HomeMy WebLinkAboutMiscellaneous - 49 VILLAGE GREEN DRIVE 4/30/2018 (2)Date.. A�? i .......
o? TOWN OF NORTH ANDOVER
•X PERMIT FOR GAS INSTALLATION
ACHUSEt
This certifies that ... n.!�!' t. «'... .! .� .
has permission for gas installation ..... ........ .
in the buildings of...�L..°.............................
at 't. 3J-- . `. t � u ! CrthAndover, Mass.
Fee,.T7 ... Lic. No...,// O:i' :.` Vll
GAS INSPECTOR
Check # 131(/
6768
MASSACHUSETTS IJN mRM APPUCA7MN FOR PERMIT TO DO GAS FITTING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS Date Ll 21 0
Building Legations '35 "9 9 V %'AQ
- Arz
Owner's Name
New Renovation n Replacement El
SU B-BASEM ENT
BASEM ENT
IST.
FLOOR
2ND,
FLOOR
3RD,
FLOOR
4TH,
FLOOR
5TH.
FLOOR
5TH.
FLOOR
7TH,
.FLOOR
VFH,
FLOOR.
(Print or type)
Name_
Address 9�
ussiinessTeien nne 4`'' %
Permit # 0 16
Amount $ %
URA
Plans Submitted ❑ "
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Name of.Licensed Plumber'or Gas Fitter
Check one: Certificate Installing Company
0 Corp.
ElPartner.
21 Firm/Co.
INSURANCE COVERAGE
I have a current liability Insurance, policy or it's substantial equivalent Check one:
If you have checked des, please indicate the a cove Yes
Liability insurance olic Type by checking the appropriate box.
policy � Other ty a -r; d
No[:]
V m emnity D Bond
Owner's Insurance Waiver 1•
am aware that the licensee does not have the Insurance coverage required by Chapter 142
Mass. General Laws, and that my signature on this Permit application waives this requirement. of the
Signature of Owner or Owner's Agent Check one:
wner
i hereby certify that all of the details and information 1 have submitted (or entered) in above application 13 a and
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in
• accurate to the
compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter .142 of the General Laws.
By: Sign a of Licensed Plumber Or Gas F'tte
City/Town,
APPROVED (OFFICE USE ONLY)
® Plumber WA r
Gas Fitteri
License um er
Master
Journeyman
Y
1
''jrrjI`1
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„.f MI
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The Commonwealth of Massachusetts
Department of Industrial Accidents.
Oflice of Investigations
600 Wasliineton Street
L'oston, M4 02111
WW'WP?24SS.e Ild
Acia
Workers' Connpe>asatioa In. .6a
�uijders/Contractors/Eleeir�ciaa
a.nt Iafornzation s/Plumbers
Name (Business/OrganizabonMdividual):
Address:
City/State/Zip:
Phone #:
Are you an employer? Check the appropriate box:
❑ I am a employer with 4. ❑ I am a oA
empioyees (r'ull and/or part-time),* L- 'ai contractor and I
?. ❑] i am a sole proprietor or partner-
ship and have no employees
working for me in any capacity.
[No workers' comp. insurance
required.]
3. ❑ I am a homeowner doing all work
myself. [No. workers' comp.
insurance required.] t
have hired the sub -contractors
listed I the attached sheet t
These strb-contractors have
workers' comp. insurance.
❑ We are a corporation and its
officers have exercised.thetr
right of exemption per MGL
C. 152, § 1(4).and we have no
.emPloyees. [No .workers'
comp, In
Type of project (required):
6• ❑ New construction
7• ❑ Remodeling .
8. ❑ Demolition
9. ❑ Building additi-on
10.0 Electrical repairs or additions
11.[] Plumbing repairs or additions
12:0 Roof repairs
cheo urance regatred.] I 13 0 Other
+ 7'lo`n COWI M twho sub ill -filk a,i da it dicatli�u t}iey � � i`secfion bel�ow shouting their workers' compensation poltc}� rnmrmahon.
