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Home My WebLink AboutMiscellaneous - 49 SUTTON HILL ROAD 4/30/2018 / 49 SUTTON HILL ROAD J 210/097.0-0015-0000.0 i Date,/-P//7k . ........ NOFTM pf, n ,'�'O TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION �,SSAC'NUSEt< This certifies that . . . . . . . . . . . . . . . . i has permission for gas installation ;. . ?'?? . . . . . . . . . .>�1�: '�!5W. .. . . . . . . . . . . . . . . . . . . . . .. . in the buildings o at . . fir . 0 ?. . �?`�. f , North AAd' ver, ass. Fee.wcL? Sb Lic. No/-M7. . . GAS INSPECTOR Check# 20 gZ t 7840 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING Cit /Town: 7 v — Y "�1 �� lj0j-eV� , MA. Date: lb,-i-7-! L— Permit# u � Building Location: I� S �`� I �4 Owners Name: Type of Occupancy: Commercial❑ Educational ❑ Industrial ❑ Institutional ❑ Residential`Q" New:<' Alteration: ❑ Renovation: ❑ Replacement: ❑ Plans Submitted: Yes❑ No❑ FIXTURES ui WW .14 Cd Zco Co Q = m WO W W U co N 0 = W W O Z Z p IY W D LU w O F- W � W m O F' W O Q F- in > W Z Q a F- W w X W ~ W Q CO 0 W W W Z CO = W O W Z W W Z O J F- F- O Z -1 0 ILL = W F W W v o o LL _ ' °= g O a � > > > o SUB BSMT. BASEMENT 15' F OOR 2 No FLOOR 3 FLOOR 4 1H FLOOR -F'—FLOOR 6 TH FLOOR 7 FLOOR 8 FLOOR T, Installing Company Name: Check One Only Certificate# ��"�� -i-i-.,�� r � � , El Corporation i. Address:c� gIrlo1��-\' City/Town:°'6 I State: ❑ (�►�3a Partnership 4 Business Tel: 97X 4�- D a�v- Fax: firm/Company Name of Licensed Plumber/Gas Fitter: INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Yes qt No❑ If you have checked Yes,please indicate the type of coverage by checking the appropriate box below. A 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 Massachusetts General Laws,and that my signature on this permit application waives this requirement. Check One Only Signature of Owner or Owner's Agent Owner El Agent F1 By checking this box❑;1 hereby certify that all of the details and information I have submitted(or entered)regarding this 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 Pelp ent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. By Type of License: `Plumber Title Fitter �Si nature of Licensed Plumber/Gas Fitter Rkmaster City/Town []journeyman License Number: 1-3-397 APPROVED OFFICE USE ONLY ❑LP Installer The Commonwealth ofMassachusetts Department of Industrial Accidents Office oflnvestigations 600 Washington Street Boston,MA. 02111 S•� www mass govldia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers _Applicant Information Please Print Legibly Name(Business/Organizationandividual): . F Address: 0-t 15C1 w; City/State/Zip:-8!ke2(jq t! W*f 01 P Phone#: Are you an employer?Check the appropriate box: 1•❑ I am a employer with 4. ❑ I am a general contractor and I 6. E of proj ect(required): employees(full and/or part-time).* have hired the sub-contractors 6 El construction 2•SkI am a sole proprietor or partner- listed on the attached sh%et. 1 �• ❑Remodeling ship and have no employees These sub-contractors have 8. []Demblition working for mein any capacity, workers'comp.insurance. IN workers comp. 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 insurance required.]t employees. 12,[]Roof repairs [No workers' COMP,insurance required.] 13.❑Other *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 ro viding workers con pensation znsurance for my employees Below is the policy and job site L information. . Insurance Company Name: y 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby cert' under the pains and penalties ofperjury that the information provided above is true and correct. Si nature. Bate: P.iione#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Is 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#: 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,ora'1 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 apartinents 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-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 cavy 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 fixture 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 C0111).,U0nwealth oa IVIassachusetts Department of Industrial Accidents Office of Investigations _ 600 Washington Street Boston;.M14- 02111. Tel.#617-727-,4900 ext 4406 ox 1877-MASS,AFE Revised 5-26-05 Fax#617,727-7749 Www.mass.gov/dia f COMMONWEALTH OF MASSACHUSETTS IN PLUMBERS AND GASFITTERS LICEN pT�:SAARAI TN& JPLUMBER - ALAN S FREEMAN Rf 24 PILGRIM RD HAVERHILL MA 01832-294 I t i i'. i t 4 'Y . i t i i L , ,�L CORS DATE(MMIDDIMY) .�- LL!! CERTIFICATE OF LIABILITY INSURANCE FRSE 1 06/14/11 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Michaud, Rowe And Ruscak Ins. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR P.O. Box 188 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. North Andover MA 01845 Phone: 978 688 8829 Fax:978 557 2130 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURERA: . Preferred Mutual Insurance Co. 15024 INSURER B: Alan Freeman C o R.T. Ratte Inc. INSURER C: 340 Mt Vernon Street INSURER D: Lawrence MA 01843 INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. NUK LTR NSR TYPE OF INSURANCE POLICY NUMBER DATE MNWDCTNE POLICY TION LIMITS GENERAL LIABILITY EACH OCCURRENCE $500000 OAED- A X COMMERCIAL GENERAL LIABILITY CPP0100600831 05/06/11 05/06/12 PREMISES Eaoocurence $100000 CLAIMS MADE OCCUR - MED EXP(Any one penton) $5000 PERSONAL&ADV INJURY $500000 GENERAL AGGREGATE $1000000 GEITL AGGREGATE LIMIT APPLIES PER- PRODUCTS-COMP/OP AGG $1000000 PRI POLICY JET LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) $ HIRED AUTOS - BODILY INJURY NON-OWNED AUTOS : (Per accident) $ PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS I UMBRELLA LIABILITY - EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ $ &T DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY YIN TORY LIMITS ER ANY PROPRIETORIPARTNERIEXECUTIVED E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? u (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION i DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN All ' /I � NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZ REPRESENTAT ACORD 25(2009/01) o ACORLTICURPORNTION. All rights reserved. The ACORD name and logo are registered marks of ACORD I