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HomeMy WebLinkAboutMiscellaneous - 99 OGUNQUIT ROAD 4/30/20181 07/07/2011 To Whom It May Concern. I, Ali Mandalinci, have relieved Victor Piniero of Pine Electric of all electrical duties associated with the property 99 Ogunquit Road located in North Andover, MA. Subsequently I have hired Dave DeVincentis to complete all remaining work. Thank you,. ; t' Ali Mandalinci 3 *95u5 Date 1. - f• • ?... ......./ J TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .j. �jh.-Z ... C? e-.,— 461, ........... _............................. has permission to perform .. a,.y ..;p10........�.0�aj./vf wiring in the building of f .................................. A r.T.....S �Y..'......................... . North Andover, Mass. i Fee.....,`......... Lic. No..... .4 ......... ....... .......... .... ..... ELECTRICAL INSP Check # Permit No. �`tir OJ Department of Fire Services • BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 1/07] (leave blank M 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 WINK OR TYPEALL INFORMATION) Date: City or Town oi. NORTH ANDOVER 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) 19 i T d 6 i f7 (as Owner or Tenant ��1 f) GiQ I (iC.l V Telephone No. ex '-i(pLl Owner's Address I CA u n a i 2 Uf9nk Uf r A Q,( 6' a g& Is this permit in conjunction with a build g permit? Yes ©� No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion of the following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Above In- Swimming Pool rnd. ❑ rnd. ❑ o. o mergency Yg mg Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS I 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 g No. of Waste Disposers Heat Pump Number Tons KW ............. No. of Self -Contained Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems:* No. of Devices or Equivalent No. of WaterKW No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER:10 Q 0',-)d Q, Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. 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 permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: LIC. NO.: F� Licensee: Signature LIC. NO.: 2j (If applicable, enter "exempt" in the license number line) Bus. Tel. No.: Address: Alt. Tel. No.: *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature be w, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's Owner/AgentPERMIT FEE: $ S Signature � Telephone No. � 3��31 I Alvt/c- - &-7 9!57c-- I" eqrl� J-6-8 No i eF 5 0/1'1 AFA� , l I Alvt/c- - &-7 9!57c-- I" eqrl� J-6-8 No i eF 5 0/1'1 AFA� , The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 4 s• www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lellibly J/�11 Name (Business/Organization/Individual): CJ:Y t U_. Address: l % 1) ,L City/State/Zi 0 d'lnjoye t- Phone #: 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).* 2. I am a sole proprietor or partner- ship and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t have hired the sub -contractors listed on the attached sheet. t These sub -contractors have workers' comp. insurance. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no 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. F1 Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other *Any applicant that checks box #I1 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 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: .>1 Q C' Policy # or Self -ins. Lic. #: Job Site Expiration Date: 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 pains and penalties of perjury that the information provided above is true and correct. 1 y" K �-- � Date: R I 1 -� / 10 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 #: 3/20/11 PINE ELECTRIC Pine electric will not be finishing the electrical work in regards to the pool permit at 99 Ogunquit Rd., North Andover, MA. Victor Pineiro Jr. Pine Electric Andover, MA As of today, 3-21-11, Pine Electric will not be finishing the electrical work in regards to the pool at 99 Agunquit Rd., Forth Andover, MA. Cc: Peter Murphy V" Pine Electric Andover, MA As of today, 3-21-11, Pine Electric will not be finishing the electrical work in regards to the pool at 99 Agunquit Rd., North Andover, MA. 7441 Date /0. —.. Z�. — / .. A TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that.. has permission for gas installation . ....... .............. ivGin the buildings of ...... 