The URL can be used to link to this page

Home My WebLink AboutMiscellaneous - 371 SUMMER STREET 4/30/2018 (2)Is X12°'-0 1 ' Date6/ TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ......... has permission to perform ...... ........ ��71 ... . ............................................. plumbing in the bui dings 6f7/. -6.7.6.j . .................................................................. ..'C4 North Andover, Mass. at ........... .... . ....... ....... & .. ............... Fee, ..................... Lic. No., ........................................... PLUMBING INSPECTOR Check # Ala MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ' �- PERMIT # ZZ/D CITY�r d ee^� �] Jc (- MA. DATE2cr -624CC JOBSITE ADDRESS 3 71 V U vy\ M(-(, OWNER'S NAME J46CLI\ POWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE: COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL [� PRINT CLEARLY NEW: ❑ RENOVATION: F]REPLACEMENT: aPLANS SUBMITTED: YES ❑ NO ❑ FIXTURES 1 FLOOR- BSMT 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYS DEDICATED GAS/OlUSAND SYS DEDICATED GREASE SYS DEDICATD GRAY WATER SYS DEDICATED WATER RECYCLE SYS DRINKING FOUNTAIN DISHWASHER FOOD DISPOSER FLOOR / AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE 1 MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES j WATER PIPING ')THER w 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 CHECKED YES, PLEASE INDICATE TH .TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW 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 Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE BOX ONLY: OWNER ❑ AGENT ❑ Si nature of Owner or Owner's Agent 1 hereby certify that all of the details and information I have submitted (or entered) regarding this application are true and accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and C to 42 oftheene I Laws. PLUMBER NAME S CQ 2 -L) SIGNATURE / LIC # ( \ MP []� JP ❑ CORPORATION PARTNERSHIP ❑ # LLC ❑ # COMPANY NAME eSQ k' CL ADDRESS: CITY IS --)&v 1..4 STA IP chi 2A EMAIL A\, Se -f J,' Cc- \(\ TEL q�o (nta3 CELLQi»' 123 C702 FAX i Date...j./ .�... �k ............ ;a TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION � This certifies that .......PIL-f ................ I has'permisson for gas installation .........!�`:°...................................................2 in the. buildings of .................... d-� ........... ' I ............ North Andover, Mass. FeeO.4...:....... Lic. NoW .3D........................................................................ GASINSPECTOR Check # '7 3 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 Iia ce ith all Pertinent provision of the MassachusettsS e Plumbing Code and Chapter 142 of the General Laws. PLUMBER/GASFITTER NAME: t w L�1t,10 LICENSE # I_L3 SIGNATURE COMPANY NAME: ADDRESS:_ CITY : 1 '\�C-r ST ZIP: FAX: TEL: 9Crz �:):) O CELL: Z 1-20V EMAIL: MASTER ❑ JOURNEYMAN ❑ LP INSTALLER ❑ CORPORATION #_ r Lj a PARTNERSHIP 0 # LLC ❑ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK ✓ GOWNER a TYPE OR PRINT CLEARLY CITY:In MA. DATE: 2 i t i PERMIT# JOBSITE ADDRESS: 1 V w� nn -cc S� OWNER'S NAME: O 4CLh ADDRESS: TEL: FAX: OCCUPANCY TYPE: COMMERCIAL ❑ EDUCATIONAL ❑ RESIDENTIAL L`f NEW: ❑ RENOVATION: ❑ REPLACEMENT: [� PLANS SUBMITTED: YES ❑ NO ❑ APPLIANCESI 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 INFRARED HEATER LABORATORY COCK MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER r 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. LIABILITY INSURANCE POLICY En-"� 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 ❑ 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 Iia ce ith all Pertinent provision of the MassachusettsS e Plumbing Code and Chapter 142 of the General Laws. PLUMBER/GASFITTER NAME: t w L�1t,10 LICENSE # I_L3 SIGNATURE COMPANY NAME: ADDRESS:_ CITY : 1 '\�C-r ST ZIP: FAX: TEL: 9Crz �:):) O CELL: Z 1-20V EMAIL: MASTER ❑ JOURNEYMAN ❑ LP INSTALLER ❑ CORPORATION #_ r Lj a PARTNERSHIP 0 # LLC ❑ The Commonwealth of Massachusetts M Department of IndustrialAccidents 1 Congress Street, Suite 100 Boston, MA 021142017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Name (Business/Organization/Individual): Address: a a L /l City/State/Zip: "'`L 0\�" � << �.a Phone #: 6i6a3 L Are you an employer? Check the appropriate box: 1. ❑ I am a employer with employees (full 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.] 3.0 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 contractors either have workers' compensation insurance or are sole proprietors with no employees. 5.0 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.t 6.1 We are a corporation and its officers have exercised their right of exemption per MGL G. 152, §1(4), and we have no. employees. [No workers' comp. insurance required.] Type of project (required): 7. ❑ New construction 8. ❑ Remodeling 9. ❑ Demolition 10 ❑ Building addition 11.0 Electrical repairs or additions 12. Wlumbing repairs or additions 13.0 Roof repairs 14.0 Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. i 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 state whether or not those entities have employees. If the sub -contractors have employees,' they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees.' Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. Date: fob Site Address: � � . I & i —A ..,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 MGL c. 152, §25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify ofperjury that the information provided above is true and Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, .: express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall. enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill -out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensatiou'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 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 www.mass.gov/dia ,SERIALU-M t!UMBER-M