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HomeMy WebLinkAboutMiscellaneous - 7 LACONIA CIRCLE 4/30/2018 7 LACONIA CIRCLE 2101106_g-012�00.0 Date.Allf //.. . . .. .... N°RTM 3? °`° TOWN OF NORTH ANDOVER • PERMIT FOR GAS INSTALLATION SSACHUSEt4 This certifies that . . . . . ... . . .. �. . . . . . . . . . . . . . o she r' has permission for gas installation . . J . . . . . . . . . . . . . . . . . . . . . . . in the buildings of . . . . . �' /TG,e/. . . . . . . . . . . . . . . . . . . . . . . . . . at . . .rf.L4. . .�14. el C.C. . . . . . . ., Northdover,Mass./ / �r . Fee. 30:j6�?. Lic. No..��74R. . .{l.!c�r. . . . ..• GAS INSPECTOR Check# 12 G5-�— 7886 Y MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING s City/Town:_ ' /� /�(/'� �MA. Date:--./L—2'—�/ Permit# Building Location: Owners Name:_ �� _ Type of Occupancy: Commercial❑ Educational❑ Industrial❑ Institutional❑ Residential �! New:❑ Alteration:❑ Renovation: ❑ Replacement Plans Submitted: Yes❑ No El FIXTURES DEDICATED a SYSTEMS Uj H > O V) LU Z v� n `^ d z tQ- Y Q v U ��. W O 0 Ln a W z W z Q N z Ca Z a p m Ln a y Q 0 p F- N g aj w o F Q Q Z rr p a z y W u 0. x ¢ F- Q Q x O m _ ❑ �- �- d Q d 4 y y O0 E- U j Q y x 2 w w w dl O y w Q m m o o LL z Ln En 3 W d -SUB BSMT. a 3 BASEMENT 1ST FLOOR 2ND FLOOR 3RD FLOOR 4'FLOOR 5T"FLOOR 6T"FLOOR 7T"FLOOR 8T"FLOOR Insti_iil,, ry Ap �ma `3 I El Corporation Address City/Town: �zZ fG- State: ` Business Tel: l� � 3 Fax: ElPartnership Firm/Company Name of Licensed Plumber: t ell INSURANCE COVERAGE: 1 have a current Iia_ bility 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 policyy Other t > Y`%% �� ype of indemnity ❑ Bond E]OWNER'S INSURANCE WAIVER:I am aware that the licensee does 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 3i nature of Owner or Owner's Agent Owner ❑ Agent ❑ I hereby cei'my that ail of the details and information I have submitted(or entered)regarding this application are true and accurate Knowledge and that all plumbing work and installations Performed under the permit issued forthis application will be in compliance with all Pertinent provision of the Mas ch setts State Plumbing Code and Chapter 1Pe m the General Laws. a e to the best o.my ✓ s Type of License: Ye ❑Plumber Signatur L' ed Plum r 'y/Town ❑Master 'PROVED(OFFICE USE ONLY) ourneyman License Number: 7 The Commonwealth ofMassachusetts bepartment oflndustrial.Accidents Offlce oflnvestigations 600 Washington Street Boston,MA 02111 s� www.massgovIdia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Ai,7plicant Information Please Print Ledbly Name(Business/organizagon/Tndividual): Address: -City/State/Zip: Phone#: Are you an employer?Check the appropriate box: 1.❑I am a employer with 4. Type of project(required): ❑T am a general contractor and T employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑I am a sole proprietor or partner- listed on the attached sheget.t 7. ❑Remodeling ship and have no employees These sub-contractors have 8. [�T)emblition working for me in any capacity. workers'comp,insurance. [No workers'comp.insurance 5. ❑ We are a corporation and its 9• ❑Building addition required.] officers have exercised their 10•❑Electrical repairs or additions 3•❑ I am a homeowner doing all work right of exemption per MGL 11. Plumb' ❑ m re airs or additions , g p mons myself.[No workers comp. c.152 1 4 ,§ ( ),and wehave no 12,[]Roofrepairs insurance required.]t employees.[No workers' comp,insurance required.] 13.❑Other *tiny 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. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp,policy information. IM an employer that is providing workers'compensation insurance,fOF my e'nployees Below is the policy ancijob site inforfnation. Insurance Company Name: Policy#or Self-ins.Lie.#: ExpiratlonDate: 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 ofMGL c.152 can lead to the imposition of criminalpenalties of a fine UP to$1,500.00 and/or one-year imprisonment,as well as civilpenalties 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. t'do hereby certify under the ains and en o J ry , P p fpef•'u that the information provided above is true and correct. 