Loading...
HomeMy WebLinkAboutMiscellaneous - 8 HEMLOCK STREET 4/30/2018N National General Autq Wrnc & Health insure February 10, 2015 Building Inspector's Office 120 Main Street North Andover MA 01845 Insured: Property Address: Underwriting Company: Policy Number: Date of Loss: Claim Number: PO Box 1623 Winston-Salem, NC 27102 Amy Sarofian-Moeller 8 Hemlock Street North Andover, MA 01845 Massachusetts Homeland Insurance Company PHD0088838N1301 February 1423872 Claim has been made involving loss, damage or destruction of the above - captioned property, which may either exceed $1000 or cause Massachusetts General Laws, Chapter 143, Section 6 to be applicable. If any notice under Massachusetts General Laws, Chapter 139 Section 313 is appropriate, please direct it to the attention of this writer and include a reference to the above - captioned insured, location, policy number, date of loss and claim number. On this date, I caused copies of this notice to be sent to the persons named above at the address indicated above by first class mail. Signature: CU4 toYv Lawet,L Clinton Lowell, Property Claim Adjuster 781-884-4407 National General Insurance PO Box 1623 Winston Salem, NC 27102-1623 C] Date ...... �'....-.Z.V.-13.... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ............... O�.:.�......... V..L.;%.... has permission to perform........1�/2f-............�(.��GS...................... ��ZD...<.................................. wiring in the building of ........... � � ......... aC ....... U... t"..! ...........(. L...D. ............... S '................... , N rth Andover, Mass. F.......1.. Lic. No. � eg4........................... ELE CAL INSPECTOR Check # go 11679 Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. Ile, 7% Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] (leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code W),527 CMR 12.00 (PLEASE PRINT ININK OR TYPE ALL INFORMATION) Date: ? �)/c? City or Town of: NORTH ANDOVER To the Insp for of Wires: By this application the undersigned gives notice of his or her intention o perform the electrical work described below. Location (Street & Number) C Lc►C K �' Owner or Tenant Owner's Address t ✓Z.?7u A.) Telephone No. 1 /%G Is this permit in conjunction with a buildin ermit? Yes ff No ❑ (Check Appropriate Box) Purpose of Building d N6 ct /-7 Utility Authorization No. - Existing Service 1W Amps 110 Volts Overhead Undgrd ❑ New Service Amps / Volts Overhead ❑ Undgrd ❑ Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: 4-Nw ✓�r�� / 2,� 2� w 1J --o,, L No. of Meters / No. of Meters Completion of the following table n& be ivhived by the Inspector of Wires. No. of Recessed LuminairesNo. 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 ElIn- Elo. rnd. rnd. o mergency Lighting BatterV 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 Tons No. of Alerting Devices No. of Waste Disposers HeatPump 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 Signs Ballasts No. of Devices or Equivalent `,No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or E uivalent OTHER: ,, e Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: Uv (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 ins nce including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such cover e is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) X certify, tinder the pains and penalties of erjury, that the information on this application is true and complete. FIRM NAME:. ✓ti u � LIC. NO.: _ Licensee: -r—&(,OM M I . Du 1PAA-1 Signature LIC. NO.: � (If applicable, enter "exempt" in the license number line) Bus. Tel. No.: Address: ? dti1X—GU EZ fa Alt. Tel. No.: *Per M.G.L c—.147, s57-61, security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent PERMIT FEE. $ Signature Telephone No. ❑ 2012 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 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. ❑ Rule 8 — Permit/Date Closed: *** Note: Reapply for new permit❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection Pass [N Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass IN Failed 0 Re- Inspection Required ($.) ❑ ., Inspectors Comments: . Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass 1E Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INS ECTION: r r Pass M Failed 0 Re --Inspection Required ($.) ❑ Inspectors C ments: P4 Inspectors Signatu Date: FINAL INSPECTION: Pass 0 Failed Re --Inspection Required ($.) ❑ Inspectors Co ments: r - Inspectors Signature: Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com I The Commonwealth of Massachusetts Department of IndustrialAcciknts Office of Investigations 600 Washington Street Boston, MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: City/State/Zip: l TU1 Phone #: 5 0D —56q Are you an employer? Check the appropriate box: L employer with 4. ❑ I am a general contractor and I 71mampla yees (full and/or part-time).