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HomeMy WebLinkAboutMiscellaneous - 56 MAPLE AVENUE 4/30/2018 56 MAPLE AVENUE 210/019.0-0010-0056.0 _ �lassachuctt•- Dclrutincnt of Public Sat ctN Board of Building_ Rc�gul:ttiOn. :tnd Standards Construction Supervisor License License: CS 73579 Restricted to: 00 { ''"*► STEPHEN E BOGUE III 7 SHEPARD WAY :. ". CANTON, MA 02021 Expiration: 7/17/2010 ( ouni.�i„n�r Tr#: 28263 C Boar o u� m egulatto sand Standards. lugHOME IMPROVEMENT CONTRACTOR Registration: 123963 Expiration: 4/29/2011 Tr# 281828 Type: DBA BOGUE ROOFING&REMODELING STEPHEN BOGUE 7 SHEPARD WAY CANTON,MA 02021 Administrator Date.:aL...�ff . /s............ OF NOR7h,� TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION gB�CHUg� This certifies that ..... rd..... .1............................................................................ has permission for gas installation ... UT !? e....................................... in the buillddi/ngsLS7 ....................:........................................................................................... at.s�.. ..................:...................... No Andover, Mass. Fee,. ?..9Q.... Lic. No. l .Q,,. .3 ......... .................................................... A INSPE TOR Check# ° 828 -` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY o f T� '�.�c/ --,_, — MA DATE I-2 I�PER wji # 6 JOBSITE ADDRESS Kms- _ OWNER'S NAME _ GOWNER ADDRESS TE =FAX TYPE OR OCCUPANCY TYPE COMMERCIAL I EDUCATIONAL ® RESIDENTIALO PRINT CLEARLY NEW:F.1 RENOVATION:El REPLACEMENT: PLANS SUBMITTED: YES© NO® APPLIANCES 7 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE1 FRYOLATOR FURNACE GENERATOR �- --- ---- -- ------- GRILLE INFRARED HEATER LABORATORY COCKS —( MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER I _ _- ( ( _ ROOF TOP UNIT TEST ONIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER ..........._.............. �.. .......... J= ==== _ -- _ — _._-._— - -•---�- -- --_ .-INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO _ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY � OTHER TYPE INDEMNITY Ej 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: OWNER 0 AGENT [�[ SIGNATURE OF OWNER OR AGENT 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 c pliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME �U(d1/ _ J LICENSE# L SIGNATURE MP-fp MGF� JP [I JGF 0 LPGI 0 CORPORATIONM# PARTNERSHIP®# LLC # COMPANY NAME: ADDRESS CITY STATE ZIP[E kP TEL FAX CELL EMAIL r1Oq"LyS ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION N S Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES �-i The Commonwealth of Massachusetts Department of Industritd Accidents Office of Investigations 600 Washington Street Boston,MA.02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Address: City/State/Zip: Phone#: 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 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. g F1 Building addition [No workers' comp.insurance 5. El 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.]r employees.[No workers' q 13.[j Other comp,insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. } r Homeowners who submit this affidavit indicating they a're doing all work and then hire outside contractors must submit a new 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. lam 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.#: ExpirationDate: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation-policy declaration page(showing the policy number and expiration date). ecoverage as re uiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a Failure to secure q p 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 may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certo under the pains and penalties ofperjury that the information provided above is true and correct Simature• Date: Phone#: 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.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other - - - Contact Person: Phone#: Information and Instruct.®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 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 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 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. d 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(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. 