HomeMy WebLinkAboutMiscellaneous - 6 MILLPOND 4/30/2018 6 MILLPOND
210/095.A-0006-0000.0
p Date/ .'.�. '�.. ......
` .� NORTH,
:°�-" "° TOWN OF NORTH ANDOVER
PERMIT FOR WIRINGqLL
L
,SSACMUSE�
�/
This certifies that ... .........
has permission to perform ..../
.................................... ......
....
wiring in the building of....... . ..........
at...1..... ./f��/ � ........IV!............21'
North An over,Mass.
.�1.� - -
Fee...VC,?........ Lic.No—Al.
.. :
ELEC L%NSP
-Check # �
10.473 -
1012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance-with the provisions of M.G.L.c.143,§3L,the
permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be.filed E
on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166,§32,an
electrical permit shall be issued to the person,finn or corporation stated on the permit application. Such entity shall be responsible for the
notification of completion of the work as required in M.G.L. .143,§31.,.
Permits shall_be limited as to the time ofongoing construction activity,and may be_deemed_by-the Inspector-of Wires abandoned_and_invalid-ifhe---. _
or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written
application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written
request of either the owner .or.the installing entity stated on the permit application.
❑ The Permit Extension Act was created by Section 173 of Chapter 240 ofthe Acts of 2010 and extended by Sections.74 and 75 of Chapter 238 of
the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this
purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With
limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was
"in effect or existence"during the qualifying period beginning on August 15,2008 and extending'through August 15,2012.
ffOE]Per7imit
Permit/Date Closed: Z A ***Note:Reapply for new perm.
xtension Act—Permit ate Closed:
Commonwealth of Massachusetts Official Use Only
Department of Fore Services Permit No. l PY 722
rOccupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 (leaveblank
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 PRINTININK OR TYPE ALL INFORAfATIOI9 Date:
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) 7/_/_ pp lto /eli
Owner or Tenant d Se O Telephone No.
Owner's Address
Is this permit in conjunction with a building permit? Yes ❑ No � (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Existing Service Amps / Volts Overhead ❑ Undgrd❑ No.of Meters
r
New Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters
Number of Feeders and.Ampacity
Location and Nature of Proposed Electrical Work: /Qo 4� ec-7/e /_
Completion of the following table may be waived by the Inspector of Wires.
No.of Recessed Lumi nares No.of Ceil:Susp.(Paddle)Fans No.of Total
Transformers KVA
No.of Luminaire Outlets No.of Hot Tubs Generators KVA
No.of Luminaires Swimming Pool Above ❑ In ❑ o.o cy ig ng
nd. rnd. Batter Units Units
--. No.of Receptacle Outlets ` No.of OR Burners FIRE ALARMS No.of Zones
No.of Switches No.of Gas Burners No..haitiating Devices
No.of Ranges No.of Air Cond. Total No.of Alerting Devices .
Tons
No.of Waste Disposers Heat Pump I.Number I Tons KW No.of Self-Contained
Totals:I Detection/Alerting Devices
No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other
Connection
No.of Dryers Heating Appliances KW Security Systems:* -
No.of Devices or Equivalent
No.of Water KW No.of No.of Data Wiring:
Heaters 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: ,j0-00 (When required by municipal policy.)
Work to Start: f f!V -/� 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 cove ge is in force,and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE [BOND ❑ OTHER ❑ (Specify:)
I certify, under fiy4vyins and penalties ofper ury,that the information on this application is true and complete. eol-17
FIRM NAME: LIC.LIC.NO.: 423
Licensee: h v}/Zq0 Signature's LTC.NO.:
(Ifapplicabl,enter"ex pt"in the license number Zine. v/$� Bus.Tel.No.
• /1 f/
Address• l+c /7s Alt.Tel.No.•
'Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety' "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 PERMIT FEE.S &0---
The Common wealth of Massachusetts
�^ ! Department ofIndustrial Accidents
' M i
Office of Investigations
' 600 Washing ton Street
Boston, MA 02111
www.haass.gov1dia .
