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HomeMy WebLinkAboutMiscellaneous - 73 WOODSTOCK STREET 4/30/201810172 Date . I ?��.... . �q"TLTib, • TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that ...............I...... . ....-. I has permission to perform ....w plumbingin the buildings o.4.. ....................... -�3 � � ` at . . , North Andover, Mass. Fee .325'.. Lic. No. �C7�U1 .�.. .., ................. ... PLUMBING INSPECTOR Check # J-6 k z-- MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY _jMA DATE (PERMIT # �� JOBSITE ADDRESS OW ER'S JME POWNER ADDRESS TEL 71FAX f TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL © RESIDENTIAL" PRINT CLEARLY !!// NEW: E] RENOVATION: REPLACEMENT PLANS SUBMITTED: YES NO 01 FIXTURES Z FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 �_- BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOIL/SAND SYSTEM DEDICATED GREASE SYSTEM1 -____J I_.._._..__f ._.-_.__-! DEDICATED GRAY WATER SYSTEM -- DEDICATED WATER RECYCLE SYSTEM I DISHWASHER I __ __I .__ DRINKING FOUNTAIN I _..____f ...__. ► _.______i __._._( — (__.._! —.__! .____ __...__ ..........I _ _ ..! __.._ _-1 E FOOD DISPOSER FLOOR/ AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK _ ._J LAVATORY { ! I ROOF DRAIN SHOWER STALL SERVICE / MOP SINK URINAL WASHING MACHINE CONNECTION ..__.._ i _ ; ___..! .____1 ,_ ..._! _f .. ___ ` . _! - 1 _ _i ._ 1 _.._ -S ..____ i ` WATER HEATER ALL TYPES / 1I I I ! I � J I _. _ . Tf .__ _ __! _.------ _ _..J _.-r _ WATER PIPING i _ i I ! I -- ------ i _. I __.._.._J ! 1 ___.-I f -- OTHER INSURANCE COVERAGE: t,have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YENO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY_ OTHER TYPE OF INDEMNITY Ell BOND Q OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coven uired by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this re rement. CHECK ONE0 LY: WNER AGENTf SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this appl ation are true a a ate th bes of o dge and that all plumbing work and installations performed under the permit issued for this application wi a in c 11 a inent pro ' o o e (Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAMEJ�Cjk LICENSE # S IATURE MP0';' JP ' CORPORATION. PARTNERSHIP Q# 1 LLC a j COMPANY NAM a., ADDRESS L CITY _. _ _...-__.__.._I STATE ZIP TEL 61+_ F CEL ._.: _- .�' MAI l H °z 0 F U W W 1 a 0E z N❑ } W � � H p w O W a ft Z _ ~ W I-- CO -'a W 5 oLLI w � w O z a a � W a U J a a a � � w x w I-- LL H O z 0 H U W a z z a a °a Io 0 The Commonwealth of Massachusetts Department of IndustriqlAccidints Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance .Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/Organizationdlndividual): '-) �s 2Z City/State/Zip: Phone #: �"l / `"C1�U l 4—.32(, Are yoga an employer? Check the appropriate box: 1 I am a employer with J— 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and'have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 1011 Electrical repairs or additions 11. El Plumbing repairs or additions 12.❑ Roof repairs 13. ❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. I 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 information. Insurance Company Nan workers' compensation insurance for my employees. Below is the policy and job site Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: 1 W . Yc, 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 u 00 and/or one= ear imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine o p to $250.00 a c a gainst a violator. Bea Ise that a. py of this statement may be forwarded to the Office of vestil?ations of the D for ' s ance covera vers dation. an tion Hereby certto - W1 57" the information provided qbove is tiue and correct. Official use only. Do ndt 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 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 he. 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 Commonwealth of Massachusetts Department ofIndustrial .Accidents Office of Investigations 604 Washington Street Boston, MA 02111 Tel, # 617-727,4900 ext 406 or 1-877:MASSAFE Revised 5-26-05 Fax ## 617727-7749 wanass.gov/dia Date.... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ....... ......k..✓..�?...'. " ' �" has permission for gas installation.............................................................. in the buildings of ............... .4) ........................................................................................ at ............... ......V �� ...................................... - .......:....... .North Andover, Mass. . Fee..�..