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 GommonwealthofMossachusetts Department of Industrial Accidents Office of InVestigation, 600 Washington Street Boston.,MA,02111 Tei,#617-727-4900 ext 406 or 1-877,MASSAFE Revised 5-26-05 Fax#617-727-7749 _ wwwanass,govfdla, XI MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) Mass. Date l - 31 _19 'v Permit#_ 7�b Building Location JT Y Y L P, v Owner's Name � A44A,JIIL� Type of Occupancy New ❑ Renovation ❑ Replacement 12}� Plans Submitted Yes ❑ No iY YW Z Q U u7 W w cr Cr O m _ ¢Cc m w Q ¢ O p Z fW W ¢ = Z v7 O 2 > w Lu W v) W Z Q = Q W W ~ W f- _ � Z ¢ W J ¢ R ♦- > to O Z LLQ ~ W J W Q = O C7 = LLp C7 5O ¢ > p a !- O SUB-BSMT. BASEMENT 1 ST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR 5TH FLOOR 8TH FLOOR -7TH FLOOR 8TH FLOOR Installing Company Name----2 �� lt6 A� ? Check one: Certificate Address `�— I.:1 Corporation I I Partnership Flu-0n.ess Tslaphonc E3r6 Iq-,r-1r-M/C0. �---` Name of Licensed Plumber or Gas Fitter.. INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch 142. Yes p/ No ❑ If you have checked yes, please indicate the type of coverage by checking the appropriate box. A liability insurance polis,- r Other type of indemnity 1-1 Bond OWNERS INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 oft_taes-613TTgraI Laws and that my signature on this permit application waives this requirement. Check one: Inature of Owner or Owner's Aaent ---- -- gen I hereby certify that all of the details and Information I have submitted (or entered) in above application are true and accurate to the beat 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 PI ode and hapter 142 of the General Laws. By T��yyppe�--oof License Title imiumbar ❑_ G�sfitter g ure o Lic d Plumber or as Fitter CIt /Town k(JLlafaster A r'nr V-F-D OFFI , - S - 1 n Journeyman license Number BELOW FOR OFFICE USE ONLY FEE NO: II APPLICATION FOR PERMIT TO DO GASFITTING OWNER: NAME & TYPE OF BUILDING LOCATION OF BUILDING: PLUMBER OR GASFITTER: ;;ICENSE NO: PERMIT GRANTED DATE: 19 GAS INSPECTOR r r i 4 i r 24-78 9 Date �/!�A. .... .. e C7 H NpRTI, TOWN OF NORTH ANDOVER CL pF ,e1�0 PERMIT FOR GAS INSTALLATION N P O 'rs ��no• �4h ,SSACHUSE� co 1 This certifies that . J). .1). . !:� .�.1.s. • . .C J'�• . . . . • • • • • • • • Q m has permission for gas installation . V—. ,l f, , , , , , • • , , . . . . . . in the buildings of . . . . . . . . . . . . . . . . . . . . . . . . . . . . .0. . at . . . 9/.' ' . ty.k. e . . . . .. North Andover, Mass. Fee. . A?.: . . Lic. No..//?.4::t. . LAS'CENS�POEC�;� . . . . . . . WHITE:Applicant CANARY:Building Dept. PINK:Treasurer t � MASSACHUSETTS UNIFORM APPLICATION FOR PER T TO DO PLUMBING o. (Print or Type) a N•/ky(Jd M �G , ass. Date �- �1 19 Permit#�- Building Location `�G M Owner's Name 0105- Type of Occupancy New ❑ Renovation 1-1 Replacement C]/- Plans Submitted Yes ❑ No L7— FEATURES z Crn U) z r: Y F¢_- Ui + U) Z (n ¢ m tt O= ~ Z O C7 d .r fn _w (n U) = Q Q W U) Y ¢ (n lL Z a Z H z ¢ m Q < w Q (n z o ¢ (n O ¢ n ¢ O (i w = r. 3 cr O z _Qcc (J ~ w 1 ll (n ¢ J v Z Z Y Ill Y m o 0 5 3 °z i¢- 0 � c¢7 Z) o Q 3 ¢ m 0 SUB•BSMT. - BASEMENT ' 1ST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR 5TH FLOOR 6TH FLOOR 7TH FLOOR 8TH FLOOR Installing Company Name �' `✓ �e�tX9 _` Check one: Certificate Address �1 � 17 Corporation O 4& 11 Partnership � Business Telephone I U a! J�4 Girm/Co. '-- Name of Licensed Plumberd t✓� t`3��-LS INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch 142. Yes No ❑ If you have checked yes, please indicate the type of coverage by checking the appropriate box. A liability insurance policy C Other type of indemnity 1.-1 Bond F] OWNERS 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: SI nature of Owner or Owner's Agent — Owner O Agent ❑ I herebycertify 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 the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Plu ing Code and Chapter 142 of the General Laws. By igna ure o icen er - Title Type of License: Master V.1�- Journeyman D City/Town License Number__ APPROVED OFFICF USF ONI.Y) BELOW FOR OFFICE USE ONLY FEE NO: APPLICATION FOR PERMIT TO DO PLUMBING OWNER: NAAE & TYPE OF BUILDING LOCATION OF BUILDING: PLUMBER OR GASFITTER: LICENSE NO: PERMIT GRANTED DATE: 19 I PLUMBING INSPECTOR Date. r� ► � . --3617 NORTM o TOWN OF NORTH ANDOVER a PERMIT FOR PLUMBING SSACMusEtl(°� This certifies that AD.. . .Ut(=. 4 �.s �a°� has permission to perform . . W/ . . . . . . . . . . . . . . . . . . . . . . . . . . . . plumbing in the buildings of . . . �. . . . . . . . . . . . at. �_.h*14,/£. . `!,t, . , . . . , , North Andover, Mass, Fee. .j:fit. . . .Lic. No /A 4�9. . . . . . . - . . . . . . . LUMBING INSPECTOR 02/20/98 08:38 15.00 PAID WHITE: Applicant CANARY: Building Dept. PINK:Treasurer Date/...��."d....�F.