -------- ---------- ---------------------- SPORD CASH SALE 198924 06/24/12 HSE ORDERED B/0 QTY SHIPPED U/M DESCRIPTION PRICE AMOUNT -- ---- ------------------------------- ------------- ------------- THE ORDER TOTAL OF 2289.90 HAS BEEN REDUCED BY THE FOLLOWING PAYMENTS: DESCRIPTION REFERENCE/CHECK # AUTH CODE DATE AMOUNT ---------------- --------------------- ---------- -------- ----------- VISA 6845072 00 06/24/12 2289.90 A balance of $0.00 is due on this shipment. June 24, 2012 18:05:51 OT:12573 1 / 0 MERCHANDISE: 2155.20 * Pick Ticket OTHER: 0.00 TAX: 6.250% 134.70 PAGE 2 OF 2 BARGAIN OUTLET IS NOT RESPONSIBLE FOR FREIGHT: 0.00 MERCHANDISE NOT PIKCED UP WITHIN 30 DAYS. TOTAL: 2289.90