HomeMy WebLinkAboutMiscellaneous - 87 WOODCREST DRIVE 4/30/2018 (2)N
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Date. CT
NORTH
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TOWN
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o= TOWN OF NORTH ANDOVER,
..PERMIT FOR GAS INSTALLATION
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KThis certifies that \ !'yj.J.... -te n- .......`— ....
has permission for gas installation' r .............. .
in the buildings of f,? .. .C/ ................. .
at ..��r�O-'.��*` , North. Andover; Mass.
Fe... Lic. No..G.x.36.. ....� T
GAS mSOR
Check # !/
6760
MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS FITTING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS Date
Building Locations
Owner's Name
New Renovation Replacement
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SU B-BASEM ENT
BASEM ENT
]ST.
FLOG R
2ND.
FLOOR
3RD.
FLOOR
4TH.
FLOOR
5TH.
FLOOR
iTH.
FLOOR
7TH.
.FL 00R
IT H.'
FLO0R
(Print or type)
Name_ I0ex,
Address
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Permit# &.160
Amount
Plans Submitted ❑
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Check one: Certificate Installing Company
❑ Corp.
Partner.
FCrm/Co.
y Name of.Licensed Plumber'or Gas Fitter
FINSURANCECE COVERAGE
rent liability Insurancepolicy or it's substantial equivalent. Check one:
checked es please indicate the a cove y Yes❑ No❑urance otic �P rage b checking the appropriate box.
P Y ❑Other type of indemnityBond13
urance Waiver. I am aware that the licensee doesdoes nave the Insurance coverage required by Chapter 142 of the
ral Laws, and that my signature on this permit application waives this requirement.
Signature of Owner or Owner's Agent Check one:
Owner 13
Agent 13
: hereby certify that all of the details and information I have submitted (or entered) in application are true and accurate
best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be to
in the
compliance with all pertinent provisions of the Mass setts S
as Code d Ch 142o a General Laws.
By:
Title
City/Tol nk
APPROVED (OFFICE USE ONLY)
yr vas titter
cense t
u wci
4
nce required ] er
.Any applicant that checks box #I .must also fill out the section below showing th--ir workers'. comR:rtsation policy information.
l ontmewners t ch11(j lz thit.ilo e,.rdevit iudicattn� liiey ere uair. e6)'E ;_� ; dict then hi.-- outside conireciur6 rnu8t submit a new affidavit indi —iirt Bach.
�onuactors that check this box must attached an additional sheet showine the nam, of the sutrcor.,actors and their workers' comp. poi icy illfim nnatior..
I am an. employer t' -x is providing, workers' co ensatiori 1
information. mp assurance for ng' employees. Below is the poficy and job site
Insurance Company Name: .
Policy # or Self -.ins. Lic. #:
Expiration Date:
Job Site Address:
Attach a copy of the workerscompensation otic decla City/Stair/Zip.
P y . ration page (showing the policy number and expiration date).
.Failure to secure coverage as required under Section 25A of MGL c. I52 can lead to the imposition of
fine up to $1,500.00 and/or one-year imprisonment; as well as criminal penalties of a
civil penalties in the form of a STOP WORK ORDER and a fine
of up to .5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the O
Investigations of the DIA for insurance coverage verification. ffice of
`-• J.l, �ci ,..Ze pains and pe'l } es of perjur3' that the inform1oiinn provided above is true and correct
Official use onip. Do not write in this area, to be completeQ' by city or town official
City or Town:
Issuing Authority (circle one): Permivucense #
1. Board of Health 2. Building Department 3. City/Toh,n
6. Other .Clerk 4. Electrical
Contact Person:
Phone 4-
The Commonwealth of Massachusetts
it [�K - �/
Cl
Department o
.f Industriol Accidents
Offzce
of Lnvestigations
;r
r �r
6UU Washington Street
s
Boston
, 111.4 02111
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Workers' Compensation Insurance.Affiday..it_
wwxr.rsiass.;ov/dig
ADPflicant Information
Builders/Contractors/Eiectricia ns/Plumbers
Name(3usiness/Drganizationllndividual):
Please Print Leaibiv
Address:
City/State/Zip:
Phone #:
EAre you an employer? Check the appropriate box:
am a employer
TypeofProiect
with
employees (full and/or part-time)-*
I
4. ❑ I am a general contra„^tor and I .
