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Home My WebLink AboutMiscellaneous - Suite 2101-4 11,166-1 This certifies that 'C d, ,�w -t tk� 14.,j ....................................................................................................................... Date ....... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING has permission to perform ... -74 .......... ..................... plumbing in thef Wilding .- . .................................... at ..... 14060 ....... (PI . ........... . .......................... ... i�OWh Andover, Mass. Fee..iF Lic. No. 3P34 ...... ................................................................................. i�Nj - t (al 3 PLUMBING INSPECTOR Check 4t ! 4 , MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK 4 CITY _ u,=_..1_ MA DATE/ S PERMIT # JOBSITE ADDRESS / OJ Sop p�1 OWNER'S NAME POWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL PRINT CLEARLY NEW: RENOVATION: REPLACEMENT: 0 PLANS SUBMITTED: YES NO 01 FIXTURES'l FLOOR--' BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM �! DEDICATED GAS/OIL/SAND SYSTEM .—Al ..__...J DEDICATED GREASE SYSTEM _J J �_.. J _...J _—_J 1 _.._._J _-.-.__1 DEDICATED GRAY WATER SYSTEM (.._ [ ----- I _=._..► DEDICATED WATER RECYCLE SYSTEM DISHWASHER i __..__.J _. __- J __j ----I.__.....J ______1 __.... 1 _._J-.__-__.1 ___._f 1-___.__ i DRINKING FOUNTAIN FOOD DISPOSER _.____.J_..INTERCEPTOR FLOOR/AREADRAIN 1 J __- 1 J _.....lic (INTERIOR) ! f r i I_._J_...__-__ iKITCHEN SINK I .1 ! ----_.__1 ___ _L ______I ______l-__-...__ -_-___(--__�LAVATORY_--__-1ROOF DRAIN ----._-ISHOWERSTALL f I I J [ ___I______._SERVICE / MOP SINK J 1 1 f JJ ._-J ___J____[ .. .� __-1TOILET 1 J I 1 E J 1 f J __J __. J URINAL 1 _._..__J f J � _____J ___._.1 __..._._I __._J WASHING MACHINE CONNECTION ____f ! _.._...J _ _ _I _ ____ _ ; .__._.__f WATER HEATER ALL TYPES WATER PIPING 61HER _ _ i I ---f _---._ _f1 ( I 1 __I __.. INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES P] NO Q IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY DI BOND 0 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 Q AGENT 0 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 ac urate N the b s f my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in�mp anc it all Pe in vision of the lk4assachusetts State Plumbing Code and Chapter General Laws. r114422�offtthe PLUMBER'S NAME 1 �� cwt �'"�GLi-.. LICENSE # . ��? NATURE MP�Q JP Q CORPORATION N#E_ 3 _i PARTNERSHIPQ# s LLC U COMPANY NAME J, 0,h, ICA ADDRESS CITY ✓�-�--___.._.._..__i STATES _ ZIPy i /� (� TEL 7 6 3 d •� FAXELL._..._.__.._............. ... ------------ _ N ❑ The Commonwealth of Massachusetts _ Department of Industrial Accidents I Congress Street, Suite 100 Boston, HA 02114-2017 ,vt www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contxactors/Electricians/Plum ers. TO BE FILED WITH THE PERMITTJNG AUTHORII S'. ,,, ^ v, ;„{ 1 Name (Business/Orgariization/lndividual): Address: city/state/zip: Are you an employer? ;cic the appropriate box: Phone #: 1.Q I am a employer with employees (full and/or part-time).* 2.❑ I am a sole proprietor or partnership and have no employees working for mein any capacity. [No workers' comp. insurance required.] 3. ] I am a homeowner doing all work myself [No workers' comp. insurance required.] t 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5. ❑I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have einpioyeas and have workers' comp. insurance.t Type of project (required): 7. [] NbVdonstruction 8. [] Remodeling 9. [J Demolition 10 [] Building addition 11.❑ Electrical repaixs or additions 124E] Plumbing repairs or additions 13•. n Roof repairs 14. M Other 6.FJ We are a corporation and its, officers have exercised their right of exemption per MGL c. I I 152, §1(4), and we have no empldydes. [No workers' comp. insurance required] s bo9c #1 must also fill out the section below showing their workers' compensation policy information: *Any applicant that checkmit•th.. ffidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such et showing the name of the sub -contractors and state whether or not those entities, ha $Contractors that check this box must attached an additional sheve t Homeowners who suba have employees, they must provide their workers' comp. policy number. employees. If the sub contractors X am an employer that is providing -workers compensation insurance for my employees. Below is the policy and job site information. [ `1, Insurance Company Name- A s �{ Expiration Date:. Policy # or Self -ins. Lie. #: Job Site Address: (Ji UZ i L DO 6S 6b 1 ��City/State/Zip: % "'' �1 Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiratioxx date). nal violation punishable by a fide up to Failure to secure coverage as requ-wel as civer il penalties enalties in the form of a25A is a aSSTOP WORK ORDER and a fine of up to $200-00 50.00 a and/or one-year imprisonment, as P day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. ==I—do hereby c fy 'der ae sin n e of perjury that the information provided shove is true and correct. i, r / bate: 1 / f- 6 8' -7 - 687 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 Phone #• Contact Person: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for theiremployees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of We, express or implied, oral or written.,, An employer is defied 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 receivef6r, 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 ofthe 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 ofsuch 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=contractor(s) name(s), address(es) and phone number(s) along with their certificates) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for 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 pennit/Ecense 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 burn leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 www.mass.gov/dia I? r / \ � � � $