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Home My WebLink AboutMiscellaneous - 41 HERRICK ROAD 4/30/2018 41 ZRICK ROAD 2101015.0-0054-0000.0 I I ' I i I I i I I I 1 I Date.... �4 Le.............. tAO T#j 0 TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ....... .. .. .. .. ........................................... ... ... . has permission for gas installation Y the build* g f trl > 2 a( e u, in so ........................ ...Andover,'*-*-*-,-**'***,Mass.,***-**''*'' ............................................. Fee.Ra.!�O. Lic. Noiq; f�-........ ...... ............. IOLA................................. GASINSPECTOR Check# 96 0 3 •` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY �.� RUr/'z�— _ �( MA DATE P� PERMIT# JOBSITEADDRESS fL1L,�ri _ OWNER'S NAME Z-ea1 ST � G�►�s� GOWNER ADDRESS t TEL[ TYPE OR OCCUPANCY TYPE COMMERCIAL 6 EDUCATIONAL ® RESIDENTIAL PRINT CLEARLY NEW:[ RENOVATION:El REPLACEMENT:Ej PLANS SUBMITTED: YES NOD APPLIANCES"I 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 - GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS (— ( L. _..._ I .- 1 ---1 I -- IT a l Lam.- I —-- MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT _ I _._. I __j TEST .UNIT HEATER UNVENTED ROOM HEATER WATER HEATER ' OTHER �._...� �—� --- _ _ � _. . ( ,-� --- - — ,=--1 L__._I --J F--� INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES10—NO Ej 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 Ea A ENT D SIGNATURE OF OWNER OR AGENT here ertify 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 t at 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. PLUM BER-GASATTER NAME 11 —.��C—'�'_ LICENSE# ��0. I. SIGNATURE MP 0 MGF 0 JP0-'J—GF LPGI EJ] CORPORATION[]# PARTNERSHIP 0#=LLC[�E# COMPANY NAME: I ADDRESS CITY �� STATE- ZIP FAX CELL( --'� EMAIL ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES The Commonwealth o,f'Massachusetts - Department ofIndustrialAceld nts Office of Investigations 600 Washington Street .Boston,lt2A 02111 www.mass govIdia Workers'Compensation Inssurance Affidavit:Bupders/Cont.actors/Elect7ricians/Plrimbex.s A p'plicant Information Please Print Legaibly Name(Business/Organizaiion&dividual): Address: City/State/Zip: Phone# Are you an employer?Check the appropriate box: Type of project(required): 1.f] I am a employer with 4. ❑I am a general contractor and I 6. ❑New construction employees(fall and/or part-time,).* have nodthe sub-contractors 2.® I am a sole proprietor or partner listed on the attached sheet.T 7. ❑Remodeling ship and1ave no employees These sub-contractors have 8. ❑Demolition worldug .for me in any capacity. workers'comp.insurance, g. E]Building addition [Nb workers'comp.insurance 5. ❑We are a corporation and its 10.[]Electrical repairs or additions required.] officers have exercised.their 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 insurancerequired.)i employees.[No workers' 13.[]Other comp.insurance required.] ` !Any applicantthat checks box#1 must also fill outthe section bel6w showingtheir workers'compensationpolicy information. Homeowners who submit this affidavit indicating they tie doing all work and then hire outside contractors must submit anew affidavit indicating such. lContractors that checkthis box must attached as additional sheet showing the name of the sub-contractors and their workers'comp.policy information. X am an employer that is providing workers'compensation insurance for my employees: Below is thepolicy and'joh site information. Insurance Company Name:. Policy#or Self-ins.Lic.#: Expiration.Date: Job Site Address: City/State/Zip: Attach,a copy of workers'compensation-policy declaration page(sh.owing 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 one-year imprisonment,as well as civil penalties i a 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. X do Hereby!cartify under the pains and penalties of perjury that the information provided above is True and correct, Signature: Date: Phone#: 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 i - - - 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 id the service of another under any contract of him,. express or implied,oral or written." An employee is defined as"an individual,partnership,association,corporation or other legal entity,or any two ormore of the foregoing engaged in a j oint enterprise,and including the legal representatives of a•deceased employer,or the receiver or trastee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having notmore 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 shallnot because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local lieensing 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 contracting authority." Applicants Please fill out the workers'compensailon affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone mumber(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 notrequired to carry workers'compensation insurance. If au 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 he. City or Towns 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/iicense 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 maybe provided to the applicant as proof that a valid affxdavit-is on file for future permits or licenses, Anew affidavit must be filled out each year.Where a home owner or citizen is obtaining a license ox 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 CQMMoxawt,aMofMa�apftsPtt� - De-paftent of IndusWal,A,cddoxxta ofte offAvestigationa 60 wwapa fleet Boston, :42111 9 MUFF, Revised 5-26-05 FaW#617-727-7749 WWWaMus,govIcha