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Home My WebLink AboutMiscellaneous - 415 MAIN STREET 4/30/2018 415 MAIN STREET 210/056.0-0031-0000.0 0 Date.?/ 9510 NoarM <.�•� TOWN OF NORTH ANDOVER �? °oma ¢: o PERMIT FOR PLUMBING 40 SACMUS� This certifies that ` has permission to perform 1�-. . `.. . plumbing in the buildings of . . . . . . l.�?° .. . . . . . . . . . . . . . . . . . s at .y/� . . . . . . . . . . . . . . . . . . .. North Andover, Mass. Fee. . pLic. No.. . . . .. . . . . . . . . . .qj� PLUMBING INSPECTOR Check ." ��/ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK - CITY MA DATE ( PERMIT# JOBSITE ADDRESS / _- GuG��`'� �� OWNER'S NAME OWNERADDRESS _ �j6^-ti _ f TEL TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL D RESIDENTIAL PRINT CLEARLY NEW: 01 RENOVATION: REPLACEMENT: ' PLANS SUBMITTED: YES[] NODI FIXTURES 7 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB I, CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM � 1 l I I ..._._....I _._._-_.I .__,__...1 __-_.....f _._J _..__...I _........_f DEDICATED GAS/OIL/SAND SYSTEM f .-,...._.._I __-[ _.__._..J _-_.I _._..-1 DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM I _-...-_....1 .._.___f __ ( ._-_-__J .._.._._i --_I .---.-_i .,_.--J __-___.{ .._.___._i DISHWASHER } .---....____. ___.._-� ----_._-_I .---___.-J DRINKING FOUNTAIN _ _i .__...._( __...._,...1 I _...__.._( _ [� ._--....__I .__----! ........_._� ........_f _.__..__� _..__...I ___[ ...__....( FOOD DISPOSER I .._ ..__I --I —31 FLOOR/AREA DRAIN ---------- __.__I .--_...__.; ._____. _.____. INTERCEPTOR(INTERIOR) [ KITCHEN SINK _........._-[ ---_..-. ...__._._l ____._-...f ...-----_ LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION _ ..__€ _ _._1 ....,._ ..._....F __....:.. 4 _ ..__! .. . ._J F7 WATER HEATER ALL TYPES , -- WATER PIPING_______ OTHER _ ____. _-! __j INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO El OF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY L9 OTHER TYPE OF INDEMNITY _i BOND ..I 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 _1 AGENT �0 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 accur to the best my k wledge and that all plumbing work and installations performed under the permit issued for this application will be in comp' e wit I Perti ent pr isio the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME "''�- •^""�- _.._-(LICENSE# NATURE IVIP ff JP 1 CORPORATION "#�PARTNERSHIP _1#[_-_��LLC D � COMPANY NAME -? �� _�t_/..,.._-__.._._._.�_�- . E ADDRESS U QLJk CITY _ +�,'/ 11STATE ZIP TEL L 8``7 S TEL 1 FAX � -C_ € CEL 7t /,�. 3_S MAIL _—�_.._._....__....---- -.-_...__..._.._.. -- ._... -... _ _...._...__...._.__......__..._..- ._....._._..... -- ROUGH PLUMBING INSPECTION NOTES I FLOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No / THIS APPLICATION SERVES AS THE PERMIT ❑ ❑AA11, S9 _ FEE: $ PERMIT# PLAN REVIEW NOTES i The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,AM 02111 s� www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: 10. b , +/�p y Z City/State/Zip: '7,, U Phone#: j, 7 D 2 Are you an employer?Check the appropriate box: Type of project(required): 1.[rI am a employer with ?/ 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. 7• ❑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.❑ 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.] 1 employees. [No workers' 13.❑Other comp.insurance required.] Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. a III Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. ram an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site nformation. nsurance Company Name: -)2-Pf A, 'olicy#or Self-ins.Lic.#: Expiration Date: ob Site Address: l l k 14 (if/ L City/State/Zip: ' - �ttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER anda,fine C up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of r nvestigations of the DIA for insurance coverage verification. do hereby certi unde he pains an:17 es of pe 'ury that the information provided above is trite and correct. i nature: Date: 7 1 hone#: -7 ) Official itse 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#: I f 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, 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 re P requested,not the Department of q 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 evised 5-26-05 www.mass,gov/dia