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HomeMy WebLinkAboutMiscellaneous - 414 FOSTER STREET 4/30/2018 (2) W14 FOSTER STREET 210/104.6-0011-0000.0 Date . fL'TiD 4 � TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that . . . .\,7nes. . . . . . . . . . . . . . . . . has permission to perform . i wiring in the building of . . . . . . . . . . . . . . . . . . . . . . . . . at . .4.ILI . . . . . . . . . . . . . . .North Andover, Mass. Fee ./1/4-. . . . Lic. No. .',)pQ S'fc7 . . . . . . . . .PeTRICAL �'!:?�e►,!ELENSPECTOR Check# � � l I0 � II Commonwealth of Massachusetts Official Use Only Permit No. 1 �� Department of Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(NEC),527 CMR 12.00 (PLEASE PRINT W INK OR TYPE ALL INFORMATION) Date: `k _ 1 - o-J k 13. City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) �/ r�S ICA 4 ` 5 Owner or Tenant _ p��0yl/ Telephone No. 171- Irl t Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No d9__ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service 20LO Amps f / _2DVolts Overhead Undgrd[:] No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters / Number of Feeders and Ampacity ( .�✓;c __-)>0© � Location and Nature of Proposed Electrical Work: C, t.e_ t='t LC C*N • Completion of the followin table may be waived by the Ins ector of Wires. No.of Total No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA Above In- o.of-Emergency ig mg No.of Luminaires Swimming Pool rnd. ❑ rnd. El Batter Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones No.of Detection and No.of Switches No.of Gas Burners Initiating Devices Tot No.of Ranges No.of Air Cond. Tons No.of Alerting Devices No.of Waste Disposers Heat Totals Number Tons......KW ..... No.of Self-Contained Detection/Alerting Devices Municipal No.of Dishwashers Space/Area Heating KW Local❑ Connection ❑ Other Heating Appliances KW Security Systems:* No.of Dryers No.of Devices or E uivalent No.of Water No.of No.of Data Wiring: Heaters KW Signs Ballasts No.of Devices or Equivalent Telecommunications Wiring: No.Hydromassage Bathtubs No.of Motors Total HP No.of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections 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 ❑ BOND ❑ OTHER ❑ (Specify:) I certify,under thepains andpenalties of pe ury,that the information on tl:is application is true and complete. FIRM NAME: �1�t S �riu�-c.1.ln..C� LIC.NO.: Licensee: �� Signature C LIC.NO.: q (If applicable,enter "exem,,PPt"in the license number Zine.) nn 'nn Bus.Tel.No.:_1 7 Address: ,� C-h.a�(s'o s s"V ,�iN 1()l��rVy cJ t Alt.Tel.No.: *Per M.G.L c. 147,s.57-61,security 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 agent. Owner/Agent PERMIT FEE: $ Signature Telephone No. J ' r ., A+.1�J�r�.LJl�.1.'VF�J'3•�ft�.+n'p-r�a.'a�..'L�iJ-r.J�'�'�•�®�w �'( J'� .s-+.S��J:I`UJ4.R��.x.`aJ:�J.®�l.i r ��sse[�•-�j �� �+'aileB-�r � �e-xnspectZou xet�uzz'ed'(��O.OD)�� j hspectors,Comments. i E.r• (X'nspee�oxs5�'zgn,atux'e��,o�x�ffa7s) ,.r-, �a$e lu5�ectaJrS'comments; • ( iisiectoxs' fgnatu>e no xnztfals) date UNDAR GROD"M9R)TCTjOX- 'assec�•—�' � �+'aiXe�--j � ate-ans�eetZo�,xec�uiret���s0.00)�[ � aspeetors'comments; (cusp ectoz s'uignatuxe o�nitaTs} date . �se�-- afie j P,6 xnspectionxequired($50.00) Ped6s'eo m.eits: spectoz' fg ,tuXe�7io jnitfaxs) date ��'EC�'XO�"•-ORc" ' eR---f � �`afXer�-,[ �_ 'ate�nsp ec�fon xequizer�{$50.OD)•-[ � BCtOxs�COI�]1lents: ' ' S xusp ectoxs'Sfgnaftue••no inYfals) Plate ' The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): e)e 15; Address: _ �� C/a-, 4, City/State/Zip: A �'� ,� �/.— (o q .�✓+� O�� Phone#: y .Z Are you an employer?Check the appropriate box: Type of project(required): 1 4�!h am a employer with '1-2- 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. # E]Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its ' required.] officers have exercised their 10.F1 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.❑Roof repairs insurance required.]t employees. [No workers' 13.❑ Other comp.insurance required.] *Any applicant that checks box#I 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. Insurance Company Name: Ve__ : 5 Policy#or Self-ins.Lic.#: Expiration Date: 2-00 Job Site Address:_ /e City/State/Zip: i1/Alv b / 4 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under 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 Df 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. F do hereby certify under th pains n petfCilties of perjury-fijat the information provided above is true and correct. 3i nature: _ _ --� Date: H.-- ?hone#: �`I 72 _ - � 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#: r 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 i 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' 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 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 5-26-05 �xrtxnu mace vnv/rlia ✓� 9 6 y Date...�v:-.. ....... NORTH TOWN OF NORTH ANDOVER PERMIT FOR WIRING SACHUS This certifies that <<,�x�/1R1) ....................... ............. ......... ................. has permission to perform ......s �<g wiring in the building of;.. .. y "M....l./V............................................... ,. at......... ..........