2�.Onu=tors that Ch=j, this box most e V t r ..#rte s htrr
tttached an additional street showirtg t outside conirxciurs muni su'rnnii a new amriavit inditxtirt� s ch.
he na.ne offh-
,- - +iib-Cuuu`aCtOr$ 8a({ titrir v.
crrrfscr,J.�; acct a provedung workers' compensation c __._ —."I" ,,,, 3. mronmtlon.
information assurance for n9' e�np[oyees. Below [s theoft
P c) and job site
Insurance Company Name:
Policy # or Self -.ins. Lic. #:
Expiration Date:
Job Site Address:
Attach a copy of the workers' Failure to securcompensation otic decla City/S1ate/Zip:
P y ration page (showing the policy e coverage as required under Section 25A of number and expiration date).
MGL c. 152 cmposition of criminal penalties of a
fine up to $1,500..00 and/or one-year imprisonment, as well as an lead to the i
civil penalties in the form of a STOP WORKORD
of up to .1250.00 a day against the violator. Be advised that a copy of this statement may ER and a fine
investigations of the DIA for insurance coverage verification. } be forwarded to the Office of
pacne sass penalties of per iirj� that the information provided above is True and correct
Official use only. Dn not write in this area, to be completed city or town official
City or Town:
Issuitag Authority (circle one): Permit/1,icense
I. Board of Health 2. Building Department
6. Other 3. City/Town Clerk 4 g Electrical Inspector S. Plumbin
b I nspector
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 ".. everry 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 includi-ng the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, associati on or other legal entity,employing employees. However the
owner of a dwelling house having not more than .three ap artments 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 a r local licensing agency shall withhold the issuance or
renewal of a license or permitto operate a business or to construct buildings in the commonwealth forany
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 wor]ic 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 comps-etely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contra.ctor(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 r
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. Theaffidavitshouid
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 re -Pi -.-ding the lww or if you are requited to obtain a workers'
compensation policy;please call the Department at the rim ber,lis�wd below. Self insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the:'kftfidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit foryou to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the perrmit/iicense number which will be used as a reference number. In addition, an applicant
that must submit multiple petmitnicense applications in arty 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 Iicenses. A new affidavit must be filled out each
year. Where. a home owner or citizen is obtaining a licenses 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 t6 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 Comsnonw-tadth of Massachusetts
Department of lmdustrial Accidents
Office of Iavestigations
600 WashLi gton Street
Briton; MA (12111
Tel. # 617-727-4900 e):t 406 or 1-977-MASSAFE
Revised 5-26=05
Fax 4 61 7-r-7-7749
v<Fwu.m ass. a ov/di:a
4
Date.
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that
.................... :-1 ...... 7 .................
has permission to perform ... .....................
plumbing in the buildings of (c .........................
at ... -� !^.PjRorth Andover, Mass.
Fee. 2?. Lic. No. ... ...... ..... .........
PE
PLUMBING INSPECTOR
POR
Check #
8054
A ,
MASSACHUSETTS UNIFORM AppLICATION FOR PE
4 ° RMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER MASSACHUSETTS
Building Location 3—�q �a�lotq
of
New Q Renovation Replacement '
Date y0
Permit #21y�y
Amount — -� c
Plans Submitted YesNo
. El
installing.Company Name--\ J n\ '?,v Check one: Certificate
Address `J �( P.A �`1�� A�, � Corp.
�L� te e.\d. 1�1A Ci1�Y�i n Partner.
usm .ss. elephone t
Firm/Co.