Workers' Compensation Inshrance Affidavit: Builders/Contractors/Electricians/Plumbers
A Iicant Information Please Print LeQibt
Name (Business/organization/Individual)' �P V S Z �/�� 45
Address*: S� �ou ems/ 5'/7—
City/State/Zip:
City/State/Zig: Phone#: . 7,2e- e
FRII
employer?Check.the appropriate box: '
Type of project(required): t,
mployer with 4. ❑ I am a general contractor and Iees(full and/or part-time),* have hired the sub-contractors 6' ❑New construction
ole proprietor.or partner- listed on the attached sheet.I �• ❑Remodeling
ship and.have no employees These su&contractors have 8. [J Demolition
working for me.in any capacity. workers' comp.insurance, g ❑Building addition
[No workers'comp,insurance 5. ❑ We area 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.n. Plum
repairs or additions
myself,[No-workers'comp. c. 1.52, §1(4);and we have no 12,0 Roof repairs
insurance required.]t employees, [No workers'
comp. insurance required.] 113.n.Other
*Any applicant that checks bo)'#1 must also fill out the section below showing their workers'compensation policy information,
t Homeowners who submit this affidavit indicating theyzz doing all work and then hire outside contractors must submit a new affidavit indicating such.
#contractors that check this box must attached an additional shsetshowhag•t_he name of the sub-contractors and their vmrka s`cernp.pciicy infe,�.at on.
o a errraatinaa.bvsployvr that lspYaruideFrg:tvo;•lsePr'
infcoastpearsataoaa lasu"a'"fop try.enVlnyees: Below is tlaepolicy and job site
•`
Insurance Company Name:
Policy#or Self-ins.Lie..#: Expiration Date: �f
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.
1 do hereby certif under the pa' an pe adties o erju that the information pravlded above is true and correct
Sieh rut—e—
Phone#:
Official rase only. Do not w"rye hi i'kis area,to be c.7.—pte_ted by cky or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2.an
Department 3.City/Town-Clerk Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person:
phone#:
0372 Date....
........................
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
4L
This certifies that ...................... .0..
has permission to perform ........ G2... .......
.... ........
wiring in the building of
...................................................................................
12
at.... .......0......... N rthAndover,M S.
Arl;'
FeelLic.No....... ................. ....... .. .........
• ICAL INSPECTOR,
C he c k 7, 2—-2—
A
,112 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance-with the provisions of M.G.L.c.143,§3L,the
permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed
on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c.166,§32,an
a electrical permit shall be issued to the person,firm or corporation stated on the permit application. Such entity shall be responsible for the
notification of completion of the work as required in M.G.L.c.143,§3L.
Permits shall-be limited as to the time of ongoing construction activity,and may be-deemed-by the Inspector-of Wires abandoned-and_invalid.if he—.
or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written
application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written
request of either the owner or the installing entity stated on the permit application.
❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections.74 and 75 of Chapter 238 of
the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this
purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property,With
limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was
"in effect or existence"during the qualifying period beginning on August 15,2008 and extending'through August 15,2012.
rmit/Date Closed: /,Z/Z3- ***Note:Reapply for new permit
rOPe7rmitExtension A.ct—Permit/Date Closed:
Official Use Only
i�gmtnertweaLth of l�ussc�:nuBe�.
Permit No. 2 2, I
...lJePrzrLm,ert of.Dire erutGej
Occupancy and Fee Checked
OAI�.O OF FIREPRE/E`t T ION RGUL4TIONS (Rev. 1/07] (leave blank)
APPLI%/.]?�A ION FOR PERMIT TO PERFORM ELECTRICAL WORK '
All work to be per:`ortned in accordance with the Massachusetts Electrical Code(IvIEC),527 CMR. 2.00
(PLEASE PPJiVTINMKOR TYPE ALL1,'VT0RI.�ITY N) Date: �»
City Gr To'yin of: N o t j A(f d 0 if f 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) �-
Owner*orTenant r Telephone No. `L
Owner's Address tG ;Z,(
Is this permit-in conjunction strith a Building permit? Yes ❑ No. ® (Check Appropriate Box)
Purpose of Building Utility Authorization,No.
Existing Service�_- Amps Volts Overhead ❑ Und;rd❑ No.of Meters
New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters
Number of Feeders and Ampaci}y -
Location and Nature of Proposed Electrical Work:
Com lesion of the following tablem be waived b he b_nrector o
li'ires.
No. of Recessed Luminaire^- No.of Ceil.-Susp.(Paddle)Fans No.of Toms
l Transformers KVA
No.of Luminaire Outlets No.of Hot Tubs Generators KVA
I AboveIn- v'T o.of emergency Lig 11:11119 ---- ;
No. of Luminaires {S} imtring Pool grnd. ❑ ❑garnd. Battery Units _ 1
�No. of Receptacle Outlets lNo.of Oil Burners FIRE ALARMS No.of Zones
No.of SNvitclies iNo.of Gas Burner No.of Detection and
. _ I,.itiating..evtees
No.of Ranges �No-.of Air Cord. Tonal No.of Alerting Devices -
Heat Pump. Numbr_(Tons K
eW No.of Self-Contained.
