HomeMy WebLinkAboutMiscellaneous - 88 HERRICK ROAD 4/30/2018k
ti
AP Date...
... .. .. ..... ........
Xll I
TOWN OF NORTH ANDOVER
ee
PERMIT FOR WIRING
.... . ......
This certifies that A.4 ..................... X� .................... .................
, , 1 4)0(- /& "',
has permission to perform i4v? ..... X! . ........ ... Y,.k..
wiring in the building of ......
.......... ..... I ...........................
at ........ ... ..... North over /)*S.
Fee..A......... Lic. No .............. .,Vt,7 .......... ......................
ELEemcAL I14SPECTOR
Check # ��% �-�/ d
10599
2012 Massachusetts Electrical Code Amendments 527 CMR ]2.00 § Rule 8: In accordance -with theprovisions of M.G.L. c. 143, §. 3L, the
permit application form to provide notice of installation of wiring shall be uniform throughoutthe 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. 01c. 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 maybe deemed_bythe,Insp.ector_of_Wires abandoned.anflnxalidEhe_.
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.l e terminated upon the written
request of either the owner or the installing entity stated on the. permit application.
4 �
❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended byr6ections.74 and 75 of Chapter 238 of
the Acts of 2012. The purpose of this act is to promote j&growth and Iong-term economic recovery and the Permit Extension Act f nfhers 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 dxtends, 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.
le 8—Permit/Date Closed Note:Reapply for new per,
❑ Permit Extension Act — Permit/Date losed: J
Official Use Only
l,ornrnnncueccL"L�t o� !'l'(ae3cecltccseLL9 6���
cc��
Permit No.
2epcu,bnerd o1 �7ir•e serviced
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULAI IONS (Rev. 11/99) (Icavcblank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code (MEC), P7 ChJ.R 12.00
(PLEASE PRINT IN INK OR T %1fl\TF0RX_A'T10Y) Data:City or Town of: a��_ (11 C9u P��i To the Inspector of fres.
By this application the undersigns notice of his or her intention to perform the electrical work described below.
1 1
Location (Street & Number S�
Owner or Tenant 'vim
Owner's Address
Telephone No.
Is this permit in conjunction with a building perm t? Yes No ❑ (Check Appropriate Box)
Purpose of Building b 4, too vy-, Utility Authorization No.
Existing Service Amps Volts Overhead ❑ Undgrd ❑ No. of Meters
New Service Amps Volts Overhead -11 Undgrd ❑ No, of Meters
Number of Feeders and Ampacity
�r1
, Location and Nature of Proposed Electrical
i Completion of the following table may be waived by the Inspector ofWcrea.
Kll UUn ueeuu--, —uu IJ L- I1..., vi — IAV I.I J , ,—
Il,ATSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee
provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such
coverage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: D-NTSURANCE .❑ BOND ❑ OTTER ❑ (Specify:)
Estimated Value of Electrical Work:
Work toStart:_
1 certify, ander the
FLRlvi NAME:
(Expiration Date)
(When required by municipal policy.)
Inspections to be requested in accordance with MEC Rule 10, and upon completion.
and penalties of perjun), that the infomiarion on this application is true and complete.
rt
LIC. NO.: <5"169 / r
Licensee: Signature LIC. NO.:
(If applicable, enter "erernpt" in the license ruonber fine.) Bus. Tel. No.:
Address: Alt. Tel. No.:
OWI\IER'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 �l
Signature Telephone No. PERMIT FEE: $
of Total
No. of Recessed Fixtures
No, of Ceil.-Sus P� (Paddle) Pans
TTransformers KVA
ra
No. of Lighting Outlets
No. of Hot Tubs
Generators KV4
AboveIn
❑ ❑
No. of Emergency Lighting
No. of Lighting Fixtures
Swimming Pool gmd grnd
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
No. of Zones
No. of Detection and
No, of Switches
No. of Gras Burners
Initiating Devices
No, of Ranges
Tot
No. of Air Cond. Tons
No. of Alerting Devices
Heat Pump
Number
Tons _
__ KW---
No. of Self -Contained
No. of Waste Disposers
Totals:
Detection/Alerting Devices
No. of Dishwashers
Space/Area Heati
S n
P g KW
Municipal
Local ❑ Connectton ❑ Other
Sec
No. of Dryers
Heating Appliances KW
No. of Demes or Equivalent
No. of Water
No. of No. of
Data Wuing
Heaters kW
Signs Ballasts
No. of Devices or Equivalent
Telecommunications Wiring:
No. Hydromassage Bathtubs
No. of Motors Total HP
No. of Devices or Equivalent
OTHER;
Kll UUn ueeuu--, —uu IJ L- I1..., vi — IAV I.I J , ,—
Il,ATSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee
provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such
coverage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: D-NTSURANCE .❑ BOND ❑ OTTER ❑ (Specify:)
Estimated Value of Electrical Work:
Work toStart:_
1 certify, ander the
FLRlvi NAME:
(Expiration Date)
(When required by municipal policy.)
