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Home My WebLink AboutMiscellaneous - Exception (522)MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY //r? I'..�, — _ - MA DATE PERMIT # b t(d JOBSITE ADDRESS OWNER'S NAME u�� ____ T r = OWNER ADDRESS _____.._ .. j'Yt `Z _. _. TELJ_c i i P-.LI...'...C�� FAX TYPE OR OCCUPANCY TYPE COMMERCIAL ® EDUCATIONAL ® RESIDENTIAL I" PRINT CLEARLY NEW: ® RENOVATION: ® REPLACEMENT: PLANS SUBMITTED: YES E] NDE] FIXTURES Z FLOOR— BSM 1 2 3 4 5 6 7 1 8 9 1 10 11 12 13 1 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/ AREA DRAIN INTERCEPTOR (INTERIOR) KITCHEN SINK LAVATORY ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHENow R INSURANCE COVERAGE: I 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 THE 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 t best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be iniiance W a IF e ' ent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME I. Richard B es Jr. LICENSE # 15435 SIGNATURE MPEI JPEl CORPORATION Q# 3498 PARTNERSHIP®# LLC®# COMPANY NAME I Nurotoco 1 of MA d.b.a Roto -Rooter ADDRESS _ 175 Maple Street F --_ , CITY Stoughton. STATE = ZIP 102072 LLl TEL 781-297-7049 FAX 781-341-8817 CELL 617-212-4589 EMAIL Richard.6 mes@rrsc.com 10673 Date .. l 7hy... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that .... 1.. ................. ... ...!......:k..... has permission to perform ...G u•!�a .GGY plumbing in the buildings of......... at .. N./....!r��!r. �.... ................ Fee /,... Lic. No. JKW. Check #/S -JL 4ic D .................................................................................. orth ndover, Mass. ....................................................................... PLUMBING IN PECTOR The Commonwealth of Massachusetts Department of IndustrialAccidents m Office of Investigations 1 Congress Street, Suite 100 ve�< Boston, MA 02114-2017 'aM www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Hanle (Business/Organization/Individual): Nurotoco of MA d.b.a. Roto -Rooter Address: 175 Maple Street /State/ZiD: Stoughton,MA 02072 Phone #: 1-781-297-7049 Are you an employer? Check the appropriate box: 1. K I am a employer with 66 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 me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.# required.] 5. ❑ We are a corporation and its ❑ I am a homeowner doing all work officers have exercised their myself. [No workers' comp. right of exemption per MGL insurance required.] t 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.❑ 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. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Old Republic Insurance Co Policy # or Self -ins. Lic. #: MWC 11826400 Job Site Address: Expiration Date: 4/1/2016 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 certjfyjunder t un nd penalties of perjury that the information provided above is trye and correct Si afore: _ � Date: Y/ � 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 #: .� ` mV 6 y3on \ \ \ - � Ln , «oa��1 . � �r . &w « � • t „ �: a « , .: : ? 2 a ® = �' Im : 0. \ » -�» co . . � e �. .� CERTIFICATE OP LIABILITY INSURAV_= E14TE IS !SSU AS. -r1 SyTt�jNFp(ilUp-jpN p{iIL,AND' CbNFERS NO:RIGI#TS`OHE CERTIFICATE HOLOER.'THIS �. . �ERfiFMCATErOB �AFF(RMAT�Y �OR •NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLtC1Eg BELOW. THIS CERTIFICATE OF INSUIkANCE -GOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: It the certEtil;ate holder Is an ADDITIONAL INSURED. the policypes) must be endorsed If SUBROGATION IS yyANED� subject to the terms ant! Gond 110114 of the Polley, eerhdn policies may )+squire an andomenteM. A stdoment on this N:eAiBcate does not Confer rights03to the cerflticate holder In lieu of such endmseme s PRODUCER. MARSH USA INC. ' ' 525 VINE STREET. SURE 1600 PHONE F CINCMAI'1, CH 45 2IanMai Atha: cUdn+dub ogn 400W*AC-CAUW 415'ER INSURAFFORDING covomanc IUJC N INSURED 00015 INSURER A: Old R*ft hallranoe Ctr 24141 15- ROTO4aDO Bt SERVICES CONPANY INSURER e : wA WA 175 MAPLE STAEET STOUGHM NA 02072 INSURER C : M )►q;0111 ny ----------------------- 23612 ROMER0 S: - WMns IMPA I c NUMBER; 2E-003892 R4 REVISION NUMBER: 3 tH13 9S TO CERTPI/ TWIT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO- THE INSURED NAMED ABOVE FOR. THE POLICY PERIOD INDICATED. NOTIMTHSTANDING ANY REQUVMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS :CERTIFICATE MAY' BE ISSUED OR .MAY PERTAIN, THE INSURANCE 'AFFORDED BY THE. POLICIES DE$�RIB� HEREIN 1119 SUBJECT TO �U.L THE TERMIS IXCLUSIONS AND CONORIpN8 OF SUCH POLICIES. LIMITS SNOWN MAY HAVE BEM REDUCED BY PAID CLAIMS: TAPEOF WIT M—ma A - aban � UAenm AtV121160132 I11� ulama X 04101/.2014 040V2016 �ypljgR i 20001 NMd�RCV1L G6NEWIL LIABILITY . CLAIAAS�NgOE a OOCUR. .. • .. .. i' 750;0 . . ERP m» • s . 5,0 FERSONai'sAOV.aam : 210.0 ENT. AGGREGATE Uff APPLU PER A6MM7g• i' 6,000,0 X PoucY PF I, Vis.R ME10PAGG s 6000,0 A . AU10110111LELABL1y AItAfl1321857i 04/01i10w" • 001=5X ANY AUTO 510011 AUTOS SCHEDULED MLY%Wrwpwm) S X HIiEDAUTOS X �ED SODRYQNI{�Ylpp S .. UNBRELLA LIAR ' OCCUR i EX�Se un.. o -,--- EACH OCCURRENCE a ROTO=ROOTERSERVICES COMPANY 175 MAPLE STREET STOUGHTON, MA 02m . 1 ACORD 26(2010106) CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED -POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE'. THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUINORMD REPRESENTATIVE. of marshUSA Ma= Manasht Mukhggee ®1988-.2010 ACORD CORPORATION. All rights reserved. The ACORD name -and logo are reglstered;inarke-of ACORD