No.of Waste Disposers 'Totals: _ _ - ^� Detection/Alerting Devices
No.of Dishwashers ISace/Area Heating KW Local❑ un echo
? g ❑ Other.
b onnection _ �.
�HeatingA Appliances . Security. stems:"
No.of Dryers 5 PP hW.
No.of evices or Ecluiva,ent
110.of Water 'No.of No.of Data Wiring:
Heaters - It�N I Ballasts r
Signs No.o! Devics or Ee,uiyatent �
No.Hydro 5 + Telecommunications Wiring: —
dromnssage Bathtubs Vo`of i'�fotors Total HP I No,of Devices or Equivalent
OTHER: -2�-i� A J
Attach additional detail if desired or as required bythe Inspector of hVires.
e
Estimated Valuf Electrica;Work: / ffhen required by municipal policy.) ;
Work to Start:_ Insoections to be'regr.ested in accordance with MEC Rule 10, and upon ccrnpl?tion.
INSUF ANCE COVERAGE: Unless waived by the owner,no perm it for the performance ofelectrical work may issue unless
the licensee provides,proof of Iiability 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 pernit issuing office.
CHECK ONE: INSURANCE ® t30N7? ❑ OTHER ❑ (Specify:)'
I certify, under the pains andpenalties ofperjury, that thein ormation.on this application is true and complete.
FIRM NAME: TAT S s�r SeZ t LIC.NO.: LV5
t
Licensee: (Y�Q(' �✓Z'CgJ�t Signator _ _ LIC.NO.: C% V(If applicable, enter "oxem t"in the license numbeF`rne.3 t l Bus.Tel.No,. 6,C'
O 3
Address: c L-4 Y dr1 C) Alt.Tel.No.:— —
*Per lvi.G.L. c. 147,s.57-61,secunry work requires Depart«:ert of Public Safety"S"License: Li c.No. Do 53
OWNER'S INSURANCE WAIVER: 1 am aware that the Licensee does not have the liability insurance coverage-normally
required by-law.law. By m signa uie beloti.,f?hereb--vaivc th 3 re uirement. I am the(check one)❑owner U owner'S a ent.
q � _ y � y q
Owner/Agent
SiQaature Telephone No. PERMIT FEE:
..__.. -- ,n•1�t•i' .t '•t•f:��-+t•kf:1�-1••7•i:.fi{,I��n•i_,:••_•I� - _-_�
=A REG{STERED SYSTEM CON.►RAC T OP...a._'_:
ISSUES T HEABOVELICENSE TO:
fiDTg SECURITY. ER IC
---:..IetAP.K-A :BROPHY::,.SR
r;.la :UNIVERITY.'A�E
iN
.-.WEsTWQ0D MA:.02090 231:3.:_:=
C' 07/5111-38 9174.'..
_
fntd.'R1an OvtzUt AJ-9APseurneons - -
Keep top for receipt and change of address notification.
h
DPS-CRs u 2WA-10.Q19.10162009LICENSEFORMI -
✓��-�nv�t-�,.o�rcuecl�.c�ir/�ataa��ueLGs
�\ DEPARTMENT PF PUBLIC SAFETY
y_ S-License
g.." Number.'SSCO 000953
Expires:-Oy07l2013 Tr.no: 195.0
S-License: ADT
MARK A BROPHY-SR /
� 410 UNIVERSITY RVE ��1 .'
WESTWOOD, Iv1A 02090 DIG SA=E CALL CENTER: {88B)344-7233
Commissioner
f
I
.. NORTh
TOWN OF NORTH ANDOVER
O 9
• - PERMIT FOR GAS INSTALLATION
y
SACMUSEt�
This certifies that . . �!`.. . . . !. .r�e. �'� . . . . . . . . . . . . . . . . . . . . .
has permission for gas installationf�
in the buildings of .-Yoe, ,O&. .n d'�'a . . . . . . . . . . . . . . . . . . . .
at ?.�. . 6. . .A/w�!'u'•. . . . . . . .p., North
Andover, Mass.
FeeJ4:,P° . Lic. No.14Z.& . .