Inspections to be requested in accordance with MEC Rule 10, and upon completion.
and penalties of perjun), that the infomiarion on this application is true and complete.
rt
LIC. NO.: <5"169 / r
Licensee: Signature LIC. NO.:
(If applicable, enter "erernpt" in the license ruonber fine.) Bus. Tel. No.:
Address: Alt. Tel. No.:
OWI\IER'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 �l
Signature Telephone No. PERMIT FEE: $
The Commonwealth of Massachusetts
Department of Industrial Accidents -
-- —Office -of Investigations - -
600 Washington Street
Boston, MA 02111
www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
nlicant Informntinn "I — . , t .. .
Name (Business/Organizatio ndividual): /` 1
Address:,- t4-
City/State/Zip:
Phone 4:_617-20 __?dQ S
Are you an employer? Check the appropriate box:
1. ❑ I am a employer with
4. ❑ I am a general contractor and I
^ployees (full and/or part-time).*
have hired the sub -contractors
2. I am a 'sole proprietor or partner-
listed on the attached sheet. I
ship and have no employees
These sub -contractors have
working for mein 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
-1Y 4pp11oa11L LIM cnecxs oox s t must also till out the section below showing their workers' compensation policy information.
t 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. 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 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 certify under the pins and penalties pe V that the information provided abovei/true aid correct.
`7 3102' s— I 1
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):
L Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
.6. Other
Contact Person: Phone #:
9248 Date . 111141171 .
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that ../. 7,;'-! .. u"! -meal .................... L .
has permission to perform ../k/ .............
plumbing in the buildings /of .`fir ........................
at..p✓t`i�r.��� ........... . , North Andover, Mass.
Fee. 0",�..... Lic. No. 4 ........ .
PLUMBING SPECTOR
Check # _ y�7
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
.,-9
r
New Renovation Replacement
ierxrrrrrrb-o.n
Date
Permit #
Amount
Plans Submitted Yes ❑ No
(mint or type)
Installing Company Ntdge /
Check one: Certificate
❑ Corp.
❑ Partner.
ffFirm/Co.
Name of Licensed Plumber:
Insurance Coverage• Indicate of insurance coverage by checking the appropriate box:
Liability insurance policy Other type of indemnityEl Bond
Insurance Waive: I, the undersigned, have been made
three insurance aware that the licensee of this application does not have any one of the above
6ignat
er Agent
I hereby certify that all of the details information I have sub *tied (or ered)' veIi _
umbing w d, installa ons erfo P and accurate to the
best of my knowledge and that all pl
compliance with all pertinent P P d far this lication will be in
provisions of the Massa s in C de d pt 2 e General Laws.
By:
i nire or Mumise um er
Title Type of P1umbind Licens
City/Town 6 %
APPROVED (omcEusF oNLY icense um �r Master Journeyman ❑
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office ofInvestigations
600 Washington Street
. Ut Boston, M14 02111
www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
anlit nnf InfnV-M,0" _
Name (Business/Organization4ndivi ud al): I / Al
Address:
City/State/Zip:
1_)-
f - IM w Phone #:1—/43A
!43 A
1
comp. msurance required.]
tfiay applicant that chw'.�W box rl must also fill out the section below show;��* f: oy wo-}
Type of project (required): ❑
6. New construction
7. ZRemodehng
8. [] Demolition
9. ElBuilding addition
10. F-1 Electrical repairs or additions
11.0 Plumbing repairs or additions
12.[] Roof repairs
13-ElOther
Comp;mSaLion
Homeowners who submit this affidavit indicating they are doing all work and then hire outside Contractors must summit 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
information. for my employees Below is the policy and job site
Insurance Company Name: r Y)f (-C
Policy # or Self -ins. Lic. #:
Expiration Date:
Job Site Address:(r �T%��C�
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 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 ad ' ed that a copy of this statement may be forwarded to the Office of
Investi ons of th_e__Dbk for insurance
I do herek-seztiry under
?k_
-X- 32
that the information provided above is true and correct
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):
I. Board of Health 2. Building Department 3. City/Town CIerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Fmnr_:1®
Contact Person:
Phone #:
Are ou an employer? Check the appropriate boa:
1 I am a employer with �—
4. ❑ I am a general
employees (full and/or part-time).*
2. ❑ I
contractor and I
have hired the sub -contractors
am a sole proprietor or partner-
listed on the attached sheet t
ship and have no employees
These sub=contractors have
working for me in any capacity.