34 nature: . Date: `:none#: • Official use only. Do not write in this area,to he completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: 91 bo Date./1/.�'�l. . . �tio TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING 40 s o � •'a SACHUS� —�-- r This certifies that . �� !r . . . . . . has permission to perform �L✓.]♦r� �K e j .,l P! or . plumbingl�n the buildings �. . /�� . .f. . . . . . . . . . . . . . . . . . . . . at. . . L9���,!9. .e,.;-L ... . . . . . . . . . . . .. North Andover, Mass. FeeLic. No.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . PLUMBING INSPECTOR Check # 12 GSr X •,� MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING City/Town: Atrk ���C +' MA. Date: �[ Permit# ,�f - Building Location: / / /1�� G/i'Yi�� Owners Name: Type of Occupancy: Commercial❑ Educational❑ Industrial❑ Institutional❑ Residentiale New: ❑ Alteration:❑ Renovation: ❑ Replacement: Plans Submitted: Yes❑ No❑ FIXTURES co W W co co Z Q Co U = � (002ww W p W 0 cn ~ co TW O J 0 co F O = O Z Z O W W W W O I– �n > W Z °° o Q a IW- 0 0 w X W H W Q W W W Z fA = W O W 1-- > 0 ❑ = ti W Z O J 1- H O Z J C7 LL N 2 W W W 0 W Q IQ IQ M W O Z 0 F > Z I. _ 0 0 ❑ LL0 0 s M g 0> a0 g W0 P > > > 0 SUB BSMT. BASEMENT , 1 FLOOR 2 WFLOOR 3 FLOOR s 4 FLOOR 6 FLOOR 6 FLOOR 7 FLOOR 8 FLOOR Installing Company Name: �4 R�rng•tl I Check One Only Certificate# ❑Corporation Address:*, �City/Town: 4✓ A(e— State: L/1 Business Tel: �����/ eo3 Fax: ❑Partnership Name of Licensed Plumber/Gas Fitter: ` kirm/Company �d [IfNSURANCE COVERAGE: have a current liabili insurance policy or its substantial equivalent which meets the requirements of MGL.Ch. 142 Yes❑ No❑ you have checked Yes,please eindicate the type of coverage by checking the appropriate box below. A liability insurance policy X Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER:l 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 Si nature of Owner or Owner's Agent Owner ❑ Agent ❑ By checking this box I];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 my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent prov' ion of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. By Type of License: ❑Plumber Title I�/ �/ ❑Gas Fitter Signature sed er/Gas Fitter ❑Master City/Town uInsyman License Number: 2D 7� APPROVED OFFICE USE ONLY ❑LP Installer i The Commonwealth ofMassachusetts Department oflndustrialAccidents Office of Investigationg 600 Washington Street s� Boston,MM 02111 www.massgov/d'ia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information please Print Le�bly Name(Businesslorganization/Individual): ���. �✓' �� J Address: 10-0 •City/State/Zip:_ 41#- 002q60 phone#: ` — — ,Vm O Are you an employer?Check the appropriate box: _ 1.❑I am a employer with 4. Type of project(required): ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2I am a sole proprietor or partner- listed on the attached sheget.t 7. ❑Remodeling ship and have no employees These sub-contractors have 8. working for me in any capacity, workers'comp.insurance. ❑Demolition [No workers' comp.insurance 5. ❑ We are a corporation and its 9• ❑Building addition required.] .officers have exercised their 10.El Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.El Plumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no 12.E]Roofrepairsinsurance required]t employees.[No workers' i comp,insurance required.] 13.E]Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are 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.