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This certifies that
�6
Date . �J
TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
I -a', L......./� '4"
&'
.......//.............................
has permission to perform ../�r ..�� ..... ................ .
plumbing in the buildings of ..AA44 .�
��r.��c.A...-.......
at ..� ...C� vg4..-I �............... North Andover, Mass.
_
Fee. / l� � .. Lic. No.. �.� � ��j.. 1* ........................ .
/� Com. PLUMBING INSPECTOR
Check # J
850
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or Pmt)
NORTH ANDOVER, MASSACHUSETTS
Building
Owner
G 116-f)e ---
New [] , Renovation n Replacement
FIXTITRFC
Date t1l
_
Permit #
Amount % (/
Plans Submitted Yes [] No
(Print or type)
Installing Company Name , i 1 lle , _
Check one: Certificate
11 Corp.
0 Partner.
0Firm/Co.
Name of Licensed Plumber: k L kQ l
Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box:
Liability insurance policy Other type of indemnityEl Bond
El
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 Agent rl
I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the
best of my knowledge and that all plumbing work and 'installations perf ed under Permit Issued for this application will be in
compliance with all pertinent provisions of the ssach State P ing od and Chapter 142 of the General Laws.
By: e or Licem—,
um
ype
Title of PIumbing License
�
City/Town APPROVED (OFFICE USE ONLY
rcense um er Master Journeyman ❑
The Commonwealth of Massachusetts
Department o f frddush ial Accidents
Office of, nvestiorations
600 Washington Street
Boston, MA 02111
Workers' Compensation Insurance Affidavit: Builders/Cont
A licant Informationractors/Etectt'icians/Plumbers
Please Print Legibly
Nagle (Business/Organization/Indi Adual):
G
Address:
City/State/Zip: �1 p �G�
Phone #: 12— y3
Are you an employer? Check the appropriate boa:
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
?. I 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 5. ❑ 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. msuran
required.]
3. ❑ I am a homeowner doing all work
myself. (No workers' comp.
insurance required.] t
Type of project (required): .
6• V[]ew constriction
7• emodeling
8. ❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
I I-YPlumbing repairs or additions
12•❑ Roof repairs
ce required.] I 13 ❑Other
`.-ny agpiicant that checks box 4l must also til: oul these fio• b�lov shop W., t„
Homeowners who submit this affidavit indicating they are doing all work and thea hioutside
�i ontractors must submit a new affidavit indicating such.
+Contractors that check this box must attached an additional sheet showinP the YV �t mit ahcn
e name of the sub -contractors and their warkPrc' ,.,...... __:___ • ,. g
` "`" "" e"`Pwyer zitat isproviding workers' compensation insurance for my employees. Below is the policy and P 11Y j
information. 6
site
Insurance Company Name:
Policy # or Self -ins. Lic. #:
Expiration Date:
Job Site Address:
Attach a copy of the workers' compensation policy declaration page(showingCity/State/Zip:
Failure to secure coverage as required under Section 25A Of MGL o 152canld to the policy number and expiration date).
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
P aminal penalties of a
Of up to $250.00 a day against the violator. Be advised that a copy ofstatementhemay
forwarded to the Office a
Investigations of the DIA for insurance coverage verification
T do b --- 1_
7- . J .ne pacts art5es of perjury ijtQt the information provided
D //' n above is true and correct
Dfficial use only. Do not write in this area, to be completed
by city or town official
- //J
City or Town:
Issuing Authority (circle one): Permit/L,icense #
1. Board of Health 2. Building Department 3. City/Town
6. Other Clerk 4. Electrical inspector 5. Plumbiab Inspector
Contact Person:
Phone #:
Information an- d Instructions y
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 apartuXents and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintennance, 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 it license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of co=mpliance 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 uatzl acceptable evidence of compliance with the instance
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' comp enation 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 slue to sign and date the affidavit. The affidavit should
be mtu-ned to the city or town that the application for the permit or license is being reaues*.ed, not the .Deparent of r
Industrial Accidents. Should you have any questions regardirLg the jaw 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 Investigation bas 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 yew, 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 Ince to thank you in advance for your cooperation and should you have any question,
please do not hesitate to give us a call
The Department's address, telephone and.:fax. number.._
The Commonwealth of Massachusetts
DeRarta3ent of Industrial Accidents
Of lice of lnvestigations
600 Washington Street
Boston, MA 02111
Tel. # 617-72.7-4900 east 4Q6 or 1-8 77-MASSAFE
Revised 5-26-05 Fax # 617-727-7749
vrvrw=ass._gov/dia
TOWN OF NORTH ANDOVER
i - r
PERMIT FOR GAS INSTALLATION
\94.. • _w yr
This certifies that ... k 0. �.. `�` � ...........
has permission for gas installation ..... e a /.6 4A -.............
�in the buildings of ..... N��'� eIle:
at ....�.�.....� D. l�tt�-!!� ....`� � . , North Andover, Masrv�
Fee. Lic. No. A. J57CY l ' I" ...................`.6
GAS INSPECTOR
Check #
7025'
MASSACHUSETTS UNIFORM APPLICATON FOR PERNIIT TO DO GAS FITTING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
_ d
Building Locations
Owner's Name
New ❑ Renovation ❑ Replacement El
Date
Permit #
4mount $
D2
Plans Submitted ❑
Name of Licensed Plumber or Gas Fitter
Check one: Certificate Installing Company
❑ Corp.
❑ Partner.
aFirm/Co.
