HomeMy WebLinkAboutMiscellaneous - 417 MARBLERIDGE ROAD 4/30/2018 (3) 1
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Date.� �. .�l. �. . . .... .
�ORTM
3j0ry`�...o ,e eryOL �•
TOWN OF NORTH ANDOVER
' O P
- PERMIT FOR GAS INSTALLATION
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C �9SSACMUSEtt
This certifies that .�1�1 . %.G�/`? . . . . .�� ` . . . . . . . . . . . . . . .
F, t� �,a
has permission for;gas` installation . . (? . . . . . . . . . .
in the buildings of . :, a.r.&N. . . . . . . . . . . . . . . . . . . . . . . .
at . . .�,r�G7. . .j , 2n ��/?r. � . . . . . . . ..(North Andover, Mass.
Fee. .3.t1. . . , Lic. No.. . . �. �._.�
G AS INSPECTOR
Check# 3)Gf
7302
MASSACHUSETTS UNIFORM APPLICATON FORPERMIT TO DO GAS FI*ITING
(Type or print) Date �" �( — C�o I U
NORTH ANDOVER,MASSACHUSETTS
Building Locations C�1 �� Permit#
Amount$
Owner's Name
NeRenovation Replacement Plans ubmitted
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SUB-BASEM ENT
oC4
BASEMENT
IST. FLOOR
2ND . FLOOR
3RD . FLOOR
4TH . FLOOR
5TH . FLOOR
6TH . FLOOR
7TH . FLOOR
8.TH . FL,O0R
(Print o eCheck one: Certificate Installing Company
e It, ❑ Corp.
Address Q ��Z
®. Partner.
usmess a ep oneFirm%Co.
Name of Licensed Plumber or Gas Fate , 1g, 1
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes 1:1 No
If you have checked yes,please b>dicate the type coverage by checking the appropriate box.
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
Mass.General Laws,and that my signature on this permit a plication waives this requirement.
Check one:
Signature of Owner or Owner's Agent O er ent
I hereby certify that all of the details and info ation I have submitted or t ed)in ove appli do a true and accurate to the
best of my knowledge and that all plumbing wo d installations perfo d e it I r thi application will be in
compliance with all pertinent provisions of the Massac us ode C h apter of eral Laws.
By; S gnatur of Licensedl b
Per or Gas Fitter
Title ,� Plumb r110761
City/Town Gas F tter License Number
Laster
APPROVED(OFFICE USE ONLY) Journeyman
I
w ' The Commonwealth of Massachusetts
Department o f Industrial Accidents
Office of Investigations
600 Washington Street
Boston,-MA 02111
www.mas&gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual). v7
Address:
City/State/Zip: Phone#: ( -" G
Are,you,an employer?Check t e appropriate box:
Type of project(required):
1. am a employer with 4. El am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6.
❑New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet 1 7• ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers' comp.insurance.
[No workers' comp. insurance 5• El We are a corporation and its 9' ❑Building addition
required.] officers have exercised their 10.[]Electrical repairs or additions
3.F_1 I am a homeowner doing all work right of exemption per MGL .11.F- 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'
comp,insurance required.] 13.❑Other
`.Any applicant that checks box#1 must also ir�l out the section below sbov.Z=b Tam`e'r wow ::e compeasatioc policy ^fo:auon
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 isproviding workers'compensation insurance for my emp
information, loyees Below,is the policy and job site
�-�
Insurance Company Name:
j
Policy#or Self-ins..Liic.#: Expiration Date:
Job Site Address: G 60( _ City/State/Zip: 4wt
Attach a copy of the workers'
compensation policy declaration
page(showing the
policy number and expiration date).
Failure to a coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
p to$1,500.00 or one-year imprisonment,as we ivil penalties in the form of a STOP WORK ORDER and a fine
up to$250.00 a day ag st the viola r. Be advis that c py of this statement may be forwarded to the Office of
Inve tions of the DIA fo incur cove ge rifica '
Ido hereby certify u e the pa and en ties of u that the information provided above is true and correct
SignaDate:
Phone#:
Official use only. Do not write in this area, to be completed by city or town official
City or Town: Permit/License#
j Issuing Authority(circle one):
1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.PIumbing 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 perrson 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 apartmLents 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 n 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-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 stare to sign and date the affidavit. The affidavit should
be returned to the city or town that the application:for the pernait or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regardigg the law or if you are required to.obtain a worlcers'
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 homeowner 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 wouldli1ce to thapk 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
Depar me&of Industrial Accidents
ice of Investigations
600 Washington Street
Boston,lA 02111
Tel. # 617-727-4900 east 406 or 1-877-MAS.SAFE
Revised 5-26-05 Fax#6.17-727-7749
www.mass._govfdia
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
"'SA US r�
This certifies that . . . . I- . <.�4.L�. . 1 . . . . I . ?� . .t . . . . . . . . . . .
has permission to perform . . . . . . . . . . . .
plumbing in the buildings of •U.. . . . . . . . . . . . . . . . . •
at . . lyCi. .'. .&17& n.(,�E /�.�.�•f 2. . . . . . . . , North Andover, Mass.
Fee. .�t�7. .Lic. No.. ./0).01 . . . . . . . . . .'. .'. :. . . . . . . .