Name of Licensed Plumber. _ 3bhY-N :. ,
Insurance COveraze: Indicate the type of insurance coverage by c
Liheckin
ability insurance policy Other type of indemni g the appropriate b
Three insurance ox:
tY � Bond El
Insurance Waiver. I the undersigned, have been made aware that the licensee o f this application does not have any one of the
above
Signature ❑
Owner Agent ❑
I hereby certify that all of the details and information I have submitted
best of my knowledge and that all plumbing work and installations (or entered) m above application are true and accurate to the
compliance with all pertinent provisions of the Massachu efts tate p
pe ormed under Permit Issued for this application will be in
By:
Co d Chapter 142 of the General haws.
ianature �. "r�n� rr
�Titie Type. of Plumbing License
City/Town \i D1A
APPROVEDLicense vumoer Master
(oF!-iCE USE Ot�n.Y Journeyman ❑
Are you an employer? Check the appropriate box:
I he commonwealth of Massachusetts
j
Department o ,f Industria114ccidents
Offlee
Type of project (required):
of Investigations
;
600 W
ashinoQton Street
'
Boston , MA 02111
C i- e diQ
Workers' Compensation Insurance .A�cl;avit: guilders/Contraactors/Eiectricians/Piumbers
At►iieant Infomation
r
sub -contractors have
workers' comp. insurance.
Name
Please Print Leaibii
(Business/organization/individual): n1,'Ni
Address:
��Of- �\ 1A
City/State/Zip:
.10:❑ Electrical repairs or additions
work
myself. [No workers' comp,
Phone #:
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with
4. ❑ I am a a contractor
Type of project (required):
employees (ffill and/or part-time).*
2 i am a sole
general and I
have hired the sub -contractors
.6. ❑ New construction
proprietor or partner-
ship and have no employees
Iisted oxi the attached sheet 1
These
7• ❑ Remodeling .
working for me in any capacity.
sub -contractors have
workers' comp. insurance.
R. ❑ Demolition
[No workers' comp. insurance
5. ❑ We area corporation and its
9. ❑ Building addition
3. ❑required.]
I am a homeowner doing all
officers have erercised.their
.10:❑ Electrical repairs or additions
work
myself. [No workers' comp,
right of exemption per MGL
c. 152 1(4),
11. Plumbing repairs or additions
insurance required_j t
and we have no
employees. [No .workers'
12:❑ Roof repairs
coinsurance required.]
Any applicant.that checks box mp, # 1 .must also fill out the sectian below showing
t�
13.[] Other
Homeownem who submil,lui . asdevit indicatinG t,'tey arc doing En V.,f :e; Biu �� him aaiSiQE cont( lUi6' alu$Ly inform
tieeir workers' compensation policy infomuttion.
Canmu tors that eheck this box must ataiched an additional sheet sh- irts the name. now al`ndaVEC lndi�
...
off. _ -.1 ccnnaetors and
.such.
fheir workLm, �,,,., ,.r:_. _-.--
••..1...1. inaz isP`o'A&r, workers' comp=afiorz i urefor g� r. - J ....-j,
i0ormation employees,
Below is theoft
P cy and job site
Insurance Company Name:
Policy # or Self -.ins. Lic. #:
Expiration Date:
.lob Site Address:
Attach a copy of the workers' compensation policy deciaration as City/State/Zip:
.Failure to secure coverage as required under Section 25A of p be (showiQe the policy number and expiration Efate).
c. 152
lead to
imposition of cr
fine up to $1,500.00 and/or one-year imprisonment as well as civil penalties in the orm of a STOP WORK O imina1 penaltiesRDER and a of a
of up to .S250.00 a day against the violator. Be advised that a copy of this statement may A fine
Investigations of.the DIA for insurance coverage verification. be be forward. d to the Office of
t do hereby certify under the pains and penalties oJperrurj, that the information provided above is true and correct
Signature:
Date: Z'7 Q of
Phone #: - b
Official use onlp. Do not write in this area, to be completed by city or town ofciaL
City or Town:
PermitlLicense #
Issuing Authority (circle one):
I. Board of Health 2. Building Department 3. City/Tovvn
6. Other Clerk 4. Electrical Inspector $. Plumbing Inspector
Contact Person:
Phone 4-