GASINSPECTOR
Check# l
7890
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
City/Town: MA. Date: /I 4 �f Permit#
Building Location: Owners Name: 'VOz C !L
Type of Occupancy: Commercial❑ Educational ❑ Industrial ❑ Institutional❑ Residentialo
New: ❑ Alteration:❑ Renovation: ❑ Replacement:❑ Plans Submitted: Yes❑ No❑
FIXTURES
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SUB BSMT.
BASEMENT 1
1 FLOOR
2 FLOOR
3 FLOOR
4 FLOOR
6 FLOOR
6 FLOOR
7 FLOOR
8 FLOOR
Installing Company�Name:
l Check One Only Certificate#
� L/ i l �-�- El Corporation
Address: 7L ( City/Town-48:tv�'e _ State:
A/,
��`�� ❑
Business Tel:� �.� � �frf`? Fax: Partnership(p
Firm/Company
Name of Licensed Plumber/Gas Fitter: -L-jL% ,e v
[INouSURANCE COVERAGE:
ave a current liabili insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Yes No E]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 ❑ Agent ❑
By checking this box(];I hereby certify that ali 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 Pert' ent provision of the Massachusetts State Plumbing Code and Chapter 42 of the General Laws.
B �?Plumber
e of Lcense:
By
Title Gas Fitter Sig ature of Li ens d Plumber/Gas Fitter
Master
City/Town Journeyman License Number:�f7�
APPROVED OFFICE USE ONLY ❑LP Installer
e ..
r
The Commonwealth ofmassachusetts
Department oflndustrialAccidents
Office oflnvestigations
600 Washington Street
Boston,MA 02111
yY
wwlti mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
APPIicant Information
Please Print Le ibl
Name(Business/Organization/llndividual): �
Address: �9 �I'Cb1C .
City/State/Zip• C:2fil oleo j 3 Phone#:_��� �'� t
[hd
an employer?Check the appropriate box: ,
a em 10 er with 4. Type of project(required):
p Y ❑ Iam a general contractor and I
loyees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
a sole proprietor or partner- listed on the attached sheet. 7• Remodeling
and have no employees These sub-contractors haveDemolition
ing formein any capacity. workers'comp.insurance.workers com ,insurance 5. 9• ❑Building addition
' p ❑ We are a corporation and its
red.] officers have exercised their 10.❑EIectrical repairs or additions
a homeowner doing all work right of exemption per MGL1.❑Plumbingrepairs or additions
lf. [No workers'comp, c. 152,§1(4),and we have no
nce re aired. 12•❑Roofrepairs
q ] f employees.[No workers
comp,insurance required.] I3.❑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 providing workers'compensation insuranc
information. e for my employees th
Below is alepolicy and job site
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.
fP J n'that the information provided ,
Ido hereby certify un r the pains and ties o er'u ab ve is true and correct.
Si ature: /
Date:
Shone#: _
Official use only. Do not write in this area,to be coittpleted by city or town offcial. •
City or Town: Permit/License#
Issuing Authority(circle one):
I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.PIumbing Inspector
6.Other
Contact Person:
' Phone#:
s
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 licensing agency shall withhold the issuance-or
renewal of a Iicense 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 Depaitment 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 permittlicense 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 NOTrequired 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:
Me Com, ORWealth o,i 1Vj'assaeaLisetts
Departmeat of Tndustrial Accidents
® ce ofInveSagations
600 Washington S`reet4
Boston;MA.02111
TO.#617.727-•4900 ext 406 or 1-877-MASSAFE
Revised 5-26-05 Fax#617•-727-774.9
Www.mass.g-av/dia
Date.AA1,< �!. �.. .
.. NORTM
°f
o� TOWN OF NORTH ANDOVER
• ' PEANUT FOR GAS INSTALLATION
• a
SACH
This certifies that . . . . . . . . .�U.r".�2. . . . . . . . . . . . . . . . . . . . . .
s 1 J 44"has permission for gas installation . ��°. . . . . . . . . . .
in thebuildingsof . . .C.Ov1i,. . . . . . . . . . . . . . . . . . . . . . . . .
at . . . . . . . . . . . . . . . . . . .. North Andover, Mass.
Fee.,,�r.-rp Lic. No../?.'Q0. .
GAS INSPECTOR
Check#
7881
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
City/Town: /,*1 �,��/� MA. Date: /` !/ Permit#
�!/ J �j—
Building Location: � Qq) �� y¢ ��;/Owners Name:
Type of Occupancy: Commercial❑ Educational❑ Industrial ❑ Institutional❑ Residential&
New: ❑ Alteration: ❑ Renovation: ❑ Replacement: Plans Submitted: Yes❑ No❑
FIXTURES
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SUB BSMT.
