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HomeMy WebLinkAboutMiscellaneous - 85 FARRWOOD AVENUE 4/30/2018 (2)I" Date . 01PI H......... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that KAjz I..... 1--rJ c............... i ... . + ....... has permission to perform ... ( ........... ..................... plumbing in the buildings of... (�`.............trP..... at .... v*?--v,,j D -a North Andover, Mass. Fee ... �' L i c. N*o" ........................................................ PLUMBING INSPECTOR jt Check 0�'k 1� TT4K MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY a MA DATE ., l rz 1... -_-.._i PERMIT # I `� t, - JOBSITE ADDRESS_._._OWNE'S NAME. _ _�� ' P OWNER ADDRESS I TEL 66G9FAX TYPE, OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL F] RESIDENTIAL PRINT CLEARLY NEW. E-1 RENOVATION:REPLACEMENT:[,}_I PLANS SUBMITTED: YES E] No FIXTURES Z FLOOR- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB _ _a _---._-� .., _._! ._. __ ___ 1 __.-__, ...-. ,..! _- I _-_._-_I-.---_CROSS PBIM CONNECTION DEVICE ! I ,._,-J . _..JDEDICATED SPECIAL WASTE SYSTEMDEDICATED GASIOILISAND SYSTEM DEDICATED GREASE SYSTEM. DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN _,.__I _.._ -- -- _-! .--....:...__._ _-.__...� ._.. •_-.. .__-_ ! _....._....______! __.-_._..1 ....__.. ..._.-._I _....._' .._.._ FOOD DISPOSERFLOOR/ AREA DRAIN INTERCEPTOR INTERIOR ---- .__._ ` KITCHEN SINK__1 L.____ LAVATORY _ ... t .__.___ __._._._ _-: ROOF DRAIN SHOWER STALL SERVICE I MOP SINK ------------l TOILET I _1 _.-- _i EE URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES__..I_.. WATER PIPING OTHER I ---- - --- _ J . ---� - -- ' -- -- I I - tt--- -- ------------ - -1 =.=.= = 1-7 --- -- —, INSURANCE COVERAGE: �� I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. YES,�C�( NO IF YOU CHECKED YES, PLEASE INDICATE TH PE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY -1 OTHER TYPE OF INDEMNITY [J BOND 0 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 I hereby certify that all of the details and information 1 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 la ce with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME ,...,. _ .__.-5�._-- .. ......_... _ .__� LICENSE # _J_ . _ ._ _' SIGNATURE MP E] JP .. CORPORATION [:]# PARTNERSHIP[I#� ... _.__j LLC COMPANY NAME 11ADDRESS b o1 D - CITY 11SJ���.��'''''_...-..���� ISTATEZIP �CD._ ....__. _....._ .11 TEL%`T/" . Qi0_- FAX__ i CELL 7i-380.337 MAIL . /1 �°... luS_✓� Cdr" ' - --- ---- _..-.__..._ - L� 1� TT4K A y ✓'- The Commonwealth af.Massachusetts - Department of Jnd1!strig1 Acc1d&fs Office ofIfavestigations 600 Washington. Street Boston, MA 02111 k1pi www mass gov1dia ' 'porkers' Compensation Insurance Affidavit: Builders/Contrcacto�cs/EX plea a Pain I,eb bb .u- ,fj,U.U1GF7�. 1;) City/State/Zip: ��'� Phone #: 9 7 �- 3 3 U Are you an employer? Check the appropriate box: 4. El am a general contractor and I 1. F1 I am a employer with _ to ees full and/or mt ' )• )ems * have hired the sub -contractors 2. I am sole proprietor or partner- listed on the attached sheet. 'These sub -contractors have ship andfave no employees working forme in any capacity. workers' comp. insurance. 5. E] We area corpoxat on and its [No workers' comp. xnsuran ce officers have exercised their required.] 3. El am. a homeowner doing all work right of exemption per MGL myself. [No workers comp. c. 152, § 1(4), and we have no p em to ees. o workers' y insurancerequired.] i comp. insurance required.] Type of project (required): 6. EINeur construction f [[ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.[] Roofrepairs 13.❑ Other Mny applicant that checks box#i must also fill outthe section below showing their workers' compensation policy information. r -Homeowners who submit this affidavit indicatingthey R' doing all work and then hire outside contractors must submit a new affidavit indicating such. Tr,­rnf,mre that eheckthis 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 formy employees Below is thepolicy and joh 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 Section25A of MGL o. 152 can lead to the imposition of criminal penalties of a tine 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 ofup to $250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Of ca of Investigations of the DIA for insurance coverage verification. f X do lierehy cer a pat s ancipenalties ofperjury #1 at the information provided above is true and correct. +o• ' �� e) 3 -3 C7 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 6110): x. 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 def7ned 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 wdeceased 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 fiu out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificates) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If au LLC or LLP does have employees, apolicy 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 retumedto 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 Deparknenthas provided a space at the bottom of the affidavit for you to frll out in the event the Office of favestigations 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 id on file for future permits or licenses. Anew affidavit must be filled out each year. Vhcre a home owner or citizen is obtaining a license ox 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 Common walth oplasaachvsPttq Depa e,u.t o£ir'.t wWal Aceldonta Ofte dwestrgatiom a Wadliugtou stow Bo02111 TO, # 6X7 -7-2,'x_4900 ext 406 ox 1-877 M'ASSOB Revised 5-26-05 Fax # 61M27-7749 'uFwwams,gova'a• ^ ', 9 V } ul �LLJ . z:ca 4n ui « .e _ 6y >y <C : a (S ®O d o y < \ \' . 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