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes ❑ No ❑
If you have checked .es, please indicate 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—niaL vtu i itavc bUUtntueu kor emereaJ in above application are true and accurate to the
best of my knowledge and that all plumbing work and installat' s performed under ennit Issued for this application will be in
compliance with all pertinent provisions of the Massac etts Sta GasCodapte2 of�the General Laws.
(APPROVED (OFFICE USE ONLY)
Signature of 1
pPlumber
❑
Gas Fitter
Vn
Master
Journeyman
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SUB -BASEM ENT
LT.
0
H
o
B A S E M ENT
IST. FLOOR
2ND. FLOOR
3RD. FLOOR
4TH. FLOOR
5TH. FLOOR
6TH. FLOOR -
LOOR7TH.
7 T H FLOOR
1-
8TH. FLOOR
l
Name of Licensed Plumber or Gas Fitter
Check one: Certificate Installing Company
❑ Corp.
❑ Partner.
aFirm/Co.
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes ❑ No ❑
If you have checked .es, please indicate 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—niaL vtu i itavc bUUtntueu kor emereaJ in above application are true and accurate to the
best of my knowledge and that all plumbing work and installat' s performed under ennit Issued for this application will be in
compliance with all pertinent provisions of the Massac etts Sta GasCodapte2 of�the General Laws.
(APPROVED (OFFICE USE ONLY)
sed Plumber OtfGas Fitter
License Number
Signature of 1
pPlumber
❑
Gas Fitter
Vn
Master
Journeyman
sed Plumber OtfGas Fitter
License Number
I
The Commonwealth of Massachusetts
Department ofIndustrial Accidents
Office oflnvestigations
600 Washington Street
of Boston., AIL4 02111
www.massgovldia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): Q , l�l(iliiJ
Address: 17 11 hu..DW„ 14
City/State/Zip:__ 41)- �,tQj�L�pqA, 3bPhone #: ��i' f 1g IdV b2
Are you an employer? Check the appropriate bog:
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
2Q 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.]
3. ❑ I am a homeowner doing all work
myself. [No workers' comp.
insurance required.] t .
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. [1 Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.0 Roof repairs
13.❑ Other
—I.Y ayy.. WM �AIQ%;Gb also nrf out me 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 certiun� er the pains gxzj p� alties�of perjury that the information provided above is true and correct
. aid.?
Official use only. Do not write in this area, to be completed by city or town official
City or Town:
Permit/License #
eC
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 #:
4
Informafion and Instructions d
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-contactor(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 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 Commonwealth of Massachusetts
Department of Industrial Accidents:
Office of Investigations
600 Washington Street
Bost, on, M!A 0.2111
Tel. 4 617-727-4900 ext 406 or 1 -977 -MASSA -FE
Revised 5-26-05
Fax 4 617-72.7-7749
v�� A1M7.Ma&&.gov/d-ia
Date. .1/7x1 - 0.`. - ... .
Of AORoTPI 1ti
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This -certifies -that .. )Pw.� r-/ 57.... .............
c
his permission for gas installation ... /.? ...................
in the buildings of ...: < �? � ?�....................... .
at ... ............. , North Andover, Mass.
Fee .A . Lic. No.
GASINSPECTOR
Check #/_ l
4707
6�Gv
i
MASSACHUSETTS UNIFORM APPUCATON FOR PWZNffr TO DO GAS FIT LNG
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
Building Locations
3 PP z1
NewRenovation Replacement
F1 13
Plans Submitted
Date
Permit # y7a
Amount $ ;td —
(Print or type) %� Check one:
Name G J� ❑Corp
Certificate Installing Company
Address 1/ ` 04/ ❑ Partner.
Business Telephone -�J 7 V 9'5'% 5-4:� 11Firm/Co.
Name of Licensed Plumber or Gas Fitters
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes 171 No
If you have checked Yes, please indicate the type coverage by checking the appropriate box. ❑
Liability insurance policy ET, Other type of indemnity D 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 of the details and mtormatton 1 nave sUrmneo dor enrere(l) In auuve appncauU„ aic uuc aiiu accurate io me
best of my 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 Massachusetts State Gas Code and Chapter 142 of the General Laws.
-,r. 'L�",Oogs,
By:
Title
City/Town
PROVED (OFFICE USE ONLY)
Signature of Licensed Plumber Or Gas Fitter
❑ Plumber
® Gas Fitter Icense Number
❑ Master
❑ Journeyman
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SUB -BA SEM ENT
BASEMENT
1ST. FLOOR
2ND. FLOOR
D. F L O O R
-3R
4TH. FLOOR
5TH. FLOOR
6TH . F L O O R
7TH . F L O O R
STH. FLOOR
(Print or type) %� Check one:
Name G J� ❑Corp
Certificate Installing Company
Address 1/ ` 04/ ❑ Partner.
Business Telephone -�J 7 V 9'5'% 5-4:� 11Firm/Co.
Name of Licensed Plumber or Gas Fitters
INSURANCE COVERAGE Check one:
I have a current liability Insurance policy or it's substantial equivalent. Yes 171 No
If you have checked Yes, please indicate the type coverage by checking the appropriate box. ❑
Liability insurance policy ET, Other type of indemnity D 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 of the details and mtormatton 1 nave sUrmneo dor enrere(l) In auuve appncauU„ aic uuc aiiu accurate io me
best of my 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 Massachusetts State Gas Code and Chapter 142 of the General Laws.
-,r. 'L�",Oogs,
By:
Title
City/Town
PROVED (OFFICE USE ONLY)
Signature of Licensed Plumber Or Gas Fitter
❑ Plumber
® Gas Fitter Icense Number
❑ Master
❑ Journeyman