�... R jhj + OL TOWN OF NORTH ANDOVER .6 PERMIT FOR WIRING ww"VVI CHU This certifies that ........... ...... ................................... has permission to perform .............................. wiring in the building ............................................................. at ..................... ................. North Andover,-.......... Mass. Fee........ . .. ............ Lic.No:�4�'�A ...... . C.;�L �S OR Check # 1713 4 7960 .i Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT ININK OR TYPE ALL INFORMATION) Date: I — / S => ,& City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) 5(A m .Lt= kVE Owner or Tenant �E F_2- MvD .l a�. t- O i s Telephone No. 01b j Owner's Address Is this permit in conjunction with a building permit? - Yes 0 No ❑ (Check Appropriate Box) Purpose of Building_ �Es Utility Authorization No. Existing Service 160 Amps / Volts Overhead ❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: 32p F�o� ?� 7P Completion of the ollowin table may be waived by the Inspector of Wires. No,of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires 4t Swimming Pool Above ❑ In- ❑ o.o Emergency Light—mg rnd. rnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Znes No.of Switches e6 No.of Gas Burners No.of Detection and InitiatingDevices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons g No.of Waste Disposers Heat Pum Number Tons KW o.of Self-Contained Totals -. . ..... . . ..... Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW <00 0 Local❑ Municipal Connection ❑ Other No.of Dryers Heating AppliancesKW Security Systems:* No.of Devices or Equivalent No.of WaterNo.KW No.of No.of Data Wiring: Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work (When required by municipal policy.) Work to Start: i - /C v e Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury,that the information on this application is true and complete. 5 FIRM NAME: _J�V�414 C- Al LIC.NO.: 3 /3 2.t..- Licensee: 0",0 CY,4,Af Signature 7,7174,— C �' ,,�,..� LIC.NO.:�3 /3 2 (If applicable, enter"exempt"in the license number line) r Bus.Tel.No. �'�'�' 6�c -6 Scl Address: _// /V� A._T1_( 4OLigLt: S� I"'�rT//ft r N MA 0I44 Alt.Tel.No.: *Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one) ❑owner ❑owner's agent. Owner/Agent cs Signature Telephone No. PERMIT FEE: ,\'b , " 1. r x The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Ali;tt; 600 Washington Street i� Boston, MA 02111 cam; www.nzass.gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/plumbers Applicant Information Please Print Ledlily Name (Business/Organization/Individual): : Otl(--( N' Address:jj City/State/Zip: "-rl1L -0' ktiq Z)1d4-9 Phone #: . -<ti,1 Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ 1 am a general contractor and I 6. ❑New construction employees(full and/or pari-time).* have hired the sub-contractors 2. I am a sole proprietor or partner- listed on the attached sheet.t 7• ❑ Remodeling ship and have no employees These sub-contractors have S. ❑ Demolition working for mein any capacity, workers' comp. insurance. q, ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its 10.7Electrical repairs or additions required.] officers have exercised their 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself.[No-workers'comp. c. 1.52, §1(4),and we have no 12.❑ Roof repairs insurance required.)t employees. [No workers' . comp. insurance required..] 13.❑Other *Any applicant that checks boy'#I must also fill out the section below showing their workers'compensation policy information. r Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tCont actors that check this box mustattached 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. Lie.#: 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 may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby certify der the pains andpenalties ofperjury that the information provided above is true and correct Signature: <1 • Date: Phone# 4`� L 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.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector y 6.Other Contact Person: Phone#: �f 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,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 liednsing agency shall withhold the issuance or renewal of 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-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 peimit or license is being requested,nofthe 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 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 Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street r Boston, MA 02111 Tel. #6I7-7274900 ext 406 or 1-8.77-MASSAFE Revised 5-26-05 Fax#617-727-7744 www.mass.gov/dia r 2� Date �S 0 r ".O RT:��a TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING I •' ,SSACNUS� I. This certifies that61.4 � �,� !. .