#: 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#nderheins andpenalties ofperjury that the information provided above is true and correct._ Si nature: Bate: ?hone#: - Offacial 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): L Board of Health 2.Building Department 3.City/Town Clerk 4.Electric 6.Other al Inspector S.Plumbing Inspector Contact Person: Phone#: . v 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 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 carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may besubmitted 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. • pity 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 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 CO.-COMOR-Wealth of Massada setts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston;ASA.Q211 X Tel.4 617-727-4900 ext 4406 Or 1-877 MASSAFE Revised 5-26-05 Fax 4 61.7.727-7749 Www.mass,jZovfdia r" 10 L 15 Date.....y. ..�. . . l.... MORTI{ TOWN OF NORTH ANDOVER PERMIT FOR WIRING ��ss^CHUSE� This certifies that ....... /.' .' U w..... ...................... ............ ..................... has permission to perform ...lv .......................n.zI..r�'.�..�..J............... wiring in the building of...../,)r.............�l...���..��............................... at.....~,1..... y.. ........`....'........................... ......... .North Andover,Mas Fee..,.? Lic.Nod.-�.�'�Z...... -i".�:�`........ ELECTRICAL LECTOR Check # 0 7 Commonwealth of Massachusetts Official Use only Department of Fire Services Permit No. e Z �� 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: y`/ - /l 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 /, A C 0k j n r i QC 13 Owner or Tenant b t.K - K 1 T7 �-,IZ Q Telephone No. Owner's Address S IN V-1 e— Is this permit in conjunction with a building permit? Yes�K No ❑ (Check Appropriate Box) Purpose of Building I T- 1q&t I-S144�u g Utility Authorization No. Existing Service Amps Volts Overhead ❑ Undgrd ❑ No.of Meters New Service Ams / Volts Overhead n r Amps ❑ U dg d ❑ No.of Meters Number of Feeders and Ampacity Pj T i +nk l T,(o + 110 li LL Location and Nature of Proposed Electrical Work: 'rV\( 'xv* C►4 3,e UVAE S i vs, % t-a 40- tw i vs,w, ; L U Ro©!q-j . Completion of the following 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 Above In- o.o Emergency Lighting No.of Luminaires Swimming Pool rnd. ❑ rnd. 11 No. Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained Totals: 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 Si ns Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: N—' h'ITP— s7 Q,r3mb, q CtAb\-Z- I-Nwv—1 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: 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 ti certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ZBOND ❑ OTHER ❑ (Specify:) I certify,under the pains and pens ies of perjury,that the information on this application is true and complete. FIRM NAME: Soytia VIAARC)- LIC.NO.: tlf 19 .2 Licensee: &Ryyyy–, Signature l , LIC.NO.: (If applicable,enter "exempt'-in the license number line�,w IF Bus.Tel.No.: t7-21- 7y 0 -9600 Address: gQ k6,1 ,L i A 16SS S(, �1 „ M A 0 G 117- 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 Owner/Agent [PERMIT FEE. $ Signature Telephone No. 41 i a 1 r f The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Y www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Address: Ik6 X1.5 �S -5 City/State/Zip: Phone #: !ZS L 0 Lf ►1 CO© 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.gi am a sole proprietor or partner- listed on the attached sheet. + �• E]Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. ❑ Building addition [No workers' comp.insurance 5. ❑ 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.]fi employees. [No workers' comp. insurance required.] 13.0 Other *Any applicant that checks box#I 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. t6mractors 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 insurance for my employees. Below is the policy and job site information. Insurance Company Name: 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 may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cer ' under the pains andpena/tis of erjury that the information provided above is true and correct. Signature: 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#: s vV f p f 9 1 0 6 Date. NORTp TOWN OF NORTH ANDOVER p PERMIT FOR PLUMBING i i r ,SSACMUS E� This certifies that X !' has permission to perform . . . . fl r�G//a 1` 1o1? . . 