HomeMy WebLinkAboutMiscellaneous - 91 SURREY DRIVE 4/30/20186/22/2016
20676
This is an e -permit. To learn more, scan this barcode or visit northandoverma.viewpointcloud.com/#/records/20676
OF TAOR I H qti
S�� OCL
O m
� 7]
SSACHUSE
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that Robert A Sammataro
has permission for gas installation replace cookstove
in the buildings of PUGLISI. JANET C
at 91 SURREY DRIVE B, North Andover, Mass.
Lic. No. 18214
Date: June 22, 2016
1/1
UV MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY i� fir MA DATE PE T #
— —
JOBSITE ADDRESS
OWNER'S NAME
G
OWNER ADDRESS 9 TEL��_J/ • —!� �"
TYPE OCCUPANCY TYPE COMMERCIAL.— EDUCATIONAL RESIDENTIAL.e
PRINTT
CLEARLY NEW:, , RENOVATION: _._ REPLACEMENT:—
PLANSSUBMITTED; YESNO_'
APPLIANCES Z !T�
8SM 11 2 1 3 1 4 15 6 7 8 9 10 11 12 13 14
BOILER - r --
BOOSTERi -
DIRECT VENT HEATER
DRYER.
ROOF TOP UNIT
TEST
UNIT HEATER
UNVENTED ROOM HEA
WATER HEATER—
OTHER..—
INSURANCE
_EATER._ _ _
OTHER
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch.142 TYESILY NO
I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
LIABILITY INSURANCE POLICY j -e^ 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.
SIGNATURE OF OWNER OR AGENT
CHECK ONE ONLY: OWNER AGENT
"Ordoy cenuy mat an of the details and Information I have submitted or entered regarding this application are a and accurate t e best of my knowledge
and that all plumbing work and installations performed under the permit issued for this application will be in m 11a wit II P ' ant provision of e
Massachusetts State Plumbing Cod and Chapter 142
the General Laws.
PLUMBER-GASFITTER NAME /
�L-�'(�/Z LICENSE # ATURE
MP ✓ MGF _ _ JP JGF LPGI _ CORPORATION PARTNERSHIP _#_ LLC
_ #
COMPANY NAME __ ZGADDRESS
CITY
+LOW-- � STATE ZIP TEL ---�.
FAX► CELL
E Al
The Commonwealth of Massachusetts
Department of IndustrialAccidents
I Congress Street, Suite 100
Boston, MA 02114-2017
www nws gov/dia '
Workers' Compensation Insnrance Affidavit: Builders/Contractors/EleMriciangPiUmbei'e:-
TO BE FILED WITH THE PERMITTING AUTHORITY.
Are you an employer? Check the appropriate box:: Type of project (required):
1. Q I am a employer with employees (full and/or part-time).' 7. ❑ New construction
2.❑ I am a sole proprietor or partnership and have no employees working for me in g, ❑ Remodeling
any capacity. [No workers' comp. insurance required.]
9. ❑Demolition
3.❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.]'
10 ❑ Building addition
4. ❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will
coure that all contractors either have workers' compensation insurance or are sole 11.❑ Electrical repairs or additions
proprietors with no employees. 12. ❑ Plumbing repairs or additions
5r3l am a general contractor and I have hired the sub -contractors listed on the attached sheet. 13. Roof repairs
sub -contractors have employees and have workers' comp. insurance?
6.am a corporation and its officers have exercised their right of exemption per MGL c. 14. [:]Other
152, §1(4), and we have no employees. [No workers' comp. insurance required]
*Any applicant that checks box # 1 must also fill 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 state whether or not those entities have
employees, If the sub -contractors have employees, they must provide their workers' comp. policy number.
I am an employer that is providing workers' compensation insurance for ►rly employees. Below is the policy and job site
informa"L
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 MGL c. 152, §25A is a criminal violation punishable by a fine up to $1,500.00
and/or one-year imprison ietrty,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. A' Copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
eoverme verification.
do hereby cel under thq paig andpqkpias of perjury (#at the information provided above is true and cor=4
t 1-rAMINM
O,,l`i W use only. Do not write in this area, to be completed by city or town oricial
City or Town: Permit/License #
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector
6. Other
Contact Person: Phone #:
+� G'nMMAAIWRAITU f%C ••w00Anulf^.-v�
a
PLUMBERS AND GASFI.TTERS
ISSUES THE FOLLOWING LICENSE
LICENSED AS A JOURNEYMEN PLUMBER
ROBERT A SAMMATARO
8 DUNRAVEN RD
WINDHAM, NH 03087-1263
18214 05/01/2018
PLUMBERS AND GASFITTERS
ISSUES THE FOLLOWING LICENSE
LICENSED AS A MASTER PLUMBER
ROBERT A SAMMATARO
8 DUNRAVEN RD
WINDHAM, NH 03087-1263
9333 05/01/2018
o COMMONWEALTU OF MASSACHUSETTS
livikateligulm ••• •
BOARD OF
PLUMBERS AND GASFITTERS
ISSUES THE FOLLOWING LICENSE
REGISTERED AS A PLUMBING CORP
ROBERT A SAMMATARO
ROBERT A SAMMATARO P&H, INC
8 DUNRAVEN RD
WINDHAM, NH 03087 v
3373 05/01/2018 34142
'
OR '75 1 r'oll''