( . . . . . . . . . . . . . . . . . . . . . . . has permission to perform . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . /y1r1 OT I s plumbing in the buildings of . . .'. . . . . . . . . . . . . . . . . . . . . . . . . . . at . . . 6 . !r5,r?1A e . . . . . . . . . . . . .. North 'Andover, Mass. Fee. � . Lic. No..! @.Ia r . . . . . . . . . . . . . . . . . . . . . . . . . . -.may PLUMBING INSPECTOR Check 7626 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING & City/Town:.North Andover MA. Date:L01/14/2008 Permit# BuildingLocation: 56 Maple St. ,- , Owners Name: OT l S Type of Occupancy: Commercial Educational 7Industrial Institutional Residential LY/ New: Alteration: Renovation: Replacement: Plans Submitted: Yes P Nor FIXTURES z z U) o LU zY V N } J = FN— W W a z � Y ga N a a W z 0 z 3 in x ga a w W ~ W z ai Y W o a X ga j � g W G t- z W 0 ga W i W rn z V a 1d x 3 0 0 1- 3 = z a LL3 0- Y a x w w W Y = a m m o o °x Y o°c ai ai 0 SUB BSMT. BASEMENT 1 FLOOR 2 No FLOOR 3 FLOOR 4 FLOOR --5'FLOOR 6 FLOOR 7 FLOOR -i'FLOOR 1 901` Check One Only Certificate# Installing Company Name: INagliaroPlumbing ---, Corporation Address: 29 Border Winds Ave. City/Town Seabrook N7 ' -- - - - - - State: Partnership - Business Tel: 603-394-0526 Fax: -- Finn/Company L T ry Mike Ma liaro �I - Name of Licensed Plumber: _ __.—g__. INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Yes ✓ No If you have checked Yes,please indicate the type of coverage by checking the appropriate box below. A liability insurance policy L� ' Other type of indemnity Bond d � - OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. Check One Only Owner Agent 1'1 Signature of Owner or Owner's Agent - 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 Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. By. Type of License: G C Title T -- _ ✓ Plumber Signa re of lice sed umber ✓ — Master F APPROVED OFFICE USE ONLY citJourneyman r! License Number: 112921 - — - The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ` a ' 600 Washington Street Boston, MA 02111 www.mass.gov/dia ` Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lehibly Name(Business/Organization/Individual): Address: • City/State/Zip: tole AWY G Phone.#:_ &6 •3�7•�-cG5 Z Are am a employer with Z ou an employer?Check tate appropriate boa: 1. ' 4. I am a general contractor and I Type of project(required):,, I � .114 employees(full and/or part-time).* have hired the sub-contractors 6.- El New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7.JQLRernodeling ship and have no employees These.sub-contractors have g, F�Demolition working for me in any capacity. employees and have workers' o workers' co co insurance.$ 9• ❑Building.addition [N comp.insurance comp. required.] 5. We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doingall work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL insurance required.]t c.-1 52, §1(4), and we have no 12.[]Roof repairs eployees. [No workers' 13.0 Other comp. insurance required.] *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. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractorshave employees,they must provide their workers'comp,policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: /L.(� /,.y S ,• ,7$ -/� Policy#or Self-ins. Lic.#: Expiration Date: . lob Site Address: —�f". /YZ A;;lC(" S-s City/State/Zip: Attach a copy of the workers' compensation policy declarationa e(showing the o P g ( g p hcy 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. I do hereby certi&u der the pains and pen 'es Arperjury that the information provided above is true and correct Si a e �41,,XAli Date: Phone#: Officiatuse 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.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6,.Other Contact Person: Phone#: I 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,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"ever state or local licensing agency shall withhold the issuance or renewal of a license or permit to,bpera`te�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 fm 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 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 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 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 Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel.#617-727-4000 ext.406 or 1-877-MASSAFE ` Revised 1122-06 Fax# 617-727-7749 wWW-mass.govldia