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HomeMy WebLinkAboutMiscellaneous - 436 MASSACHUSETTS AVENUE 4/30/2018 436 MASSACHUSETTS AVENUE ,_ 210/033.0-0031-0000.0 f 1 Date. .. . .. . . .. .. . . . ... .. AORTH TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION y9SSACH This certifies that . . . . . . . . . . . has permission for-'gas installation—.-. . . . . . in the buildings of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . at .6. . . . . . . . . . . .I North Andover, Mass. Z' Fee �- ... . . . Lic. GAS IN EGfOR Check# Ti 14 MASSACHUSETTS 041FORM APPLICATION FOR PERMIT TO DO GAS FITTING (Type or print) Date -z NORTH ANDOVER,MASSACHUSETTS Building Locations �AV Permit# Amount$ Owners Name 7� •.r.6 1 0 New❑ Renovation Replacement P Plans Submitted ❑ a o x F m° z z F w c o x °o z H ww z a x a a w w w H x x z W > W Z C d d O O W C O W F x o x 3 c a > ❑ w F o SUB -BASEM ENT BASEM ENT 1ST. FLOOR 2ND . FLOOR 3RD . FLOOR 4TH . FLOOR 5TH . FLOOR 6TH . FLOOR 7TH . FLOOR 8-T H . FLOOR (Print or Wee) Check one: Certificate Installing Company Name J O 5�'. 79y'YI/l.0 > �` ❑ Corp Address V 1 Partner. ;!BusinessTelephone [aFirm/Co. y�Name of Licensed Plumber or Gas Fitter S INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes V9— No� If you have checked yes,please indicate the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity13 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 E] Agent 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 Permit Issued for this application will be in compliance with all pertinent provisions ofthe ass chusetts State Ga 71, ode and Chapter 142 of the General Laws. By: Signature of License Plumber Or Gas Fitter . Title B—'Number � ) 2),(-71 City/Town Gas Fitter 17cense Number Master APPROVED(OFFICE USE ONLY) Ellurneyman �1 The Commonwealth of Massachusetts Department of Industrial Accidents Office ofinvestigations 600 Washington Street Boston, MA 02111 www.mas&gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information - Please Print Lea><bly Name(Business/Organization/Individual): () Address U City/State/Zip:.�O(? Phone#: J��l�(� (717 4.91`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 I employees(full and/or part-time).* have hired the sub contractors 6. ❑New construction 2.Dam 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. �o workers' coin insurance 5. 9. Building addition p. ❑ 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.]t employees. [No workers' comp.insurance required.] 13.0 Other ;.Amy applicant that checks box##1 must also fill out the section belox,s:^<^gi b trey;e errs'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. $Contactors 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 r )ate: 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 civilenalties in the form rm of a STOP WORK 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 d a fine Investigations of the DIA for insurance coverage verification. I do here c rh under the pain a d enalties o h'. P P ofperjury that the information provided ab ve is true and correct Si ._____... Date.: r� Phone#: FFBoard nly. Do not write in this area, to be completed by city or town official. Town: Permit/License# ority(circle one): ealth 2.Building Department 3.City/Town CIerk 4.Electrical Inspector 5.Plumbing Inspector [6. Other Contact Person: Phone#: a., 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, orthe 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 notbecause 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, §25CM 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 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 bum leaves etc.)said person is NOT required to complete this affidavit. . The Office of Investigations would like to than 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 Investitbations 600 Washington Street Boston,MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax# 617-727-7749 vm w.mass.