[No workers' comp. insurance
workers' comp. insurance.
5. ❑ We are a corporation and its
required.]
3. ❑ I am a homeowner doing
officers have exercised their
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. msurance required.]
tfiay applicant that chw'.�W box rl must also fill out the section below show;��* f: oy wo-}
Type of project (required): ❑
6. New construction
7. ZRemodehng
8. [] Demolition
9. ElBuilding addition
10. F-1 Electrical repairs or additions
11.0 Plumbing repairs or additions
12.[] Roof repairs
13-ElOther
Comp;mSaLion
Homeowners who submit this affidavit indicating they are doing all work and then hire outside Contractors must summit 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
information. for my employees Below is the policy and job site
Insurance Company Name: r Y)f (-C
Policy # or Self -ins. Lic. #:
Expiration Date:
Job Site Address:(r �T%��C�
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 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 ad ' ed that a copy of this statement may be forwarded to the Office of
Investi ons of th_e__Dbk for insurance
I do herek-seztiry under
?k_
-X- 32
that the information provided above is true and correct
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):
I. Board of Health 2. Building Department 3. City/Town CIerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Fmnr_:1®
Contact Person:
Phone #:
VA
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 "Neitherthe 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=contractor(s) 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 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 aypl;cauon 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 m 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 permittlicense 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: of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 021.11
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-72.7-7749
Revised 5-26-05
www.mass.govfdia
9 04
Date.
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
This certifies that .. !. !. . � : i9 ...............
has permission to perform .... S . ��..c .............
plumbing in the buildings o ..................................
at ...��f1. f'!?r�.� .. !� ......... ,North And ver, Mass.
Fee. oto . Lic. No.......... . ......
PLUMBING SPECTOR
Check # 3%!�—y
0
I.AV- V
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
City/Town: MA. Date: 3
Permit#
Building Location:s��0 / Hyl
wners Name:
Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential
New: [] Alteration: ❑ Renovation: ❑ Replacement: Plans Submitted: Yes ❑ No ❑
FIXTURES
x
7
z
LU
z
�
Z
N
N
0
W
_z
Q
o
F
I
w
O
N
z
a
w�
LU
LU
2
U
a
Z
Ln
3
O
u
3
_z
a
tW—
3&
LL
W
a gn
?
Ln
m
w
w
O
cn
I=
.J
Q
W
Q
WCC
w v
iE
O
3
Q
T
n0
U
z
a m
m
o
0
0
LL
°x
g g
SUB BSMT.
BASEMENT
1ST FLOOR
2ND FLOOR
8RD FLOOR
4T" FLOOR
5T" FLOOR
eT" F OL OR
7T" FLOOR
8T" FFLLOOR—
Installing
Com an � p' ) Name: tA-" �
Address: 1
P6 / City/Town:
Stater
Business TO:- j(�— �3��� Fax: 9%" i —30
Name of Licensed Plumbed-----,
DEDICATED
i y
7
z
z
�
Z
N
N
0
S
_z
Q
o
F
I
w
O
N
z
a
w�
2
U
a
Z
Ln
3
O
u
3
_z
a
tW—
3&
LL
Installing
Com an � p' ) Name: tA-" �
Address: 1
P6 / City/Town:
Stater
Business TO:- j(�— �3��� Fax: 9%" i —30
Name of Licensed Plumbed-----,
DEDICATED
i y
7
�
Z
N
N
W 6
S
dI
0 O
y
7
d
W
a gn
Ln
Check One Only Certificate YA
❑ Corporation
❑ Partnership
vpirm/Company
INSURANCE COVERAGE:
1 have a current liabty insurance policy or its substantial equivalent which meets the requirements of MGL. Ch
If you have checked Yes, please indicate the type of coverage by checkingthe 142 Yes El No El
appropriate box below.
A liability insurance policy' Other type of 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 a ation waives this requirement.
