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HomeMy WebLinkAboutMiscellaneous - 71 MILLPOND 4/30/2018Date.,...... t .1.4 .................... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION e This certifies that ....................S..................... .............. has permission for gas installation .. ................. inthe buildin s, of ........... ............................................................................. at .......................... ....... et.......�L ................... North Andover, Mass. .............. Fee.............. Lic. No. ....... '11� . . ................................................. C . heck #A-2-(Ia GAS INSPECTOR 9757 v -)vw MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY ]j MA DATE /� %/�I/ PERMIT#1�1 JOBSITE ADDRESS OWNER'S NAME GOWNEZADDRESS /z— TEL FAX�� TYPE OR OCCUCOMMERCIAL [ EDUCATIONALRESIDENTIALPRINTCLEARLY NEW:ON: El REPLACEMENT: ® PLANS SUBMITTED: YES Q NO _ APPLIANCES -1 FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 1 11 12 13 14 BOILER ! . BOOSTER CONVERSION BURNER _ _ __( __ COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE _ _ J __. I FRYOLATOR FURNACE GENERATOR I GRILLE-- INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT- _ OVENPOOL HEATERHEATER 1 ROOM / SPACE HEATER ROOF TOP UNIT I TEST UNIT HEATER I UNVENTED ROOM HEATER I MTER HEATER OTHER - - - INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL. Ch. 142 YES I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERA CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY _ OTHER TYPE 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: OWNER ❑ 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 knowle e and that all plumbing work and installations performed under the permit issued for this application will be in compliance with a I Pert' anrpsion of th Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER- FITTER NAME L% ` -�- LICENSE # JG_% I S A RE MP MGF JP _) JGF _J LPG] CORPORATION _J# PARTNERSHIP ©# / LLC �# ® ❑ ❑ ❑ COMPANY ADDRESS k"-- — - CITY i., �11 STATE,ZIPE, 30 TEL FAX CELL EMAIL v -)vw H .G z oa H� W� �N z❑ o N❑ w � � w O� a Z U w w I-- � CO) w OLU w w w N a o a a a U J E, a a a � w s w i- LL H °z 0 H U W a c�7 a i The Commonwealth of Massachusetts - Department of Industrial Accidents Office of Investigations IV 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le 'bl Name (Business/Organization/Individual): Z)/ Address: - 6 d" >1� City/State/Zip: A z /� -- A�/� Phone Are you an employer? Check the appropriate box: Type of project (required): 1. ❑ I am a employer with 4. El am a general contractor and I 6. F1 New construction epployees (full and/or part-time).* have hired the sub -contractors listed on the attached sheet. �• ❑Remodeling 2. am a sole proprietor or partner- ship and'have no employees These sub -contractors have S. ❑ Demolition working for me in any capacity. workers' comp. insurance. g. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions required.] 3. ❑ I am a homeowner doing all work officers have exercised their 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' 13. ❑ Other C 4 S comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers' compensation policy information. 7 -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. 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. Job Site Address: Expiration Date: 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 requiredunder 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 under t&epains an4penrgltiais ofperjtcry that the information provided above is true and correct Phone #: E 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 Pers Phone N% 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 (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: Tho Com onwealth of Massachusetts Department of Jndustdal Accidents Office of Investigations 600 Washington Street Boston, MA. 02111 Tek. # 617-727-4900 at 406 or 1-877rMASSAFr Revised 5-26-05 Fax # 617-727-7749 �vv.maSs,govfclia 71 MILLPOND A. NO. ANDOVER, MA. 01845 7 Sept. 1999 ESSEX MANAGEMENT GROUP, INC. P.O. Box 2098 Haverhill, MA. 01831 Attn: Mr. Tom Tierney Dear Tom: This letter is for the record. The large deck outside our living room was shored up in one corner approximately 6 years ago. While the deck appears to be strong and sound, the corner post is showing signs of wear at the base. Also, the siding is rotted out (down to tar paper) where the deck abuts the house. We are calling this to your attention, and wish to waive responsibility for the integrity of the deck. V r y tru y y u C" -J hn L. Ro e cc: Wm. Feldman, Pres. Bd. oT irE!ctors Michael McGuire, Bldg. Inspector, No. Andover IU ��IU SEN 8 c:.y BUILDING DEPAR Mi ENT '1 i 5� k ;* .. f �� i � , •• 4 1v vales velrYi t% r"L/vr111v14 f %j" 1r" lowle0 a.. ..