have hired fine sub -contractors
(required):
6 ❑New construction?.
am a sole proprietor or partner-
ship and have no employees
Iisted ori the attached sheet x
These st tb-contractors
7• ❑Remodeling
working for me in any capacity,
[No workers' comp. insurance
P
have
workers
5 P � comp. insurance.
❑ We art a corporation
8. ❑ Demolition
9' 713. lding addition
required]
3. ❑ 1 am a homeowner doing
and its
ofncers have exercised.their
10:❑ Electrical repairs or additions
all work
myself. [Na workers' comp..
right of exemption per MGL
c. 152 (4)' and we have
1 1. ❑ Plumbing repairs or additions
insurance required.] t
no
ern la e?
P Y s [No workers'12'❑
Roof repairs
comp, insura
13 ❑ Otl,
nce required ] er
.Any applicant that checks box #I .must also fill out the section below showing th--ir workers'. comR:rtsation policy information.
l ontmewners t ch11(j lz thit.ilo e,.rdevit iudicattn� liiey ere uair. e6)'E ;_� ; dict then hi.-- outside conireciur6 rnu8t submit a new affidavit indi —iirt Bach.
�onuactors that check this box must attached an additional sheet showine the nam, of the sutrcor.,actors and their workers' comp. poi icy illfim nnatior..
I am an. employer t' -x is providing, workers' co ensatiori 1
information. mp assurance for ng' employees. Below is the poficy and job site
Insurance Company Name: .
Policy # or Self -.ins. Lic. #:
Expiration Date:
Job Site Address:
Attach a copy of the workerscompensation otic decla City/Stair/Zip.
P y . ration page (showing the policy number and expiration date).
.Failure to secure coverage as required under Section 25A of MGL c. I52 can lead to the imposition of
fine up to $1,500.00 and/or one-year imprisonment; as well as criminal penalties of a
civil penalties in the form of a STOP WORK ORDER and a fine
of up to .5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the O
Investigations of the DIA for insurance coverage verification. ffice of
`-• J.l, �ci ,..Ze pains and pe'l } es of perjur3' that the inform1oiinn provided above is true and correct
Official use onip. Do not write in this area, to be completeQ' by city or town official
City or Town:
Issuing Authority (circle one): Permivucense #
1. Board of Health 2. Building Department 3. City/Toh,n
6. Other .Clerk 4. Electrical
Contact Person:
Phone 4-
Information and Instructions `
�a
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute; an employee is defined. as ".. -_very person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as `pan individual, partnership; association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and incluciii rig 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 ap artments and who resides therein, or the occupant of the
dwelling house of another who employs persons to dd maint-nance, 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 o r 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 wor;lc 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 compi-etely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) 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 carryworkers' 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. Theaffidavitshould
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. anyquestions re-� T -ding the -lain ar. if you a*e requi— to obtain a workers'
compensation policy; please call the Department at the no�ber:listmd below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officiais
Please be sure that the'afiidavit is complete and printed legibly. The. Department has provided a space at the bottom
of the affidavit foryou to fill out in the event the Office of Investigaations has to contact you regarding the applicant.
Please be sure to fill in the pennit/license number which will be. used as a reference number. In addition, an applicant
that must submit multiple permit/beense applications in arry 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 b. filled out each
year. Nhrhere a home owner or citizen is obtaining a licenses or permit not related to any business or commercial venture
(i.e. a dog license or permit to burnleaves 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 fay, number:
The Commonwealth of Massachusetts
Department of Lzidustrial Accidents
Office of Larvesfivations
600 Washington Street
Boston, MA 02111
Tel. 4 617-727-4900 e= 406 or 1-9 7 7 MASS:4FE
Revised 5-2645 Fax 4 617-7-7-7749
`h W W.M3SS.gov/dia