Check One Only
3i�c nature of Owner or Owner's Agent Owner ❑ Agent ❑
1 hereby certify that all or the details and Information I ha
Knowledge and that all plumbing work and Installations F
Pertinent provision of the Massa54useits State Plumbing
By_
Title
Type of License:
led under the permit
and Chapter 142 of ti
for
License Numh(er: /G�6/
are
cne cess oT my
with all
w, I
The Commonwealth of Massachusetts
Department of IndustrialAccidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
nnlieanf Tnfnrmol
Name (Business/Organization/Individual): e !
Address:_ 0 3 C st-
City/State/Zip:,. IA Phone #:
Are you an employer? Check theappropriate box:
Cf
1 a employer with
4. ❑ I am a general contractor and I
employees (full and/or part-time).*
2. ❑ I am a sole proprietor or
have hired the sub -contractors
listed
partner-
on the attached shget. #
ship and have no employees
These sub -contractors have
working for me in any capacity.
[No workers' comp. insurance
workers' comp. insurance.
5. ❑ We are a corporation and its
required.]
3. ❑ I am a homeowner doing
officers have exercised their
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'
*Anu mV++T1
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. E]Building addition
10.❑ Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.❑ Roof repairs
13.❑ Other
VUL Me section Deiow showing their
compensation
icy
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors mast 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 surance for my employees. Below is thepolicy and job site,
information.
Insurance Company Name:
���-��•-- w� to �!�
Policy # or Self -ins. Lic. #:
OJ
Expiration Date:
Job Site Address:. ( Uri / VJd ' 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 Section 25A o GL c. 152 can lead to the imposition of criminal penalties of a
fine up to $1,500.00 and/or one-year imprisonment, as ell civil penalties in the form of a STOP WORK ORDER and a fine
of up to $250.0 t the violator. Be adv' ed tha copy of this statement may be forwarded to the Office of
Investig ons of the DIA for ins cagoveraw- Prifinn
I do herebj'r ' under the a altie erj ►y that the information provided ab ve istr a and correct.
Si na Q 6�
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. 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 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 Com—aonweal`h ofrNiassachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston} MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAIiE
Revised 5-26-05 Fax # 617-727-7749
www.mass.gov/dia
7806 Date ...9/t,1b �.......
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that ... Tm . i
has permission for gas installation ...... 41.1r ......
in the buildings of ...........
................... .
at ... R9 ..hFr 'rid: K .. ........ , North Andover Mass.
Fee. Lic. No..10-3:vi ..
GASINSPECTOR
Check # S2 -SZ
Lu W
Z
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
City/Town: !V •X4C—jtj-1-, MA. Date: 7 q Alt Permit#
Building Location: Ono rf/'� [ �C► Owners Name: b*'Ieef—
—.,,
Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential,
New: ❑ Alteration: ❑ Renovation: ❑ Replacement:,?r Plans Submitted: Yes ❑ No ❑
Lu W
Z
LU
tu x
N
0 w w
Q
0
v
CO
H
=
0=
W
W
w
0 Z
w CO
Z p
m
m
w
1-
� Lu
w
z
o
0
Lu
W
t -
w
W� W 0
Z
w W W z
0
9
Q
z w
a F-
F- w
w
0
o
X
Z w W
to J Q Q
CO)
m W
O Z
C0 X
O F- F
z
W
LU
H
Fw-
Iii.
W
v o o
0 0 z m
O
o0.
z >>>
O
SUB BSMT.
BASEMENT
jbT FLOOR
-2
'FLOOR
-i
'FLOOR
4 TH FLOOR
5 FLOOR
6 FLOOR
-f'FLOOR
8 FLOOR
Installing Company Name:
Check One Only Certificate #
Address._ i) �jja City/Town: �' State:
El Corporation
7
Business Tel: %�' �o�c1- ? (n Fax: `r ���" ETUU
'
El Partnership
Name of Licensed Plumber/Gas Fitte�I .4,
Firm/Company
INSURANCE'COVERAGE:
1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes [I No ❑
If you have checked Yes, please indicate the type of coverage by checking the appropriate box below.
A liability insurance policy Other type of 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 El Agent E]Si nature of Owner or Owner s A ent
By checking this box ❑; I hereby certify that all of the details and i formation I have sub tted (or enter
accurate to the best of my Knowledge and that all plumbing work nd installations per r ed un the
compliance with all Pertinent proviPgn of the Massachusetts Stat Plumbing Code an haptep� of}
A
By /,-,
Title
Cityrrown _
❑ Gas Fitter Signature of
El LP Installer Lic sed tuber/Gas Fitter
ster /
Journeyman License Num er. l G30 /
are true and
ion will be in