-. Irani at a T al � ?� NORTH ANDOVER, -# Mass. Oats _tK� O✓ Burldinvss�� 'PermK +� 3 // 63 Location_ owner'a Name New p Renovation p ReplacemerA C� Plans Submitted: Yes ❑ No p �iXTUF�E3 � Check one: Certificate Installing Company Name ANDOVER PLG. & HEATING CO. , INC. MCorp. 2122 AIPI� Aridness 573 1/2 -SQ- UNION ST C1 Partnership LAWRENCE, MA. 01843 ❑Firm/Co. f3uslness Telephone 508 685-8383 Name of Licensed Plumber GEORGE LAROSE INSURANCE COVERAGE:ecx ° l'° I have a current liability Insurance policy or Re substantial equNWenL Yes LV! No O It you have checked yam, pleaasa Indlcale the type coverage by checking Ilia appropriate box. A ItablRy insurance pollcy Ud Other type of kidemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by Charier 142 & Ilia Mass. General laws, and that my signature on Ws permit application waives this requirement. Check one: N�iOwner ❑ Agent p nslura o er a (T*mrar s Mont I hereby mflIty that aA of the dslalls and iniormtllon 1 have aubmttted for sntet" in atwys appmallon ars true and sc=ste to the best of my ►now ge and that as plumbing wak and inNallallons p*fform*d wider the permA laupad We appMeatlon wil be In compRarx'a with eft pertinent provisions of the Massachusetts Stale PkrrnbkV Coda and Chapter 112 of Ilw r L�swa. ©y GD'L— Tflta SOFAu• crty/Town IV' IKNED (r)rrtCE USE Orrltil Llan se f bm bw 9983 7MV of Plumbing IJcanse: Maslen ❑ Journeyman ❑ O N �' M M F- u rr� • s w e IL i 1R rH M OU r a •4 M t 14 A 0 j a r L K Fes- u66 > o Y« s c ss : o v K lid { (: F- v o° .r 1< ss as z w o a < i s H eJi � i� e s i s i o $US-0OUT. SASSMSNT IST FLOOR SMO IFL00it SAO FLOOR 4THFLOOR $TH FLOOR OTH FLOOR 1TH FLOOR IT" FLOOR Check one: Certificate Installing Company Name ANDOVER PLG. & HEATING CO. , INC. MCorp. 2122 AIPI� Aridness 573 1/2 -SQ- UNION ST C1 Partnership LAWRENCE, MA. 01843 ❑Firm/Co. f3uslness Telephone 508 685-8383 Name of Licensed Plumber GEORGE LAROSE INSURANCE COVERAGE:ecx ° l'° I have a current liability Insurance policy or Re substantial equNWenL Yes LV! No O It you have checked yam, pleaasa Indlcale the type coverage by checking Ilia appropriate box. A ItablRy insurance pollcy Ud Other type of kidemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the Insurance coverage required by Charier 142 & Ilia Mass. General laws, and that my signature on Ws permit application waives this requirement. Check one: N�iOwner ❑ Agent p nslura o er a (T*mrar s Mont I hereby mflIty that aA of the dslalls and iniormtllon 1 have aubmttted for sntet" in atwys appmallon ars true and sc=ste to the best of my ►now ge and that as plumbing wak and inNallallons p*fform*d wider the permA laupad We appMeatlon wil be In compRarx'a with eft pertinent provisions of the Massachusetts Stale PkrrnbkV Coda and Chapter 112 of Ilw r L�swa. ©y GD'L— Tflta SOFAu• crty/Town IV' IKNED (r)rrtCE USE Orrltil Llan se f bm bw 9983 7MV of Plumbing IJcanse: Maslen ❑ Journeyman ❑ —r...^�.,iF'.'-y _�:...�'"+�""-rL ..-. Ara.ti "ti-�'^.,R �'r�..r.._.;;�. r+� " �L• i.:a�.�i•• .�1"'.". t'h,. +`rte.:.. ',�_...~'�i.-`� . 7 Date..,/?/.. . 3365 HORTF,, e TOWN OF NORTH ANDOVER p PERMIT FOR PLUMBING S ,SSACNUSi This certifies that .. � G'. ....t>a.( . H................`fid has permission to perform .. H v,� 7- ....................... � plumbing in the buildings of ..4r/4 . R0.6 In t�.y.�...... c at .. 7 ............. North Andover, Mass. Fee. ca?,S.r. Lic. No.. C. . ............ . PLUMBING INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer ,< � _ �!'T.�t:�...-.�..`__r �7-"',�.rtL�1`.+h'� �"�-lM:r.�%YY.,� ... _. � - �:�.. .vti « y ��.� �w y.�:.� _ .. +��