HomeMy WebLinkAboutMiscellaneous - 399 MAIN STREET 4/30/2018e
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This certifies that ... 5--e lewe-te- ep * -Ay .............
has permission for gas installation .....
in the buildings of ...
at ................. , North Andover, Mass.
Fee. . Lie. N
� 4GAS.I*NS*P*E*C*T*O'R*
Check # / �K
t
-`\- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY I " Lt� I- _ AIJ j U, i4 ✓�- _ -V� MA DATE -._/3 PERMIT #
JOBSITE ADDRESS �t�c �% C- OWNER'S NAME
GOWNER ADDRESS TE �FAX
TYPE
TYPE OR OCCUPANCY TYPE COMMERCIAL[__I EDUCATIONAL 0RESIDENTIAL^ _
PRINT
CLEARLY NEW: [� RENOVATION: El REPLACEMENT: PLANS SUBMITTED: YES [Q NOF
APPLIANCES Z FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER _L.... I __—:�I1—.,- L : I. _ .�l ..-r_ii_,
BOOSTER L ^_ . �,. _� 1 .� _,� _ -- _ _ - f _ _ r, -�_ L_
CONVERSION BURNER
COOK STOVE
DIRECT VENT HEATER
DRYER
FIREPLACE —J I z ......_1 - �—rJ l .T-`1 -._ J --_ J I I
FRYOLATORn-
FURNACE
GENERATOR I L_ I (_ l I -JI
GRILLE_!
INFRARED HEATER
LABORATORY COCKS J
MAKEUP AIR UNIT
OVEN
POOL HEATER
ROOM /SPACE HEATER
ROOF TOP UNIT
TEST --J
UNIT HEATER
UNVENTED ROOM HEATER a f:. -� _ �. t_fill -
WATER HEATER
6T-HER
INSURANCE COVERAGE
have,a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch.142 YES 12NO [
IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY [a' OTHER TYPE INDEMNITY EJj 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 �JI
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 comp' a wit II Perti7eprois"on of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMBER-GASFITTER NAME, �._a%vs�t-_ L✓ ___ LICENSE #3Co._I SIGNATURE
MP MGF JP [ JGF LPGI �_I� CORPORATION PARTNERSHIP S# LLC]#
COMPANY NAME:
r�l ADDRESS 'dS-f(�,G�
CITY
C.d I: G...-_- .__.__ __ . _,_,..-..___-_.11 STATE �I'� ZIP[ TEL ?
FAX^CEyL L5 MAIL - - -
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The Commonwealth ofMassachusetts
Department of Industriq[Accidents
Office of Investigations
UqF 600 Washington Street
Boston, MA 02111
www.mass gov1dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/individual):
Address:
City/State/Zip: Phone #:
Are you an employer? Check the appropriate box:
Type of project (required):
1. ❑ I am a employer with
4. ❑ I am a general contractor and I
6. n New construction
employees (full and/or part-time.).
2. El am a sole proprietor or partner-
have hired the sub -contractors
listed on the attached sheet. z
7• Remodeling
ship and'have no employees
These sub -contractors have
8. ❑ Demolition
working forme in any capacity.
[No workers' comp. insurance
workers' comp, insurance.
5. ❑ We are a corporation and its
9. F1 Building addition
required.]
officers have exercised their
10.[] Electrical repairs or additions
3. ❑ I am a homeowner doing all work
right of exemption per MGL
11.❑ Plumbing repairs or additions
myself. [No workers' comp.
c. 152, §1(4), and we have no ,
12.❑Roofrepairs
insurance required.] i
employees. [No workers'
13.❑Other
comp. insurance required,]
*Any applicant that checks box#1 must also fill out the section below showing their workers' compensation policy information.
T Homeowners who submitthis affidavit indicating they hie doing all work and then hire outside contractors must submit anew 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 Name:.
Policy # or Self -ins. Lic. M
_ 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 requiredunder Section 25A ofMGL c.152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or oneyear 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.