-�'....... Lic. No. q3 M....... .!....................................................... �.g GAS INSPECTOR Check # � UUU0 •` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK — CITY O MA DATE PERMIT # JOBSITE ADDRESS OWNER'S NAME (k GOWNER y ADDRESS TE�jFAx�� TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ® RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT' PLANS SUBMITTED: YES O NO APPLIANCES 7 FLOORS-- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER �! I_ ..1=J =j =j =j =1 =1,-1 BOOSTER _TJ CONVERSION BURNER COOK STOVE _ �.....1 I11 DIRECT VENT HEATER DRYER 1 FIREPLACE FRYOLATOR I FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT _ OVEN POOL HEATER J i ROOM/ SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER _ UNVENTED ROOM HEATER WATER HEATER OTHER _ I -m�.I INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES _ NO I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE V 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. C K ONE ONLY: WNER 0I AGENT SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this applica ' n are true and ac r t t he est y kno edge and that all plumbing work and installations performed under the permit issued for this application will be in 'anc I in nt p is) o e Massachusetts State Plumbing Code and Chapter 142 of the General Laws. �= PLUMBER-GASFITTER NA IA -6 ! ---- -- _ - J LICENSE#SI ATURE a 6 MP 0 MGFJ JP 0 JGF LPGI J CORPORATION 0# =1 PARTNERSHIP # { LLC [J# COMPANY NAME -E0 _ ._. _ - �- _ _ ADDRESS CITY r STATE Ei ZIP G1 ]TEL _ H O z O H U W � r w O Z O N ❑ � ~ W H °z CL U w U �- aW, X � w Q w 55 O w w co o a a a � U J H °- a a Ln tii x w F- u. W H O O H U W a The Commonwealth of •Massachusetts Department of IndusMglAccidents Office of Investigations 600 Washington Street Boston, MA 02111 www.masss gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/EIectricians/Plumbers Applicant Information L Please Print Legib Name (Business/OrganizatiorAndividual): 6 k C Address: City/State/Zip:,/ %'i Pi Phone #:�`� Are yqu an employer? Chec he appropriate bog: ❑ I I 1. I am a employer with 4. am a general contractor and employees (full and/or part-time).* have lured the sub -contractors 2. ❑ 1 am a sole proprietor or partner- listed on the attached sheet. x ship and'have no employees These sub -contractors have working for mein any capacity. workers' comp. insurance. [No workers' comp. insurance 5, ❑ We area corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.) t employees. [No workers' comp. insurance required.] Type of project (required): 6. n New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.[] Electrical repairs or additions 11.0 Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other *Any applicant that checks box#1 must also fill out the section below showingtheir workers' compensation policy information. T Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew 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 information. Insurance Company Nam workers compensation insurance for my employees. Below is the policy and job site I Policy # or Self -iris. MG. #: Expiration Date: Job Site Address: C ( CiVState/Zip: Attach a. copy of the workers' compensation policy declaration page (showing the policy number and expiration date). are—to secure verage as requiredunder S 'on 25A of MGL c. 152 can lead to the imposition of criminal penalties of a up to $1,500.00 d/or one=year imp ' onmor well as civil penalties in the form of a STOP WORK ORDER and a fine p to $250.00 a day a ainst the viol or. Be a e that a copy of this statement maybe forwarded to the Office of stigations ofthe D fbAs&-a is covera er' cation. Ido reby cert. u Qndpe ePJI!]ry that tlt2 E72f0YinafI072 pYOVl(12C1 Q oYe 3S lle QfZCl correct. Si atur . Date; 2-17-4 Phone #: L4f,,4i'7UG 11 Official use only. Do riot wrife in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle ane): 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 Anstruction'-s 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 ofhire,• express or implied, oral or written." An employeiis defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a j oint 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 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-printedlegibly: The Depaitmerithas provided a space at the bottom- ofthe 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. 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 anal fax number: Tho CQxnmonwealth,ofM-assar motts De,p.arbent of InduMal ,Accidents office of Westigati ms • , 6QU Wa$ iii am street Boston? MA 02111 Tel, # 617-727-4900 est 406 or 1-$77 MASSAFF, Revised 5-26-05 Fax # 617-727-7749 0 :.COMMONWEALTH OF MASSACHUSETTS PLUMBERS AND GASFITTERS LICENSED AS A MASTER PLUMB ISSUES THE ABOVE LICENSE TO: I TIMOTHY A GIARD 60 SAUNDERS ST NO ANDOVER MA 0184 2414 /�l 10301 05/01/lei 183494 1 ,j