-gov/dia Q NORTF1 O A « i i NORTH ANDOVER BUILDING DEPARTMENT °+♦rao�0�49 400 Osgood Street SSACHUSE Tel: 978-688-9545 Fax: 978-688-9542 BUSINESS FORM FOR TOWN CLERK DATE: NAME: - CLiq -7LC- ADDRESS: ZONING DISTRICT: TYPE OF BUSINESS: t sbylr\ D(je--r BUILDING LAYOUT PROVIDED: YES _ /� NO AVAILABLE PARKING SPACES: V - / /-( ZONING BY LAW USAGE: YES NO ✓ BUILDING INSPECTOR SIGNATURE Z-"/is � � s Revised 11.5.04 l J S 1 l Lc S BUME.SS FORM FOR TOWN CLERK awe Stil�� T (PriNnt or Type) 9-UNIFORM APPLICATION FOR PERMIT TO DO-OASFITTINO NORTH ANDOVER , Mass. Date J��',,01,7— S tg �?D Building tl r Location 3 /� ,S'SyG� Permit # J 9�s/�1 o rl t.2 Owner's z Name New Renovation p Replacement O Plans Submitted: Yes p No [p ' r • h - h „' V Z ac 0 ae r x tl J h W hu 0 F y S M q Iia ac W O .'�J 0 X w f Z 0 01 '40 Ind M J F, W ® W v W i W 'o d mom. , a °u a°c y a a thin-13111kIT. OAGIMEHT , 10T FLOOR sae.FLOOR I alto FLOOR 1TH FLOOR 8TH FLOOR ' 8TH FLOOR TTHFLOOR r FLOOR Check one: Certificate Instailing Company Name_Ld J; Corp. Address [j Partnership ' C!J Firm/Co. Business Telephone 3� Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE: Check o�e- 1 have a current liability Insurance Polley or Its substantial equivalent. Yes M No O H you have checked yes, please Indicate the type coverage by checking the appropriate box. A liability Insurance policy Other type Of Indemnity O Bond O OWNER'S INSURANCE WAIVER: I am aware that the Ilcensee does no� have the Insurance coverage required by Chapter 142 of the Mass. General Lawa, and that my signature on this permit appllcatlon waives this requirement. Check one: na ure of Owner or owners en Owner O Agent O I hereby certify that ah of the details and Information i have submitted(or entered)M 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 Gas Code and Chapter 142 of the d T License: _ Tito umber a re o cense um elor as Fitt r Gasfltter City/TownMaster License Number '9 7� �Joumeyman APPf"VE0(OFFICE USE ONLY) �? � Date. . . ORT M TOWN OF NORTH ANDOVER 0� op PERMIT FOR"GAS INSTALLATION . �- 9 , ,SSACF'UStt 4 This certifies that . . . . . . . . .` .. . . . . . . . . �.. has permission for gas installation ?T�)S115Z. fE �/1 !! f ^�irJ i in the buildings of. . . . . `. .,, . .� .wa,�;� . . . . . . . . . . . . . . . . at ��. . . .�.,.,. .�.;... q-..::, North Andover, Mass. Fee. G Lic. Noep). ` .� ff� j Z GAS INSPECTOR WHITE:Applicant CANARY: Building Dept. PINK:Treasurer GOLD: File MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO 130 CASFITTIN' G (Print or or Type) _ NORTH ANDOVER Mass. Date - / D /;� I uilding Location Permit # l � r R Owners Name�1&,f,! Jam-'71; • New -7 Renovation D Replacement Plans Submitted D '� FIXTUP.ES N , � W y h W us m Q o v Cd I x rn �-cc l- a >- z %- o h � Z m L&A H h W W O O W h N � W t3 V W O) W 4 cc Q D > W W W to ; Z d = a = a a us f. w I-- = co is W O 2 d W J G Cr F H O ? 0 h- l I- sat py O � W O N Z d ,u > C W O 6 G d < O O W _ O W N c x v O aL 3 n c7 ..t U cz y a a h o SUR—r3St.lT. ' BASEMEMT ' 1ST FLOOR i ?RD FLOOR 3RD FLOOR 4TH FLOOR STH FLOOR I 6TH FLOOR 7TH FLOOR 8TH FLOOR (Print or Type) ,/ Check one: Certificate Installing Company Name��f�/.P� �� ft Q Corp. Address ��,e,� - Partner. 7��Firm/Co. Business Telephone: 60-3 2-K3 4`07-L Name of Licensed Plumber or Gas Fitter ,OE 1 -,,5.,e 5� � Insurance- Coverage: Indicate the type of insura-:ice coverage by checking the appropriate box: Liability insurance policy �ther 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 three insurance coverages. Signature of owner/agent of property Owner = Agent I hereby certify that all of the deuds and information I have submitted (or entered)in above application are true and accurate to the best of my knowledge and that lU plumbing work and Installations performed under Permit issued to. this application will be in compliance with aL pertinent provisions of the Massachusetts State Gas Code and Cliapter 142 of tho General Laws. By YPE LICENSE: h1 Plumber Title Gasfitter Signature of LicensedPlumberCity/Town- Master Plumber or Gasfitter APPROVED (OFFICE USE ONLY) Journeyman License 7 um be` t _ Date. . . . . ,.pRTM TOWN OF NORTH ANDOVER pF 4,.ao 4, PERMIT FOR GAS INSTALLATION • 1 ^ • 4 I �9SSACHUSEt This certifies that . . . `. . .. . ..� '. . . . . . . . . . . . . . . . . . . has permission for gas installation . . . :�!!� . .. .�. . . . . . . . . in the buildings of . . °`... :.. . . ,.r . . . . . . . `. . . . . . . . . at . .���; - . ... North An er, Mads. Fee. X: -- -7-Lic. No,! /7' t{ . . . INSPECTOR WHITE:Applicant CANARY:Building Dept. PINK:Treasurer GOLD:File