6a le. ............ at ... ;P.f .... 0 . ae! gev'. %7......' North Andover, Mass. Fee...r . Lic. No,;, .................. GAS INSPECTOR Check # N- SSACHliSEITS LW,ORXI APPUCATON FOR PERPUrr ID DO GAS FTEIING (Type or print) Date lo -3o -lo NORTH ANDOVER, MASSACHUSETTS Building Locations / T� /f Permit # s Amount $ Owner's Nameg New Renovation ❑ Replacement ❑ Plans Submitted ❑ (Print or type) Name Address Name of Licensed Plumber or Gas Fitter Check one: Certificate Installing Company FICorp. 11 Partner.. E]Firm/Co: h iSURANCE COVERAGE Check o I have a current liability Insurance policy or it's substantial equivalent. Yes f No If you have checked yes, pIT icate the type coverage by checking the appropriate. box. 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 :Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner Agent I hereby certify that all or the details and information I have submitted (or entered) in above application are true and accurate to the, best of nn knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massae sts Syatc Gas Code and Chapter 143 of the General Laws. By: Title CityiT6wn APPROVED (OFFICE USE ONLY) r, Signature of Licensed Plumber Or Gas Fitter Plumber C3Gas Fitter tccnstNtfeb Master r '7 Journeyman �Tri�ls7r.► • r BASEMENT --- INEENIM MINE MINE INNIENENIME 1ST. FLOOR INNIENINEME '2ND. FLOOR !MMMMM INNINEENIM INS MINE MINE MINE MM (Print or type) Name Address Name of Licensed Plumber or Gas Fitter Check one: Certificate Installing Company FICorp. 11 Partner.. E]Firm/Co: h iSURANCE COVERAGE Check o I have a current liability Insurance policy or it's substantial equivalent. Yes f No If you have checked yes, pIT icate the type coverage by checking the appropriate. box. 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 :Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner Agent I hereby certify that all or the details and information I have submitted (or entered) in above application are true and accurate to the, best of nn knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massae sts Syatc Gas Code and Chapter 143 of the General Laws. By: Title CityiT6wn APPROVED (OFFICE USE ONLY) r, Signature of Licensed Plumber Or Gas Fitter Plumber C3Gas Fitter tccnstNtfeb Master r '7 Journeyman anoA uo asuao!I s!yl daa MEI Aq paasjed !nbei se pa;sod ao uosied, paueol eq;ou Ism pue'a6ap�ad leuos ad eusi o; pau6!ssa ao sMe"1 leaaua j'ay; to suo!s!noid a o ;� 'papuawe se 'jagwnu-asijao!1 moi( o; �ala� s�aM ;;oagns si esuao!l s!yl ;xau ;o Bup!ew aadoid amsu! o; ssaappE �o aiudeu l�aMao� % paeoq moA,fllgou 'paBueyo to s1 unnoys ssaappe ao auaeu anoA 31 "IS uo;6u!yse '00W-9Llzo VW `uo;sob '0LL'evns a M 0001 aansuaal� leuoissa;oad ;o uo!s�n!Q. 4l le p�eo8 anon( �(;!;ou 'pa�toa;sap ao ;sol s, asuaop s141 lI ' 1Nliiaodwl 5 9 L 0'0.0 H# -loalnroo 7396 Date... ./-F-xv ....... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION. This certifies that ...?.r,.5 kv? ....... ?ra. ,............ has permission for gas installation .... ...fir /,"'-f ..... ..,, in the buildings of ..... , 'Celt',.. ....................... . at ..Y � .. 61 & -U -4 6. -v. c.' ....�.� .. , North Andover, Mass. F> .�Q: Q.4.. Lic. No.Q> � .� 15- .......!� c % ' GAS INSPECTOR Check # �` If 0 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) N ANDOVER ,Mass. Date 10/8 2010 Permit # Building Location 99 OGUNQUIT RD Owner Tel# 978-687-7774 PETER BREEN Owner's Name TRAVIS & TIM CONST. Type of Occupancy RESIDENTIAL New FV/1 Renovation❑ Replacement Plan Submitted: Yet No[:] FIXTURES Installing Company Name Eastern Propane & Oil, Inc Address 131 Water Street Danvers, MA 01923 Business Telephone # 800-322-6628 Name of Licensed Plumber or Gas Fitter ROBERT GRENHAM Check one: Certificate ZCorporation Partnership Firm/Co. INSURANCE COVERAGE: I have acur liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes ✓ No 11If you have c ecked yts, please indicate the type coverage by checking the appropriate box. A liability insurance policy F✓ 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 Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Owner E3 Agent ❑ Signature of Owner or Owner's Agent I hereby certify that all of the details and information I have submitted (or entered) in eve application are true and accurate to the best of m� Knowleage ana that all plumbing work and installations performed under the pe City/Town APPROVED (OFFICE USE ONLY) State Gas Co and Chapter 142 of t6 Type License: • umber Signatur • as fitter • -Master License • -Journeyman for this appligPt!,on will begin compliance with all of Licensed Plumber or Date .