HomeMy WebLinkAboutMiscellaneous - 991 OSGOOD STREET 4/30/2018Date..................................
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
Thiscertifies that....................................................................................................................
has permission for gas installation............................................................................
inthe buildings of...................................................................................................................
at................................................................................................. . North Andover, Mass.
Fee Lic. No.
GASINSPECTOR
Check #
sl
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK
CITY F MA DATE PERMIT#
JOBSITE ADDRESS OWNER'S NAME E- 7: O'T
GOWNER
ADDRESS 4LLLL I TELFAX
TYPE OR
PRINT
OCCUPAN
'Y TYPE COMMERCIAL EDUCATIONAL Ej RESIDENTIAL
CLEARLY
N RENOVATION: F REPLACEMENT: PLANS SUBMITTED: YES 0 NO
APPLIANCES 7 FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BOILER
BOOSTER
j F _71 F'__J -------- I
CONVERSION BURNER
COOK STOVE ,__1I--!)L--_
DIRECT VENT HEATER F_j 77-1 __J _jE-71
E -I
DRYER
FIREPLACE
FRYOLATOR
FURNACE7,771 F—i 77� 7 -J F777.F7-71
[—I
F_7I F_
GENERATOR
7
IL
A I
GRILLE
1177711- F. [77�
INFRARED HEATER
LABORATORY COCKS --J I T-71
MAKEUP AIR UNIT DI
OVEN F
• I
F J=F-
POOL HEATER 7_7711 I 11-77-1111F._ IF
717771 F -r-1 =
F771 F=j F_77j F�'
ROOM / SPACE HEATER IF— i 11i L
-
= =
ROOF TOP UNIT F
TEST F J 1--7,11177—i F-1
,'JNIT HEATER ----- -- - I I f
1771 i--1 F-7 F ---7j
UNVENTED ROOM HEATER F�
JVATER HEATER - ------ --J I
OTHER 771 7_77-11 77-1 1_11 I IF-
I
�_.l F-1
F-1 I i 7- IIL
-:17-1-J, -
_A_ .- _._
777=2 - �_ - F, JUI
INSURANCE COVERAGE
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MOL. Ch. 142 YES[d_1NO
I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVE BY CHECKING THE APPROPRIATE BOX BELOW
BOND [_ FL
LIABILITY INSURANCE POLICY F21 OTHER TYPE INDEMNITY _j
, j
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 011 AGENT
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 vision of the
Massachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUMB ME
W_ SIGNATURE B -GASFITTER NA LICENSE#
LICENSE #[Z SIGNATURE
MP I MGF[!Ij JGF
JP L7 CORPORION PARTNERS _14=
j LPGI E] _.j] (LLC D#=
COMPANY NAME: ADDRESS
CITYC. '5, 1STATE I- A JTELu-_� -/3
1ZIP[ L
FAX 5 t CELL - 01E MA
2
ROUGH GAS INSPECTION NOTES
THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION MOTES
Yes No �f �� 1 -h
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE: $ PERMIT #
PLAN REVIEW NOTES
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA. 02111
UV www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Lef4iblV
Name (Business/Organization/Individual):
Address:
City/State/Zip: L-) / (L ; 6' ' li 1 Phone #:
Are on 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. ❑ I am a sole proprietor or partner-
listed on the attached sheet.
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.] Ti
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10. ❑ ctrical repairs or additions
11. Plumbing repairs or additions
12.❑ Roof repairs
13. ❑ Other
*Any applicant that checks box # I must also fill out the section below showing their workers' compensation policy information.
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 4 or Self -ins. Lie. #: Expiration Date:
Job Site Address: j `1 �- �` 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 requireclunder 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 zs t ue and correct.
Phone #: (!_� `/3.7 -- L (_%i
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 S. Plumbing Inspector
6. Other -
Contact Person:
Phone
Information and In.stroctions
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 employeris 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 cavy 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 Iine.
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 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 eommonweatth of Massachusetts
Department offadustrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
TeL # 617-727-4900 ext 406 or 1-877-MASSAFB
Revised 5-26-05 Fax r 617-727-7749
Nvv. .m,ass,govfdia
COMMONWEALTH OF MASSACHUSETTS
--PLUMBERS AND GA'--t-11
LICENSED AS A MASTER PLUMBER
ISSUES THE ABOVE LICENSE T O
CHAD MICHAEL PERRY
m
80 NASHUA RD
JNIT G4
LONDONDERRY NH 03053-3464 a
130',2 05/01/14 162575
FoldTherD tacn Alcn�ti PC r'o,hons
COMMONWEALTH OF MASSACHUSETTS
PLUMBERS AND GASFITTERS
REGISTERED AS A PLUMBING Cll TP
ISSUES THE ABOVE LICENSE TO.
CHAD M PERRY
C.M.P. PLUMBING & HEATING Li('
80 NASHUA RD
UNIT B4
LONDONDERRY NH 03053-3464
3313 05/01/14 162574
J
Fold_ Theo Deiacn Along Air PerforeDo�s
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'�`��') 7
Date.............................................
