HomeMy WebLinkAboutPermits - Permits - (5) .The Commonwealth of Massachusetts Al
Department of Industrial Accidents 1
Office of Investigations \ �,
w 600 Tf'rishington Street
xoston' ;
www.mass.gav/dia
Workelrs'. Compensation Insaranae Affidavit; Builders/Contraetors/Electrici.68/ l A Iicant rnform�atioln
• Please Print
Name(Business/Organizabondndividual):
Address: ram,.tyr l re AV)
City/state/zip: �/ _ /�
Phone.#: � ' • Zl�ce� � I
r2.
e you an employer? Check the appropeiate box:
I am a e to er with� Type of pr*ct(requiredj'.m}] y 4. 0 l am a general contractor and I
employees (full and/or part-time).' have hired the sub-contractors r�. ❑New oonstructian I am a sole proprietor or partner- listed on the'attached sheet.* 7. [ Remodeling
ship and have no employees These sub-contractors have
worldng forme in any capacity, employees and have workers' $' ❑Demolition
[No workers' comp.insurance comp.insurance,$ ' -9. ❑Btiilding.addition
required.]. , We are a corporation and its 10.❑Electrical re
3 pairs or a `
dditions.❑ 1 aim a homeowner doing all work officers have exercised their
myself. [No workers' conT. 'right Of exemption per MGL 11'❑Plumbing repairs or additions
insurance required.1't c. 152, P 1(4), and we have no 12.0 Roof repairs
rniPlayees. [No workers' 13.QjOther
comp.insurance regtiired,J
* Y applicant that checks box#1 must also fill cut the section below showing their workers'compenssfian policy information,
t ftameowners who submit this affidavit indicating they are doing all work and then hire outside ng such,
ati
candic
$Contractors that check this box must attached an addifionai sheet showing the narrre otthe sins contractors and state whether or not those ntractars must submit a new affidavit'indicating
ti have
employees. Tr the sub-contractors.have employees,they must provide their workers'conxp,policy nurnhor, entifl�s
UM
inforrnati.an employer that is providing workers'eompensatiun insurance for my employees Below is the palicy.rrnd jab site
oiz.
Insurance Company Name:
Policy#or Self-ins. Lic.
Expiration Date: t3�
. . Job Site Address:-2d3 I. ra . � �• t t]tSct{s � �
Attach a copy of the workers' eQmpensatian police declaration Page-(showing the palicY number and expiration da
Faihu e•to secure coverage as mquired'under Section 25A of MGL c. 152 can lead to.the imposition of criminal penalties,of a
fine up to S 1,500.017 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
Investi ations
of up to S250.00 a day against the violator, Be advised that a copy of this statement maybe forwarded to the Office of
taf the DLA for 'nsurance covers a verification
I do hereby ce under he I my and penalties ofperjury that the inforniatiorr provided above is true and correct;
S' atur e.
Date:
Phone
OffQial.use only. Do riot-write in this area, to be completed by city or town official
City or Town:' Perrnit(License#
Issuing Authority(circle one);
"I.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5. Plumbing Iuspector
6. Other,
--------------
Contact.Person:
Phone#:
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING
(Type or print)
NORTH ANDOVER, MASSACHUSETTS
.0 / ., Date
Building Location Owners Name7� n eiT. Permit W. i" —
Amount
T e of Occu anc ( `4!11141�c����,�
New Renovation Replacement Plans Submitted YesEl
No
FIXTURES
tr
H p
W �
°
O �
y z
A F En °
a�
MFLUR
2w FLOCR
3M FUM
4IHifI OM
6M11
7M>70M
gmW=
(Print or type) / Check one; Certificate
1AIt'v 1 �I1�` Corp.
Installing Campan ey Nam '1 � 1
El
Address —_�_� C�11�� �. l? 1 t A(\A&V41t- rA A Partner,
usiness Telephone _ %/'] 44106 1" 5LI-5 Firm/Co.
Name of Licensed Plumber: ill 3 nA t
Insurance Covera e: Indicate the type of insurance coverage by checking the app
ropriate box:
Liability insurance policy Other type of indemnity ❑ Bond
Insurance Waiver: I, the undersigned,have been made aware that the licensee of this application does not have any one of the above
thrVir
x ature Owner El Agent
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 performed under Permit Issued for this application will be in
compliance with all pertinent provisions of the Massachusetts State u bi d Chapter 142 of the General Laws.
By: rig—nature 01 ElcenceciFlumoer
Title
Type of Plumbing License
City/Town
APPROVED ta�tct;use ONLY Et um er Master Journeyman �®
A