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HomeMy WebLinkAboutMiscellaneous - 48-50 WATER STREET 4/30/2018Date..... . �.q. .-....... I L4 ..-..I ...... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ..... . ... V-YX ... 0.1.�--7 ...... has permission for gas installation in the buildings of ... ...... .................................................... L4 k -U 4kkT- zS T— at ......................................................................... t ........................ . North Andover, Mass. Fee ........ ............. Lic. No. ..........c� ..I ....... ........... .... ... .. GASINSPECTOR q Check # 8905 MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES 10'NO Ej 1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVE GE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY I OTHER TYPE INDEMNITY BOND ED 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. ONE ONLY: OWNER SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this applic tion are true; and that all plumbing work and installations performed under the permit issued for this application will in complia Massachusetts State Plumbing Code and hapter 142 of the General Laws. PLUM BER-GASFITTER NAM LICENSE #2W MP 18 MGF El JP (1 JGFLPGI © CORPORATION)D# PARTNERSHIP COMPANY NAME _I f.10� �j— _ _ DDRESS CITY I�Ca �ti- �. _. .. —__ __.._ I STATE ZIP TEL FAX _ _ ...._ ....) CEEMAIL Si LLC [3(# the MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING CITY t 'W'ORK 6 v MA DATE PERMIT # 0 JOBSITE ADDRESS OWN R'S AME F�t GOWNER ADDRESS TE FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ® RESIDENTIAL PRINT IA CLEARLY NEW:Z RENOVATION: REPLACEMENT: ® PLANS SUBMITTED: YES _[�_1 NOD APPLIANCES 1 FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER_, BOOSTER I CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE _ I FRYOLATOR FURNACE v GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS _ . _ � s1 _ _. L-2-- I_—.-. J ____ 11 11 MAKEUP AIR UNIT OVEN POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES 10'NO Ej 1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVE GE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY I OTHER TYPE INDEMNITY BOND ED 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. ONE ONLY: OWNER SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this applic tion are true; and that all plumbing work and installations performed under the permit issued for this application will in complia Massachusetts State Plumbing Code and hapter 142 of the General Laws. PLUM BER-GASFITTER NAM LICENSE #2W MP 18 MGF El JP (1 JGFLPGI © CORPORATION)D# PARTNERSHIP COMPANY NAME _I f.10� �j— _ _ DDRESS CITY I�Ca �ti- �. _. .. —__ __.._ I STATE ZIP TEL FAX _ _ ...._ ....) CEEMAIL Si LLC [3(# the H O z 0 H U W a � W c ❑ z z O W N rl } O W O 3 z a W W G5�] w W CO a o a a Un ry E, U J a CL a � � x F- w W LL- W Ei O z 0 H V W a N1 V` - °a li The Commonwealth of Massachusetts Department of IndusiriglAccidents Office of Investigations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/ContractorsfFIectricians/Plumbers Applicant Information Please Print Legib Name (Business/Organization/fndividual): Address: -7 � ,� -7&2 City/State/Zip: Phone Ar ou an employer? Check the appropriate box: 4. ❑ I I Type of project (required): ' 1. I am a employer wish am a general contractor and g 6. [] New construction employees (full and/or part-time),* 2111 am a sole proprietor or partner- have hired the sub -contractors listed on the attached sheet. ? 7. E] Remodeling ship and'have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. g, El Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.E] Electrical repairs or additions required.) 3. ❑ I am a homeowner doing all work officers have exercised their 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.] ► employees. [No workers' • 13.[:]Other comp. insurance required a *.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 tie doing all work and then hire outside contractors must submit anew affidavit indicating such. tContractors 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 information. -Insurance Company Nair. compensation insurance for my employees. Below is thepolicy and job site Policy # or Self -ins. Lic. #: ExpirationDate: Job Site Address: �� �ti- r 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 requiredunder Section 25A of MGL e.152 can lead to the imposition of criminal penalties of a fine up t 500.00 and/or one=year impr ent, as well as civil penalties in the form of a STOP WORK ORDER and a fine of)af to $250.0 ay agai t th._violatq e a4vised that a copy of this statement maybe forwarded to the Office of Hereby eertlo u e t7 e ai 1s ancdpe*tils ofperjury that the information provided above is true and correct. 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. CitylTown CIerk 4. Electrical Inspector 5. PIumbing Inspector 6. Other - - - Contact Phone #• 0 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 ofhire,• 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 Ideal 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 -contractors) name(s), address(es) and phone number(s) along with their certificates) 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 maybe 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 -P-lease be sure that the affidavit is -corn lete-and rintecl Ie ilii : The D e artmerit has rovided a s ace at the boffom p p g Y p P p 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 (ifnecessary) 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. Anew 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 would like to thank you in advance for your cooperation and shpuld you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Gornmonmalth ofMassa a useits Mp.aztent of fadustd l .Accidents Offiee of111veNtigati"ons 600 Wasbiiagtoa Street Boston, U& TQL # 61.7-727-4900 at 406 or 1 -877 -MASS AFF, Revised 5-26-05 Fax # 617727;7749