HomeMy WebLinkAboutMiscellaneous - 13 Bonny Lane BUILDING FILE
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TOWN OF NORTH ANDOVER
• PERMIT FOR GAS INSTALLATION
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This certifies that . . ,.�`7�.! �rt. . . .!.�!/. . �J . . . . . . . . . . . .
has permission for gas installation . . 4A Nom' "r. .s. . kf �1*
in the buildings of . !?0 ! . . . . . . . . . . . . . . . . . . . . . . . . .
at �� . . . . -✓'�. . . . . r� f . . . , North Andover, Mass.
Fee?! .S-() Lic. No ZO.?:� T � l� *. . . . . . . . . .
�j R S X, Tom' GAS INSPECTOR
Check#0
6050
MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING
(Print or Type)
NO /-'TI' I , Q (�l�K , Mass Date cp
City, Town Permit #
Building Owner 's
AT: Location j3 n nf Name n6 ua n
Type of Occupancy: d-0-I-)C
New RenovationEl Replacement
Plans Submitted Yes ❑ No
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SUB—BSMT.
BASEMENT
1 ST FLOOR
2ND FLOOR
3RD FLOOR
4TH FLOOR
STH FLOOR
6TH FLOOR
7TH FLOOR
9TH FLOOR
(Print or Type)
Check One: Certificate
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Installing Company Name 1� �ln + P� � � � ��(' �/>
Address Q 1 I,9"9' i (' 1 t7 �-�-r p Corp. `'7
[� ❑
� Partnership
1 ❑ Firm/Company
Business Telephone 53 1 ct 9 L4 Name of Licensed PI tuber or asfitter
a• v/C
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 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.
I have informed the owner or his agent that I do not have liability insurance including completed operations coverage.
Signature of Owner/Agent
I have a current liability insurance policy to include completed operations coverage. ❑
By TYPE LICENSE: j
Title ❑ Plumber ` Sign a dire of Licensed
City/TownGasfitter Plumber or Gasfitter
APPROVED (OFFICE USE ONLY) ❑ Master '16Z f
❑ Journeyman License Number
FORM 1243 A.M.SULKIN CO. 1989
I
The Commonwealth of tlassachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Org nization/lndiAdual): ®� �lc/Lf 14. /A/`
M1
�-Address: 9
r
City/State/Zip: �'�/Q /!?/4 019,6o Phone#: -9 7 � C
Are you an employer? Check the-appropriate box: Type of project(required):
1.[ I am a employer with �5 4. El am a general contractor and I
employees (full and/or part-time).* have hired the sub-contractors 6. ❑ New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet # 7• ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ® Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its .
required.] officers have exercised their 10.El Electrical repairs or additions
3.❑ I am a homeowner doingall work right of exemption per MGL 11.
mP P ❑ Plumbing repairs or additions
myself. [No workers' comp. c. 152,§1(4),and we have no l2.❑ Roof repairs
insurance required.] t employees. [No workers'
comp. insurance required.] 13 ❑ Other
*Any applicant that checks box#1 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,
tContractors 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:iAI&Lr S1�XiE7A-14, tS'aJPPt,E7CS Com, „ter rV
Policy#or Self-ins.Lic. #: VJC /9Q03 q y_ q Expiration Date:_Oi/o r
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 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 is true and correct
Si tures F Date:
Phone#:
Oficial use only. Do not write in this area,to be completed by city or town officiat
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#!