4AV7� plumbing in the buildings of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . at. . . . . . . . .Lg�4.?!9. . C�/.�.C. . . . . .. North Andover, Mass. Fee�0-.S.U.Lic. No.. . . . . . 2o7zu� . . . . . . . . . . . . . . . . . . . . . . . . . If. 4 PLUMBING INSPECTOR Check # 4-?"5-0 i MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING S City/Town: �btc� MA. Date: � 1 �r permit# Building Location:_ ��,�, a��f r Owners Name: Type of Occupancy: Commercial❑ Educational❑ Industrial❑ Institutional❑ Residential Alteration:❑ Renovation: Replacement: ❑ Plans Submitted: Yes , ❑ No FIXTURES o: DEDICATED F- ? SYSTEMS F- §2 vLLJ0 Z a tY Z H Q y U ��. w O ❑ ¢ w Z C cry Z Q ¢ w C7 tr Z Q m vi a � L, in } w Q p z ❑ d ¢ a w ❑ LL F ¢ . ❑ ¢ Z W p z C7 U a < 8 ui H d = _ > p L ❑ ❑ w ti j 2 U u. S _� Q Q w v f- T ° ❑ 1- v ¢ " a Q R w w dt O w 3 ¢ m m o n o z g o ° ¢ a ¢ a a = " 3 3 ¢ Ln -SUB BSMT. 0 ¢ BASEMENT 1ST FLOOR ND FLOOR 3RD FLOOR 4'FLOOR 5'FLOOR 6T"FLOOR 7T"FLOOR 8T"FLOOR test- ey,, Address: '612)( Corporation / / 653 City/Town: h State: Business Tel:- 4 �—0,2—9A®_ ax:3 ® 1,� El Partnership F � Firm/Company Name of Licensed Plumber: ___S INSURANCE COVERAGE: 1 have a current Iia _ bi_ty insurance policy or its substantial equivalent which meets the requirements of MGL,Ch.142 Y s ❑ No❑ If you have checked Yes,please indicate the-type of coverage by checking thea appropriate opriate box below. A liability insurance policy. Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER:1 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 >i nature of Owner or Owner's Agent Owner ❑ Agent ❑ 1 hereby verify that all of the details and information I have submitted(or entered)regarding this application are true and +o Knowledge and that all plumbing work and installatio;,s Performed under the permit issued for this application will be in compliance with all Pertinent provisi of the Massachusetts State Plumbing Code and Chapter 142 o;the General Laws. accurate to the bes�Of ry 7 ' ` Type of License: :Ie ❑Plumber Signatused P er ,y/Town ❑Master / 'PROVFFIUE ONLY) ourneyman License Number: 11 ' COMMONWEALTH OF MASSACHUSETTS PLUA1�D" { LICENSED AS A JOURNEYMAN PLUMBER I a I ISSUES THE ABOVE LICENSE TO: `J t JEFFERY BAERINGER PO BOX 600553 NEWTONVILLE MA 0246.0-0005, 2"-0728 05/01/12 794799 ------------------------ III r The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations 600 Washington Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Address: © City/State/Zip '����N O 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 employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2. I am a sole proprietor or partner- listed on the attached shget.# 7• �E]Remodeling hip and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp,insurance. [No workers'comp. 5. 9• E]Building addition p ❑ We are a corporation and its required.] officers have exercised their ME]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.]t employees. [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 isproviding workers'compensation insurance for my employees. Below is thepolicy 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. 1 do hereby cert n e the in d penalties of perjury that the information provided above is true and correct. Si nature: Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Tokvn: 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 M 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 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. 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 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 CO-11i xowealth ofMassachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. #617-727-4900 ext 406 or 1-877-"SAFE Revised 5-26-05 Fax#617,727-7749 www.mass,govldia