�4. . .., .�.. . ........5.7..^.PILE . ,North Andover,Mass. Fee....s. ^o"�'.. Lic.No..-Vl q 1C ........ �........... CTRICAL INSPECTOR Check # �� 11 •� L.U"1t11U,1WGQ,dl1 Uff — r 1 q4 Permit No. n Departmentof Fire Services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev- 1/071 (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code MEC),527 CMR 12.00 (PLEASE PRINT WINK OR TYPE ALL INFORMATION) Date: �C F 2U/ U �+ City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice o2bf is or he i tentio to perform the electrical work described below. Location(Street&Number �� Cl/ 7L l° Owner or Tenant a/ t t7 Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. '?N"— Existing Service /)U Amps /I h 2 v Volts Overhead Q' Undgrd ❑ No.of Meters New Service `Z U O Amps tit / 9,.vVolts Overhead Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion of the following table maybe waived by the Inspector of Wires. No.of Total No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA Above In- o.o mergency ig mg No.of Luminaires Swimming Pool rnd. ❑ rnd. ❑ 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 Initiatin Devices No.of Ranges No.of Air Cond. Tons No.of Alerting Devices Disposers Heat Pump Number Tons KW No.of Self-Contained No.of Waste Dis P Totals: Detection/Alerting Devices Municipal El Other No. of Dishwashers Space/Area Heating KW Local❑ Connection No.of Dryers Heating Appliances KWSecurity Systems:.. No.of Devices or Equivalent No.of WaterKW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent Y OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: 0(J (When required by municipal policy.) Work to Start: Inspections 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 BOND ❑ OTHER ❑ (Specify:) I certify,under the pains andpenalties of perjury,that the information on this application is true and complete. FIRM NAM J J It o LIC.NO.:�� Licensee: GYr7 ,1Jr Signature LIC.NO.: (If applicab(e,enter 'exenz m th�I icen$e numb li e.) / Bus.Tel.No.: Address: // /�P- /C-//7 T7 �f P!0 1✓` Alt.Tel.No. *Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lie.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 Owner/Agent PERMIT FEE: $ Signature Telephone No. 6177 412- c26-i q i , The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 `'4 ,�• www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legib IName(Business/Organization/Individual): / !/��G� C � /� ✓� Address: City/State/Zip: �` �l�lr.. Phone#: all 2 J 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 1 6. ❑New construction employees(fall and/or part-time).* have hired the sub-contractors 2.D-1 am a sole proprietor or partner- listed on the attached sheet. E]Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ 1 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.❑Roof repairs insurance required.]i employees. [No workers' 131-1Other 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 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. Insurance Company Name: Policy#or Self-ins.Lic.#: 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 required under 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. I do hereby certify under t s and penalties of perjury that the information provided above is true and correct. Signature: Date: 6 62 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 Contact Person: Phone#: Date....�.Z- 0 ,�OR71f °�t�``°:•�"� TOWN OF NORTH ANDOVER p PERMIT FOR WIRING SACMUS� This certifies that .j.0 �JG -of�i/t�G /iotJ ..... ....... .................. ............................. has permission to perform t& F eAr ................ wiring in the building of......................... ` ... ... . ./Z.............. ..................... at �.�oS l ..... S Orth Andover,Mass. ew t t 'L �} Fee—'. . '..�.. Lic.No. + .t.l ..l.. .................... ... . { . ........ ...�.. ELECTRICAL INSPECTOR = Check # 1� 7893 Commonwealth of Massachusetts Official Use Only f Permit No. / 9 Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Occupancy 1 a cy and Fee Checked leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: /4--R -,-3 /-t,)t,) 7 City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) ii®� Owner or Tenant X) Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building Pj/ Ii Lf iy6- Utility Authorization No. Existing Service 0 0 Amps ?-elljV-cWolts Overhead ®o Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: � 1 Lv Completion of the followin table may be waived by the Inspector of Wires. 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 Swimming Pool Above ❑ In- ❑ o.of Emergency—L-19—hffn--g rnd. rnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.ofZones No.of Switches No.of Gas Burners No.of Detection and TotInitiating Devices No.of Ranges No.of Air Cond. ons No.of Alerting Devices No.of Waste Disposers Heat Pump I Number Tons KW No.of Self-Contained Totals: . ........... ........... Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water No. KW No.of No.of Data Wiring: R Signs Ballasts No.of Devices or E uivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or E uivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections 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 BOND ❑ OTHER ❑ (Specify:) 0ZS- I certify,under the pains and penalties of perjury,that the information on lti�application is true and complete. FIRM NAME: t ' e 9A C LIC.NO.: Licensee: Signature LIC.NO.:�p � (If applicable, ter exempt"in the license nu_mber ne.) �M Bus.Tel.No.• _ Address: ®/11 k7 y> S a al-2 /�'�� Alt.Tel.No.. *Per M.G.L c. 147,s.57-61,security 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 agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ f The Commonwealth of Massachusetts ! Department of Industrial Accidents j Office of Investigations 600 Washington Street i Boston, MA 02111 c www.niass.gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers At Plicant Information ry� Please Print Legibly Narne (Business/Organization/individual):_ K-0114-/e i/'Ofli Address: City/State/Zip: 162Y �// one Are you an employer?Check the appropriate box: Type of project(required): L❑ I aro a employer with 4. ❑ 1 am a general contractor and I h, Q New construction employees(full and/or part-time).* have hired the sub-contractors ' 2.❑ I am a sole proprietor or partner- listed on the attached sheet.x 7• ❑ Remodeling ship and have no employees These sub-contractors have 8. Q Demolition working for mein any capacity. workers' comp.insurance. 9 ❑ Building addition [No workers'comp, insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions required.] officers have exercised their 3.❑ 1 am a homeowner doing all work right of exemption per MGL 1 1.Q Plumbing repairs or additions myself.[No-workers'comp. c. 1.52, §1(4),and we have no 12.❑ Roof repairs insurance required.]t employees. [No workers' V comp. insurance required.] 13.[] er�J��1��Jl.C/ *Any applicant that checks bolt#t 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 mustattached 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.#: 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 required under 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. I do hereby certify under the pains and penalties ofperjury that the information provided above is true and correct Signature: Date Phone#: O fficial only. Do nLina,to be completed by city or town official n: Permit/License# hority(circlHealth 2. Bent 3.City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector rson: Phone#: ti.. 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 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 • j 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,not1he 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 02111 Tel. #617-727-4900 ext 406 or 1-8.77-MASSAFE Revised 5-26-05 Fax 4 617-727-7749 www.mass.gov/dia 4020 �aORTN ,,`?�.,��•°;•��co� TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING �ssAcHus� This certifies that �'�. . . . . . . . . . . . . t� has permission to perform . . . . . .r. . . . . . . . . . . . . . . . . . . . . . . . . . . plumbing in the buildings of . .,w.a.//?. . . . . . . . . . . . . . . . . . . . . at. . ,�e' s. S. ' . . . . , North Andover, Mass. Fee.,2.7... . . . .Lic. No.. 3?.? . . . . . . .. ., .�` . ✓.— ¢7 ' /'PLUMBING INSPECTOR 05/12/9911:22 27.00 PAID WHITE:Applicant CANARY: Building Dept. PINK:Treasurer MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Prin or Type) j' Mass. Date S 19J Permit # 0 Ear Building Location �� t (.�� � yI Owner's Name mo ij Type of Occupancy Residential New ❑ Renovation ❑ Replacement Plans Submitted: Yes❑ No ❑ FIXTURES o Y.Z > W Y J N � U Q N 7 C7 Q ¢ � W Z 0 6 ¢ _ ~ h Z O Z _N q O - W F W N F U 2 Y a (� W f49 2 m N y S > a F N Z e S 0 a a a O x N ,�Ay1 J Z Q W ... O Q N Z Q S S LL xi �' xi is 2 W O H W a m Q Q J N ¢ ¢ J - O ¢ Q W S W x a x O Z x 3 X d 0 F a Y �( W LL Y W F- UQ F F O N ' y F Z O O Z Z W r O U 7 rl a a x _ _ a a o Q J J a x rc a a o a ►- S-� 3 Y J ID N D O J 3 x F N LL 0 O J a lC N 0 SUB—BSMT. BASEMENT IST FLOOR W 2ND FLOOR A 3RD FLOOR D T 4TH FLOOR I 5TH FLOOR R S 6TH FLOOR E 7TH FLOOR C 9 STH FLOOR T D Installing Company Name Heritage Htg. &Plg. CO. Inc. Check one: Certificate Address 35 Pleasant Street CX Corporation 714 Stoneham, Ma 02180 ❑ Partnership Business Telephone . 781 —43 8-77 76 r7 Firm/Co. Name of Licensed Plumber Gordon Switzer 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 coverage by checking the appropriate box. A liability Insurance policy IN 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 Mass. General Laws. and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner El Agent El I hereby certify that all of the details and information I have submitted(or entered)in above 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 provisions of the Massachusetts State Plumbing Code a Chapter 142 ofthe G neral Laws. By9464� 12 Signature o ensed Plumber Title City/Town Type of License: Master[X Journeyman❑ APP FILE S ONL Ucense Number 8322 1. BELOW FOR OFFICE USE ONLY FINAL INSPECTIONS SKETCHES J ~PROGRESS INSPECTIONS FEE NO. APPLICATION FOR PERMIT TO DO PLUMBING NAME&TYPE OF BUILDING LOCATION OF BUILDING PLUMBER PERMIT GRANTED DATE 19 PLUMBING INSPECTOR