�—.z/..le..... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .................................... .................................... has permission to perform .......................................................... wiring in the building of .... .......... ......................... ....... .......... North Andover, Mass. ............... Fee. Lic. No. c .. f - E. E . i �EUCAL INSPE Check # 9354 Gomm onwea& of Majdac4aJetti Official Use Only cc� ��77 Permit No. T- 2epartment ol._tim Seruicei Occupancy and Fee Checked y BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] T(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 TYP ALL NFORMA ION) Date: 1/-23—/Q City or Town of: lJOH1 AYJCW,� To the Inspector of Wires: By this application the undersignedives notice of his or her intention to�perform the electrical work described below. ber Location (Street & Num) �%� / —H6,g) n B v fw J I +- .R N Owner or Tenant T r,s' ' d/ Owner's Address Is this permit in conjunction with a building permit? Yes Purpose of Building Existing Service Amps Volts Telephone No. i No ❑ (Check Appropriate Box) Utility Authorization No. f6S JC Overhead ❑ New Service 90 Amps I 0 / Volts Overhead ❑ Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Undgrd ❑ No. of Meters Undgrd 0 No. of Meters Completion of the followine table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil.-Susp. (Paddle).Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑In- ❑ rnd. rnd. o. o Emergency Lighting Batte 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 g No. of Waste Disposers eat Pump Number TonsKW """" ........... No. of Self -Contained Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems: * No. of Devices or Equivalent No. of WaterKW No. of No. of Data Wiring: Heaters Si ns Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. 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 cov rage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE 5Z BOND ❑ OTHER ❑ (Specify:) I certify, under the ails and enalties of perjur that t information on this application is true and complete. FIRM NAME: .i LIC. NO.: Licensee: SignatureLIC. NO. (If applicable, enter "exempt" in the license number line.) fB Bus. Tel. No.: Address: Alt. Tel. No.: *Per M.G.L. c. 147, s. 57-61, security work requires Department of Public Sa ety "S" License: Lic. No. OWNER'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 a ent. Owner/Agent Signature Telephone No. PERMIT FEE. $ -Selto Q� .5"- G - �r� P� A I I I Date ........ 41- .. . - .. 14 ........ ...... .... .... TOWN OF NORTH ANDOVER PERMIT FOR WIRING thiscertifies that ....... . ............ ............... ... . ..................................... has permission to perform wiring in the building of ....... .................................................................... at ..PF .... (:2.. ../ �")- .................... ........ I North Andovei,.,Mass. Fee .a....04 ........... Lic. No.,;�4 .............. .... .... ...... . .... 'EiLmEeM U INSPE Check # 9 3?- 6 r Commonwealth of Massachusetts7=N Official Use Only -- Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS cupancyand Fee Checked �d [Rev. 1/07] Qeave blank APPLICATION FOR PERMIT TO PERFORM ELECTRlCA All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 00WORK (PLEASE PRINT EV BX OR TYPE ALL INFO ,i RMATION) Date: 7 .. ? _ /0 City or Town of: NORTH ANDOVER To th6 f Wres: By this application the undersigned gives notice of his or her intention to perform the el� electrical ectorw>ies nbed below. Location (Street & Numbe R U NOlt' Owner or Tenant A G � M� r Owner's Address II J I fv Al /' > Telephone No. � - Is this permit