TOWN OF NORTH ANDOVER
9
PERMIT FOR WIRING
SS�CHUSE
This certifies that
............................................................................................................................
has permission to perform..........................................................................................................
wiringin the building of...............................................................................................................
at.......................................................................................................... Perth Andover, S.
JJ
Fee .............................. Lic. No..................
. 4NO
ELGC Rte. t
Check #
1
• Commonwealth of Massachusetts Official Use Only
Department of Fire Services Permit No.
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev -1/07] (leaveblank
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 ININK OR TYPE ALL INFORMATION) Date: / .� -.s-- / 3
City or Town of: 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) C' > Gt ��c S �''i> t l
Owner or Tenant L- G- C, Telephone No.
Owner's Address 71X 1�� h /� ��1 &
Is this permit in conjunction with a building permit?
Purpose of Building
Existing Service Amps / Volts
New Service Amps ,l O / ZZ,'f Volts
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:
/&; /1-17el6L- L14
Yes fE3,----No ❑ (Check Appropriate Box)
Utility Authorization No.
Overhead ❑ Undgrd ❑ No. of Meters —
Overhead ❑ Undgrd ❑ No. of Meters _
Cmmnletinn nfthv fnllnwiwo tnhle mm, ha waived by the Tn,vnertor of wh-es.
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. grnd.
o. of Emergency Lighting
Battery Units
No. of Receptacle Outlets
No. of Oil Burners
FIRE ALARMS
No, of Zones
No. of Switches
No. of Gas Purners
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
Totals:
Number
Tons
KW
" """" "
No. of Self -Contained
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 Water KW
Heaters
No. of No. of
Signs Ballasts
Data Wiring:
No. of Devices or Equivalent
No. Hydromassage Bathtubs =No.
of Motors Total HP
Telecommunications Wiring:
1\o. of Devices or Equivalent
OTHER:
T
Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: (When required by municipal policy.) r
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 cove e is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: 1NSLMANCE LK BOND ❑ OTHER ❑ (Specify:)
Ycertify, under thepains an enalties o perju , that the i formation on this application is true and complete.
FIRM NA7,-b,
r C ` 1 &o,L` C- / te t: t v 1 C LIC. NO. -2
Licensee: C- U 1 /1E, Lam' Signature `Z���` CNL` `"' LIC. NO.: 1 % L/6 5d"' ! ~�
(If applicable, tIV "ex pt" in the license umber_ linp) A Bus. Tel. No.: `t i` y )
Address: �,G! / �! O % c f 6' �C, Z Alt. Tel. No.:
`Per M.G. c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lie. 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 agent.
Owner/Agent PERMIT FEE. $
Signature — Telephone No.
❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the
permit application fonn to provide notice of installation of wiring shall be uniform throughout the 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. G.L C. 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 may be deemed by the Inspector of Wires abandoned and invalid if he
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 be terminated upon the written
request of either the owner or the installing entity stated on the permit application.
❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of
the Acts of 2012. The purpose of this act is to promote job gromh and long-term economic recovery and the Permit Extension Act furthers 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 extends, 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.
❑ Rule 8 — Permit/Date Closed: *** Note: Reapply for new permit ❑
❑ Permit Extension Act — Permit/Date Closed:
Trench Inspection
Pass 0
Failed 0
Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
Date:
SERVICE INS ECTION:
Pass
Failed 0
Re- Inspection Required ($.) ❑
Inspectors Comment
Inspectors Sig ature: J
Date:
PARTIAL ROUGH INSPECTION:
Pass R
Failed ❑' Re- Inspection Required ($.) ❑
Inspectors Comments:
Inspectors Signature:
- Date:
ROUGH] INSPECTION:
Pass
Failed
Re- Inspection Required ($.) ❑
Inspectors' Comm nts
Inspectors Signature:
Date:
FINAL INSPECTION: ,
Pass 0
Failed M
Re- Inspection Required ($.) ❑
Inspectors Comments:
C
�— r(J—
Inspectors Signature:
Date:
v
DEB WEINHOLD ... TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com
The Commonwealth of Massachusetts
Department ofIndustrial Accidents
Office of Investigations
600 Washington Street
Boston, .U4 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/fndividual): 1 Itat'al tr
Address:
City/State/Zip: �� � /Ll 6. C' � Phone #: 75- Y Z
Are you an employer? Check the appropriate box:
1. L ��I am a employer with J
4. ❑ 1 am a general contractor and I
employees (full and/or part-time)."
have hired the sub -contractors
2. ❑ I am a sole proprietor or partner-
listed on the attached sheet.
ship and have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. ❑ We are a corporation and its
required.]
officers have exercised their
3. ❑ 1 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.]
employees. [No workers'
comp. insurance required.]
Type of project (required):
6. ❑ New construction
7. E] Remodeling
8. ❑ Demolition
9. ❑ Building addition
10. El Electrical repairs or additions
11. ❑ Plumbing repairs or additions
12. ❑ Roof repairs
13.❑ Other
*Any applicant that checks box 91 must also fill out the section below showing their workers' compensation policy information.
f 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 checkthis 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. 4�:
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 requiredunder 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.