Ido Hereby certlo under the pains andpenaldes 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):
I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other - - -
1iuuformadon and ffust r ueflons
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
ofthe 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 ofpublic work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the cgntracting 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 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 -andprintecl legibly: TheDepaitrrieritllas pzovid6d a space at ik6-boffom'
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 permitilicense 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:
Tho Gommonwmltl ofM-assachim-tis
DDp.artmeut ofladuddat Accidonts
OfAce of IaveWigat o)u
600 Washington Street
Boston, MA, 02111
TQL #617-727-4900 W406 or 1.-877�MASS.AFF,
114 UNIt-uHM ANPLICAf1(JN FUR PERMt i 1 u uu rLUMUMU
(Prini or Type)
3a
NORTH ANDOVER, Masa. Date .t0,
Building
Location � C7
e
New p Renovation Replacement
FIXTURES
Permit # - r;�(%
Owner's
Name L�;Z a4N
O Plana Submitted: Yes ❑ No p
Installing Company Name
Address <.-D
Business Telephone -----6 6 -- 0 9- �t7
Name of Licensed Plumber
Check one:
❑ Corp.
O Partnership
�Irm/Co,
INSURANCE COVERAGE: Check one
1 have a current Ilablfty Insurance policy or No substantial equNWent Yea 111" No p
If you have checked M, please Indicate the type coverage by checking the appropriate box
A Itablilly insurance policy Other type of Indemnity ❑ Bond ❑
Certificate
OWNER'S INSURANCE WAIVER: i am aware that the Ilcensee 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:
N—vature of Oovnei or Owner a AUent
Owner p Agent p
(hereby certify that all of the detalls and Information I have submitted for entered) In above appHcatlon are true and socwat• to the best of my
knowisdp• and that all plumbing work and installations performed under the p MIAl Ws ap tion be In compliance with all
pertinent provisions of •Massachusetts State Pkrrnbfng Code and Chapter 142 of al
/ ITWVED (OFF)CE USE ONLY)
Pgnafteof
License Number U 3 b
Type of Plumbino license: Master Q--
Jowneyman ❑
Iwo
on
MEN
I ]FA I 1,111-TWENONIONINEWN
NEURONE
Installing Company Name
Address <.-D
Business Telephone -----6 6 -- 0 9- �t7
Name of Licensed Plumber
Check one:
❑ Corp.
O Partnership
�Irm/Co,
INSURANCE COVERAGE: Check one
1 have a current Ilablfty Insurance policy or No substantial equNWent Yea 111" No p
If you have checked M, please Indicate the type coverage by checking the appropriate box
A Itablilly insurance policy Other type of Indemnity ❑ Bond ❑
Certificate
OWNER'S INSURANCE WAIVER: i am aware that the Ilcensee 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:
N—vature of Oovnei or Owner a AUent
Owner p Agent p
(hereby certify that all of the detalls and Information I have submitted for entered) In above appHcatlon are true and socwat• to the best of my
knowisdp• and that all plumbing work and installations performed under the p MIAl Ws ap tion be In compliance with all
pertinent provisions of •Massachusetts State Pkrrnbfng Code and Chapter 142 of al
/ ITWVED (OFF)CE USE ONLY)
Pgnafteof
License Number U 3 b
Type of Plumbino license: Master Q--
Jowneyman ❑
"j -% - . - 71�
Date.
IM)
2887
0 TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
...............
This certifies that
has permission to perform ...............
plumbing in the buildings of ... A,-- -11'q .. ...........
at ............. North Andover, Mass.
�LUM ING 1;��P[A`CTOR
WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: File
3gel
Location_
No. D at
'AORT
TOWN OF NORTH ANDOVER
I
Certificate of Occupancy $
Building/Frame -Permit Fee $
0.
Foundation Permit Fee $
Other Permit Fee $
Sewer Connection Fee $
Water Connection Fee $
TOTAL $
Building InspVcf'o-r-
L2U% 15:58 25. 00 PAID
Div. Public Works
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