in conjunction with a building permit? Yes El NO ❑ Purpose of Building (Check Appropriate Bog) Existing Service Amps Utility Authorization No. / _ New Service _Volts Overhead ❑ Undgrd No. of Meters Amps ---Volts Number of Feeders and.Ampacity Overhead ❑ Undgrd No. of Meters Location and Nature of Proposed Electrical Work: No. of Recessed Luminaires Com lesion o theollowin table m be waived _bY the Ins ector of Wires. No. of CeiL-Sus 0.0 p. (Paddle) Fans Total_ No. of Luminaire Outlets No. of Hot Tubs Transformers KVA No. of Luminaires Swimming pool Above ❑ Ia- d• Generators KVA o. o mergency g No. of Receptacle Outlets d. No. of on Burners. Batte Units No. of Switches 1^"R ALARMS No. of hones No. of Gas BurnersDetection and No, of Ranges No. of Air Cond. °� Initiatin Devices No. of Waste Disposers Tons eat ump umber Tons KW No. of Alerting Devices No. of Dishwashers Totals:Detection/Ale o. of Self Contained Devices Space/Area Healing KW Local ❑ Municipal ❑ �� No. of Dryers o. of Water HeatingA Appliances Connection Security Systems: Heaters ' No. of Ballo. of Si s B alasts No. of Devices or E uivalent Data Wiring: No. Hydromassa a Bathtubs g . No. of Motors Total HP No. of Devices or E uivalent Telecommunications Wiring• OTHER: No. of Devices or Eanivnlpn� Estimated Value of Electrical Work: Attach additional detail if desired, or required by the Inspector of Wires. Work to Start (When required by municipal policy.) d in INSURANCE COVERAGE: -Unless waived by the ownerections to be , DO permit fo the Perfce with 1�IEC ormance electrical mon completion the licensee provides proof of liability insurance includin ctrrcal work may issue unless undersigned certifies that such cover -age is in force and g completed operation coverage permit its substantial equivalent The CHECK ONE: INSURANCE exhibited proof of same to the permit issuing office. I certify ❑ BOND ❑ OTHER ❑ (Specify:) under the pains and penalties of perjury, that the information on this m FIRM NAapplication is trueoplete ME: /sV e C T,2 Licensee: > G r al? 1A/e SiLIC. NO.x,-1__;%i _ A (If applicable, enter "exempt " in the license number line.) `Mature LIC. NO.: Address: _ /P dM4Z S% 4"VX)O ups /Ljd Of j,/ 0 Bus. Tel. No.: *Per M.G.L c 147, s 57-6 1, security work re requires D Alt. Tel. No.: OWNER'S INSURANCE W q Department of public Safety, License: Lic. No. RIVER: I am aware that the Licensee does not have the IiabiIity insurance coverage normally required by law. By my signature below, I hereby waive this requirement I am the (check one) ❑ Owner/Agent owner ❑owner's agent Signature Telephone No. PERMIT FEE: S 90 00 /�� at�l t�-- /,c 1 /, �, 0 �M. yr 4A • j ! r� The Commonwealth of Massachusetts Department of Irndustrial Accidents Office of Investigations 600 Jfrashing ton Street Boston, MA 02111 www mas.�gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Eiectricians/pinmbers Aicant Information . Name (Business/organizaEion/individual): Address: City/state/Z,ip: Phone #: . Are you an employer? Cheek.the appropriate box: I • Q I' am a employer with 4. ❑ I am 8 general contractor and I Type of Project (regniredj; employees (full and/or : part-time). 2. I am .a sole proprietor or have hired the sub -contractors 6. ® New construction partner. ship and have no employees listed ori the attached sheet, t 7. ❑ Remodeling working forme in arty capacity, These suh-contractars have workers' insurance. 8' Q Demo}ition [No workers' comp. insurance comp. 5. ❑ We are a corporation and its 9' ❑ Building addition required_] 3. ❑ I am a homeowner doing officers have exercised their I O Q Electrical repairs °r additions all work rgyseli [No -workers' comp. right of exemption per MGL c 2, § I (•4),'and we have no I I .. ❑ Plumbing repairs m additions insurance required.] t •emPloyees. [No workers' }? ❑ Roof repairs •AnY applicant gW comp. insure m required.] checks bo�C # I must also filt oat the section below showing their woh�' bompensation — t Homeowners who submit this affidavit indicating they 13.E Other policy infotmafiori are doing all work and then hire outside contractors �tnt. tots that chuck this box mustattanited an addhtioaal sheet rho wing t:he mime df f6e sub.co±ttrtcct�+rFw`tS must