* have Hired the sub -contractors 2. 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. Wemodel:g conction 7. 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions l l.❑ 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 aie doing all work and then hire outside contractors must submit anew 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. 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. 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 ini a 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 cert un r the pain and n s of perjury that the information provided above is tru andcorrect. Signature: Date: Phone #: -C, U ) 0 CI Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License Issuing Authority (circle one): 1. Board of health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - Contact Person: Phone #: Information and 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 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 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 of -permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of ludustrial Accidents Office of Investigations 600 Washington. Street Boston, MA 02111 Tel, # 617-727-4900 ext 406 or 1-877, MASSAFB Revised 5-26-05 Fax # 617-727-7749 wWW.Mass.8oV1dia This certifies that. has permission to perform ....k.. :,. ; ....(... VA-r—b')......... plumbing in the buildings of ....�' A—e ........... . . . . . . . . . . at .... P _• ..... , .... , North Andover, Mass. Pee . � � . Lic. No. 2`-i � ►' � � �'' ................ .. . PLUMBING INSPECTOR 'heck # jj� (-4� � 2S— 13 w` Lo 1-72 r MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK - CITY _ _ QUG/C _ _._ MA DATE _ /> /3 ( PERMIT# JOBSITE ADDRESSOG OWNER'S NAME OWNER ADDRESS ! TEL ------J1FAX _ TYPE OR OCCUPANCY TYPE COMMERCIAL Q EDUCATIONAL © RESIDENTIAL PRINT CLEARLY NEW: 2' RENOVATION: REPLACEMENT: ©I PLANS SUBMITTED: YES JAIN0[]I 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 GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM ._....__.__( _.�( _....._.-_._I DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN _._.€ _._...._I _..__.- J _._.._._f -----._! FOOD DISPOSER f _- 1 ...__.___€----_.__( .__.._.._.I __ ( _I ..__._.__1 ..._..--I FLOOR/AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK _€ _ .._..f ..-----_ J== _.-_J LAVATORY ROOF DRAIN __ SHOWER STALL SERVICE / MOP SINK _. -_-I J _....-..-._ _ _f .___..._€ __.__I .._____€ _..._._.._ __.._.__. _-.._._i .—_. S _.____._1 _ _ __( ....____.__I f TOILET URINAL WASHING MACHINE CONNECTION _ ._� f _ - . f - _ A= WATER HEATER ALL TYPES i f WATER PIPING _ ._f - _ _I .--i ._.-._.! DTHER _ . �._._ -__ � _ ( ! ! ...__._._..l ------ ------- 1 _ INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES ( NO Q OF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY DI BONDII OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT SIGNATURE OF OWNER OR AGENT B 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 P rtinent provisi n of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME[ .. G�nJr LICENSE # �S ! SIGNATURE —� VP o JP ol/ CORPORATION ��#�_.PARTNERSHIP LLCU�— COMPANY NAME ' ADDRESS��-j-��--�� CITY 6!L ---........ _..._.' STATE I ZIP -d 7 J it TEL FAX E CELL 11 EMAIL L_ _ 1 1 W�W E� z° 0 H U W a� d w ` `v o z N w W O a ntZ w Pk Q LLI co aLLI 5 W w co a p w~ z a � U J CL a a s w LL 0 z z 0 H U W a rA C7 P-1 p� c7 0 ki l The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA. 02111 UV www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): �P /a `aw Ig /4 f� Address: `3.J fit%%ii��'I A/0 o City/State/Zip: // A 0/'Phone��-- Are you an employer? Check the appropriate box: L ❑ I am a employer with 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. IIYY"�\�` 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 10. ❑ Electrical repairs or additions 11.❑ 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. #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 insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lie. #: Expiration Date:. Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to -secure coverage as 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. I do hereby certlo under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - Contact Person: Phone Information and 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 bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth, of Massachusetts Department ofIndustrial.Accidents Office of Investigations 600 Washington Street Boston, MA, 02111 Tel, # 617-7274900 oxt 406 or 1-877,7MASSAFE Revised 5-26-05 Fax # 617-727-7749 wwvv.mass,gov/dia r ,� • TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that .." � .. �i-�?'