The URL can be used to link to this page

Home My WebLink AboutMiscellaneous - 95 MILLPOND 4/30/2018\ N 04 j O CI � � I, g � �; � r O . z a v 0 ' o Date ..... ././�3� S TOWN OF NORTH ANDOVER . PERMIT FOR GAS INSTALLATION 5 Thiscertifies that.............................................................P.'..'......................................... has permission for gas instal/lation ...........:.:�.�.................................. in thp,,buildings o ..........�^...l 1' t-' ................................................................................................... I at .......: �........................ Dn,c,......................................, North Andover, Mass. Fee....��.....:.......... Lic. No........................... ..................................................................... GASINSPECTOR Check #a 1 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY c MA DATE PERMIT# JOBSITE ADDRESS- ` OWNER'S NAME GOWNER ADDRESS TEL— FAX TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ® RESIDENTIAL;* CLEARLY NEW: F-1 RENOVATION: ® REPLACEMENT: "' PLANS SUBMITTED: YES 0 NOD APPLIANCES 7 FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE L..— -AL _ I- - - INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER RM /SPACE HEATER ROOF TOP UNIT UNK HEATER UNVENTED ROOM HEATER WATER HEATER INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL. Ch. 142 YES NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF CO ERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY i OTHER TYPE INDEMNITY Ej 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 0 AGENT Of SIGNATURE OF OWNER OR AGENT 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 Laws. PLUM BER-GASFITTER NAME _jr LICENSE SIGNATURE MP EJ MGF Ei JP [I JGF LPGI 0 CORPORATION PARTNERSHIP D#L LLC [ I# COMPANY NAME:ADDRESS `0;L (ivt�c�c C �e CITY Ie cz _ __—� STATE �Y �1 ZIP I ? TEL FAX CELL EMAIL r The COMMOnWealth of Massachusetts F Department of IndustrialAecidents I Congress Street, Suite .100 Boston, MA 02114-2017 ,�5J4www mass.gov/dia • 'M 4: Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE Fff ED WITH TBE PERMITtNG AUTHORITY. �, L Name (Business/Orgat&ation/lndividual):- 4- (2 I A 3 V - Address: 5-�— City/State/Zip:_ Axe you an employer? the appropriate box: Phone #: eru to ees full and/or art -time 1 I am a employer with �. P Y ( part-time). 2. I am a sole proprietor or partnership and have no employees Working for me in any capacity. [No workers' comp. insurance required] 3. Q I am a homeowner doing all work myself [No workers' comp. insurance required.] t 4.❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5.C] I am a general contracto 'and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.t 6. Q We are a corporatiori and its, officers have exercised their right of exemption per MGL c. 152, §1(4), and'we --ia' rio employees: [No workers' comp. insurance required.] Type of project ()required); 7. ❑ N6*,donstr6ction 8. Remodeling 9. ❑ Demolition 10 ❑ Building addition 11.❑ Electrical repairs or additions IZU] Piu`ndbing repairs or additions 13•. [j Roof repairs 14. [] Other *Any applicant that checks box 91 wrist also fill out the section below showing their workers' compensation policy information: i Homeowners who submit•this,aMT avit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such t.' tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those,entities have ees, they must provide their workers' comp. policy number. employees. If the sub -contractors have employ 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: S 41 c/ City/State/Zip: Attach a copy of the workers' compepsa on 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 foie 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. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certier thepains andpenalties ofperjury that the information provided ahoy is tru, and correct. Date: i 0' 3 %� Phone #: t'o / ? gg l / E 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 bile, 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 receiv6f6r trustee of an individual, partnership, association or other legal entity, employing emplbyeeg..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 b6 deemed to be an employer." MGL chapter 1.52, §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=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 confinmation 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�Accidenis. 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 scMinsurance 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 "fob Site Address" the applicant should write "all locations in (city or town)." A copy o.f 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 bunt leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia /~ � �\ �...k / 0 2 m C, o : r- -.,Ln 2 : n w= m< ca d mom: oA:,4 ® \\mCA,7_ pi k e i N° 3 ; 4 9 Date . fd ..- �..zlz........ ;:„`�.;�.,"ooTOWN OF NORTH ANDOVER p PERMIT FOR WIRING This certifies that� ^ .............:..................................:............................................ has permission to perform _ �y................. ".. A. * ::?>..:. ., wiring in the building of...............` .................................................................. at .0........ ).........I............. 1.!.:....:.... ......................r, North Andover, Mass. Feel....`.......... Lic.No-:.?l.X .......-4' ................................................. / ELECTRICALINSPECTOR Check # SV'\k WHITE: Applicant CANARY: Building Dept. PINK: Treasurer 't i Is Commonwealth of Massachusetts Department of Fire Services E0"RD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No.!�! Occupancy and Fee Checked / [Rev. 11/99] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATI011) Date: ��- / City or Town of- /-/0- i9ji� �'l t/�� /;144 To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) SQI(Jd Owner or Tenant Owner's Address Telephone No. Is this permit in conjunction with a building permit? Yes No 0�, (Check Appropriate Box) Purpose of Building �pt`1Qv f Utility Authorization No. Existing Service Amps / Volts New Service Amps / Volts Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Overhead E] Undgrd F] Overhead n Undgrd No. of Meters No. of Meters Completion of the following table may he waived by the tnenorinr of Wir— No. of Recessed Fixtures No. of Ceil: Susp. (Paddle) Fans No. of t Total Transformers KVA No. of Lighting Outlets No. of Hot Tubs Generators KVA No. of Lighting Fixtures Swimming Pool Above ❑In- o. o Emergency Lighting rnd. rnd. Battery 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 Heat Pump Number ITons 1KW No. of elf -Contained Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local E] Municipal Other Connection No. of Dryers Heating Appliances Key Security Systems: No. of Devices or Equivalent No. of Water KW No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equi alent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: niiacn aaauionai aetad ij desired, or as required by the Inspector of Wires. INSURANCE 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 pe it is office. CHECK ONE: INSURANCE BOND E] OTHER E] (Specify:) � �e e' 1 7- M", (Ex iratio Date) Estimated Value of Electrical Wor ,?p0_O s' (When required by municipal policy. Work to Start: A� Q / Inspections to be requestedm accordance'with MEC Rule 10, and upon completion I certify, under the ains andpenalti of erlury, that the information information on application is true and complete. FIRM NAME: enn� / C/ -G� /e = LIC..:NO.c Licensee: iwv` L�a1f,eIr, t� .. Signature LIC. NO �j T c�(s� (!f applicable, enter "ex t" 'n the rcense tuber li e. - Bus. Tel. No . C�3rY Address: O Alt.`Te1. No.: OWNER'S -INSURANCE WAIVER: I am awl -re that the Licensee d es not have the liability insurance coverage normally ---- y- -- -- required blaw. By my signature below, I hereby waive this requirement. -I am the (check one) E] owner E] owner's agent. Owner/Agent _ . Signature Telephone No. PERMIT FEE: $