a ubmit a � affidavit ' such Pan an employer that is pr?W4ng:workers' co ensaziou ' Po1ic3' inamsiion. informafiort arisurance for Rty. employees: Below Insurance Company Name: ' is &E Poles' and joh site Policy 4 or Self -ins. Lic. #: Expiration Date: - Job Site Address: ACity/State zip. ttach a copy of the workers' compensation Pommy declaration page (showing the policy number and expiration Failure to seewe coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminalp oa dated fine up to $1;500.00 and/or one- penalties of a Of up to $250.00 a da Year imprisonment, as well $s civil penalties -in the form of a STOP WORK ORDER and a fine y againstthe violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. uo hereby certify under the 7�� peialties o er' irP lmy that the utformation provided above is time and correct Siewture: .�.r Date: l "hone #: S 7AF OJTJciat ase 0a1y. Do not write in this area, to he compleW by cfty or town o ciaL City or Town: IssuinA— Permit/License g # rRy (circle one): I. Board of Health Z Building Department 3. City/Town Clerk 6. Other Contact Person: 4. Electrical Inspector 5. Plumbing Inspector Phone #: ri Dates`. l0 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that....T) . has permission to perform . .Y.1... ................... r. plumbing in the buildings of :--:�.. ................. . 1 , at . .�77.. ........... ,North Andover, Mass. p%/ • e% PLUMBING INSPECTOR Check N 8550 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or Print) NORTH VER, MASSAC ZSETTSBuilding Location Q tJ �`` • p Date ennit # 37 Amount Owner New Renovation Replacement Plans Submitted Yes No (Print or type) \\ Installing Company Name Check one: n Corp. Partner. Firm/Co. Certificate Name of Licensed Plumber: Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity ® Bond ❑ Insurance Waiver: L the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner. ❑ I hereby certify that all of the details and information I have submitted (or ent best of my knowledge and that all plumbing work and installations perf orpNeZ compliance with all pertinent provisions of the Massachusetts State Plu&birig By'Signature rcens S� TYpe Title f Plumbing License icity/Town Agent rl in above application are true and accurate to the r Permit Issued for this application will be in Chapter 142 of the General Laws. ❑APPROVED (OFFICE USE ONLY rcenseum er Master Journeyman 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 Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: c b City/State/Zip-JA h,�,-��,c„rz,yr. al; 7S Phone #: Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2.p am a sole proprietor or partner- listed on the attached sheet. I (� ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance [No workers' comp. insurance required.] 3. ❑ I am a homeowner doing all work myself [No workers' comp. insurance required.] t ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 152, § 1(4), and we have no 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. H--i'lumbing repairs or additions 12.F� Roof repairs 13. ❑ Other o Kme._...seen" ne±ov! s�ovvamb their workers' compensation Policy nformation. 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 isproviding 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: 1 Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). 1 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 th�ains and penalties of perjury that the information provided above is true and correct 0 Official use only. Do not write in this area, to be completed by city or town official, City or Town: Issuing Authority (circle 'one): L Board of Health 2. Building Department 6. Other Contact Person: Permit/License # 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 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 15.2, §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 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 permittlicense 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 y 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�j Office of Investigations C2yo 600 Washington Street Boston, MA 02111 , a% Tel. # 617-727-4900 ext 406 or 1-8.77-MASSAFE Revised 5-26-05 Fax # 617-727-7749 wwvm7.mass-gov/dia