BASEMENT
1 FLOOR
2 FLOOR
3 FLOOR
4 FLOOR
6 FLOOR
6 FLOOR
7 FLOOR
8 FLOOR
Installing Company Name: �I
Check One Only Certificate#
nL ❑Corporation
Address: r rc Ci /Town
State:
fy
El Partnership
Business Tel: — S Fax:
r------- irm/Compan
Y
Name of Licensed Plumber/Gas Fitter: --j0woW
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 Yes,10 No❑
If you have checked Yes,please indicate the type of coverage by checking the appropriate box below.
A liability insurance policy)0 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 ❑ Agent ❑
By checking this box❑;I 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 Kn wledge and that all plumbing work and installations performed under the permit issued for this application will be d
compliance with all Pe ' e provision of the Massachusetts State Plumbing Code and Chapter 14 of the General Laws.
In
MT pe of License:
By Plumber
Title ❑Gas Fitter gn ure of Lice sed PI ber/Gas Fitter
Master
City/Town Journeyman License Number:
APPROVED OFFICE USE ONLY ❑LP Installer
The Commonwealth ofMassachusetts
Department oflndustrialAccidents
Office of Investigations,
600 Washington Street
Boston,MA 02111
'Y www.massgov/dia
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers
Applicant Information
Please Print Legib
Name(Business/Organization/Ind' idual): /yam
Address:
.City/State/Zip 14WAU ce, (01�8 phone#:
[01
an employer?Check the appropriate box: _
a em to er with 4. Type of project(required):
to e p y ❑ I am a general contractor and I 6 yes(full and/or art-time . have - ❑New construction
p ) hrred the sub contractors
a sole proprietor or partner- listed on the attached sheget. 3 7• ❑Remodeling
and have no employees These sub-contractors have8. ❑Demolition
king for me in any capacity. workers'comp.insurance.workers' com .insurance 5. 9• ❑Building addition
p ❑ We are a corporation and its
ired.] officers have exercised their 10.❑EIectrical repairs or additions
a homeowner doing all work right of exemption per MGL11.❑Plumbing repairs or additions
lf. [No workers'comp. c. 152,§1(4),and we have no
ance required.]Y employees. 12.❑Roof repairs
[No workers'
comp,insurancerequired.] 13.❑Other
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policyinformation,
7 Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors musts
lContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their
ubmit a new affidavit indicating such.workers'COMP.Policy information.
Y
-ram an employer that is providing workers'compensation insurance for my employees. Below is the policy antl job site
information.
Insurance Company Name: S v
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 winder 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 ORK ORDER and a fine
penalties in the form of a STOP W
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.
r
fP J ry `
do hereby certify�unthepai�, a penalties o er'u that the information provided above is true and correct. -
ii nature•
Date:
'none#:
O,fficial use only. Dn not fvrife an this area,to be completed by city or fown offrcial �
City or Town: Permit/License#
Issuing Authority( one):circle
.
I.Board of Health 2.Building Department artme
nt 3.Ci /Town Clerk
6. ty k 4.Electrical Inspector 5.Plumbing
Other P bm Inspector
g
P
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,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*' erred 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 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 thatthis 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/liceuse 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. Anew 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:
Me CoMmonweatth ofyiassachliSetts
Department OfJndu&ial Accidents
Office of Investigations
600 Washington Street
Boston MA 02111,
Tol.#617-727•-4900 ext 406 or 1-877,M-ASS.AFE
Revised 5-26-05 Fax#617"727-7749
WWW.mass.;;ov/dia
COMff0NWEPl.TIi OF 6ViASSANU§ffftc
p D •�. FI E
LICENSED AS A JOURNEYMAN PLUMBER.
ISSUES THE ABOVEI-ICENSETO:
JAMES . M HURLEY
79 BROOKFIELD ST
LAWRENCE MA 01843-2503
17259 05/01/12 780645.
• s • mrd,.: • a I
N
`7—COMMONWEALTH OF MASSACHUSETTS
LICENSED AS A MASTER PLUMBER-
ISSUES THE ABOVE LICENSE TO:
JAMES. M' HURLEY
79- BROOKFIELD ST :
LAWRENCE MA 01843-2503
12270 05/01/12 780644 „ a ,