LUMBING INS- C, OR
Check p 3
8368
J �
1
.MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER,MASSACHUSETTS `�_ o7U/O
Date ,�
Building Location Owners Name d 1 AC Permit# ' 51`ie
Amount
Type of Occu anc t
New Renovation 0 Replacement ® Plans Submitted Yes � No
FIXTURES
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(Print or type) �� Check one: Certificate
Installing Company Name M &C4V- a Corp.
A ss Partner.
Business Telephone — — Finn/Co. ._
Name ofLicensed Plumber:
Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box:
Liability insurance policy Other type of indemnity ❑ Bond
Insurance Waiver: I,the undersigned,have been made aware that the licensee of this application does not have any one of the above
threeinsurance
Signature r 0 Agent
I hereby certify that all ofthe details an information I have subm ed(or en d)' bo a ap cati are.true and accurate to the
best of myknowledge and that all plumb' ork and installatio r ennit r this application will be in
compliance with all pertinent provisions of the S Plum g e d 2 of the General Laws.
By: ngna o Icensea um er
Type ofPlumbin "cense
Title j 30/
City/Town icense um er Master Journeyman ❑
APPROVED(OFFICE USE ONLY
t
The Commonwealth ofMassachusetts
Depa117Mnt o f. ndu tial Accidents
Office ofrfivestigations
600 Washinb-ton Street
BOStO)Z, 3L4 0211.7
IV www-mQs&gov/dia
Workers' Compensation Insurance Affidavit:Builders/Contractor s/Electri",aa5/Plumbers
An licaut Information
Please Print Legibly
Name(Business/Ora nization/Individual):
Address:
City/State/Zip:
Phone#:
F;Arery employer?Check a appropriate box:
employer with 4. ❑ I am a a Type of project(required):yees(full and/orpart-time). have hir d the subcontrac orctor ands* 6• ❑Nevr construction2. l I am a sole proprietor or partner_ listed on the attached sheet $ 7. ❑Remodeling
ship and have no employees These sub—contractors have
` working for mein any capacity. workers' comp.insurance. 8. EJ Demolition
[No workers'comp. inc„tanCe 5. ❑ We are a corporation and its 9' El Building addition
• required.] officers have exercised their 10-ElElectrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL I L❑Plumbing repairs or additions
myself. [No workers'comp. c. 152, I(4),and we have no
insurance required.] t employees. [No workers' L
2•❑Roof repairs
wit comp.InsUrmcf,required.] .❑Other
'c nS' :.zc. t tha:c-hecLs box,#,ar.:s!a?Sso out ffie
secti-mon heeow sect W�i^� t or ers'
. . conr�s`onP Ec.Fl �eowaewhosuiniffs affidavit indicating they zredcog at1.w.o;kand nen f _ contractors t( -tsu_
�fcia nmoeo-,
m+Contractors that check the hon n•sattached an additional sheet showing the acmeothesub-c � davit indicating such.ontaetots
and their workers'comp•Policy information.
.tarn an employer that isproviding workers'compensation insurance for my employees Beloit is the policy andrma site
information.
Insurance Company Name:
Policy#or Self-ins.Lie.M.
Expiration Date:
Job Sits Address:
Attach a copy of the workers'compensation policy decIara{iCity/State/Zip:
.Qn page(shovviag the policy number.and expiration date).
Failure to secure coverage as required under Section 25A ofMGL c. 152 can e
ane up to$1500.00 and/ _ lad to the imposition of
or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and
of a
of up to$250:00 a day against the violator. Be-advised ER and a
vised that a nue
Investigations of the DIA for insurance coverage verification.CePy of statement may be forwarded to the Office of
I do hereby certify under the pains and penalties of perjury th¢t the in jormazion.provided above is true and correct
Sit=uature:
Phone M -
Official use only. Do not write'in this area, to be completed by city or town officiaL
f
City or Town Permitucense#
Issu►ng Autboriiy(circle one):
1.Board of Health 2.BuRdinb Department 3. City/Towu Clerk 4.Electrical Inspector 5.Plumbing Ins
6. Other b pector
Contact Persurt:
Phone'#:
Information an` d Instructl®ns
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 tine legal representatives of a deceased employer, or the
receiver or trustee of an individual,partnership,association ox-other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartrriL ents and who resides therein,or the occupant of the
dwelling house of another who employs persons to do mainte n=ce,construction or repair work on such dwelling house
or on the grounds or building appurhrnan thereto shall not because of such.employment be deemed to be.an employer."
MGL chapter 152, §25C(6)also states that"every state or Io.cal 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
ent=into any contract for thei performance of public work'nm-til 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-contractors)name(s),addresses)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'comp ration 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 satire to sign and date the affidavit. The affidavit should
be rvt'uued t0 the oily or`tin II that the cud hGa.`uTCn for the Pere it'or license is being regi esfed,'not the L�epartTM�t oI
Industrial Accidents. Should you have any euesedon;s regard'ir g the la T or if you are%�;ifired to ob'air,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 perimits 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 oflnvesfigations 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,lelephone.and,faznumber: .
The COMMOnwealtt of Massachusetts.
Department of Industri.aI Accidents
-01-fice of lw estigatieons '
600 Washinatcm Street
Boston,ILA 02111
Tel. # 617-727-4900 m-t 40.6 or 1-9 77-KkSS_AFE
Revised 5-26-05 Fax#6.17-727-7749
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