Ido hereby cert under the pains and penalties of perjury that the information provided above is true and correct.
Signature: Date:
Phone 9: Cj 7 ,1 — V . zz
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 producedacceptable 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. AIso 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 ur 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 no 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 Cwnmoawealth of Ma ssa chu setts
Department ofZndustrialAccidents
Office ofIuvestigations
600 Washington Street
Boston} MA 02111
TeL 9 617-727-4900 ext 406 or 1-877-MASSAFB
Revised 5-26-05
Fax 4-'617-727-7749
www.mass,gov/dia
COMMONWEALTH OF MASSACHUSETTS
BOARD OF
ELECTRICIANS
ISSUES THE FOLLOWING LICENSE AS A W
REGISTERED MASTER ELECTRICIAN a
z
ROBERT F CHANDLER W
z
w
W
5 A AVE
SALEM NH 03079-2504
21468 A 07/31/16 53470
This certifies that..
has permission to perform .....
plumbing in the buildings of
Date.............................
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
at...................................................................................................... North Andover, Mass.
Fee...................... Lic. No.......................................................................................................
PLUMBING INSPECTOR
Check #
I
MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK
—
MA DATE
CITY (?�� - — �� '�� -' - .I -3 - -, l PERMIT#
-
y-2`
JOBSITE ADDRESS_.._ -_A OWNER'S NAME
P;l
TYPE OR
OWNER ADDRESS �_-.���.-m_�____----�-----_-_ �
TEL-�---� -FAX - ---
OCCUPA Y TYPE
COMMERCIAL _ EDUCATIONAL E RESIDENTIAL
PRINT
CLEARLY
NEW: _.-' RENOVATION: 0 REPLACEMENT: PLANS SUBMITTED: YES[] NOL
FIXTURES Z FLOOR--> BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14
BATHTUB = F_ = t _
_k
CROSS CONNECTION DEVICE
DEDICATED SPECIAL WASTE SYSTEM
DEDICATED GAS/OIL/SAND SYSTEM ! _ ; I i I i _, .,___' ( _- � j j
DEDICATED GREASE SYSTEM_i i i 4_ _ I r __I ( I ; I
DEDICATED GRAY WATER SYSTEM I -I
jF_r___DEDICATED WATER RECYCLE SYSTEMDISHWASHER
DRINKING FOUNTAIN
--
FOOD DISPOSER
FLOOR/ AREA DRAIN
INTERCEPTOR (INTERIOR) �_, ��I I I-( !
KITCHEN SINK i
LAVATORY
ROOF DRAIN
SHOWER STALLI L i i j - i - I -
SERVICE / MOP SINK ^(_ i �-
TOILET I ! I I _ I 11=-
I
URINAL
WASHING MACHINE CONNECTION I_ I -' r� I_.- I- ,
! ' ,
WATER HEATER ALL TYPES
--
�_
WATER PIPING (-- I= !j I
OTHER
l
F__ [ l _ f __....' i I`1-
INSURANCE COVERAGE:
1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142, YES NO
IF YOU CHECKED YES, PLEASE INDICATE T TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW
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 AGENT �(
_ SIGNATURE OF OWNER OR AGENT
I 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
h4assachusetts State Plumbing Code and Chapter 142 of the General Laws.
PLUM BE 'S NAME ��C-_i f. _ (CENSE # _, _ GNATURE
Fv1P _, JP] CORPORATION# 1�PARTNERSHIP#� LLC#
COMPANY NAME LC /?')�� L
- -_. � ADDRESS[
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CITY �U n��r_—STATE ZIP TEL
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ROUGH PLUMBING INSPECTION NOTES
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BELOW FOR OFFICE USE ONLY
Yes No
THIS APPLICATION SERVES AS THE PERMIT ❑ ❑
FEE:
PERMIT #
PLAN REVIEW NOTES
FINAL INSPECTION NOTES
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
n ww.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): 122 %" It /
y --
Address: ,2�L2
City/State/Zip: ->n��r1��'�'�t%1 ��1� �Phone #:
Are ou an employer? Check t e 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. ❑ 1 am a sole proprietor or partner-
listed on the attached sheet.
ship and have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. ❑ We are a corporation and its
required.]
officers have exercised their
3. ❑ 1 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.] i
employees. [No workers'
comp, insurance required.]
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10. ❑ ectrical repairs or additions
11. Plumbing repairs or additions
12. [] Roof repairs
13. ❑ Other
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.
Homeowners who submit this affidavit indicating they ai•e 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 atm an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information. ,
Insurance Company Name:
In&z,
Policy # or Self -ins. Lie. #: Expiration
Job Site Address: �t G'�llL�i�'�� �� 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 requiredunder 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.
X rlo hereby certunder thepains and penalties ofverjury 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 #
///.Y//-3
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 producedacceptable 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 munber(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 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 Cone onwealth of Massachusetts
Department of Industrial ,Accidents
Office of Investigations
600 Washington Street
Boston} MA 02111
Tel, # 617-727-4900 ext 406 of 1-8 7` -MASS AFE
Revised 5-26-05 Fax # 617727-,7749
Nvw,w.mass,gov1dia