-'�c�....................... has permission for gas installatio...� . .......................... in the buildings of . ........ ................... . at.,? .............. ...... Yorth Andover, Mass. Fee3P' . Lic. NcN? -F .. .... ... GAS INSPECT6R Check #,2 793 Gj--16r1 S 67?J f j �Q d! ®®(/ �•� �� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY_ . µ MA DATE - PERMiT# JOBSITE ADDRESS _ _1 OWNER'S NAME — OWNERADDRESS / TE Gam- fbfj PFAX TYPE OR PRINT _ ____j OCCUPANCY TYPE COMMERCIAL(] EDUCATIONAL RESIDENTIAL CLEARLY NEWEI RENOVATION: Pf REPLACEMENT:® PIANS SUBMITTED: YES O NO [11 APPLIANCES _ FLOORS--► BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER J �— BOOSTER = - - -- - - CONVERSION BURNER _ _ _ J COOK STOVE DIRECT VENT HEATER - - DRYER J FIREPLACEEd FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT - OVEN - J - -- -- -- - - - POOL HEATER ROOM / SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER 1 J _.__.-..._J .._ ..1 -__.-_-_..- _---•._ UNVENTED ROOM HEATER _.,._... _ _.._ I _.._. __fl ._.___( _� __r. a J _.._._. . _ .... f _✓ _ ._ _ .f _ . _.:.,: I (-^ _. _....._ ._- .: WATER HEATER OTHER LJ INSURANCE COVERAGE have a current IlabIlify Insurance policy or Its substantial equivalent which meets the requirements of MGL. Ch. 142 YEStO [j I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY al" OTHER TYPE INDEMNITY iii 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 E] AGENT SIGNATURE OF OWNER OR AGENT 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 provision of the Massachusetts State Plumbing Code and Chapter 142 of the General taws. PLUMBER-GASFITTER NAME oe _YQ, 1" a . _-= LICENSE # I SIGNATURE MP El MGF [. JP A JGF U LPGI ® CORPORATION ®# PARTNERSHIP0# # - - LLC D# COMPANY NAME: ---____-- ADDRESS ._._. CITY STATE ZIP lJ.� TEL FAX' EMAIL Gj--16r1 S 67?J f j �Q d! ®®(/ �•� �� f: The Commonwealth of Massachusetts .Department o f Industried Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.massgov/ilia Workers' Compensation. Insurance Affidavit: Builders/ContractorsfElectricians/Plumbers .Applicant Information Please Print Legibly Name (Business/Organization/individual): Address: City/State/Zip: ��e� Phone #: Are you an employer? Check the appropriate box: Type of project (required): L 211 am a em to er with - p Y _� 4. ❑ I am a general contractor and I ` 6. �] New construction employees (fall and/or part-time,).* 2. ❑ I am a sole proprietor orpartner- have hired the sub -contractors listed on the attached sheet. z 7. ❑ Remodeling ship and'have no employees These sub -contractors have 8. ❑ Demolition working for mein 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.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL I L ] Plumbing repairs or additions myself. [No workers' comp. c. 152, § 1(4), and we have no 12. ❑ Roof repairs insurance required.] employees. [No workers' ad Other comp. insurance required] *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 tyre doing all work and then hire outside contractors must submit anew affidavit indicating such. tContractors that check this box must attached an additional sheet showingthe name of the sub -contractors and their workers' comp. policy information. lam an employer that 1s 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 requiredunder Section 25A of MGL o. 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 DTA for insurance coverage verification. Ido Hereby certlo under the pains andpenalties ofperjury that the information provided above is true anti 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. PIumbing Inspector 6. Other - - - 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 ofhire,• 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 ofthe 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 producedacceptable 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), addresses) 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 that this affidavit maybe submitted to the Department of Industrial Accidents fox 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 -andprinted legibly: The Department has provided a space at the botfom 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 aff davit 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 Coxnz oz wea tl. oFMassa.,ehvsPt s Dep.admit offadustdal Aceldonts OfAce of %yestigati ms 600 Washlugtoxa Street Boston, MA, 02111 TeX, # 617-727,4900 at 406 ox 1.-877:MASSAk'., Vag 4 41 U CY)7 47hnn