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HomeMy WebLinkAboutMiscellaneous - 132 Kingston Street �30� kl�nJG�S�� S ��� r ��� Date...<040/..... 106f) A U T TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that.................... .................................... P-06.PCXA CA, has permission to perform .......... .........V.................................................. plumbing in the buildings of....5 IL*'****'***"****'***'**"*"***"*"**"*****"*'****"**...... at.....�3.2......... ......... North Andover, Mass. M Fee-32. ......Lic. No. 5................ ........... ................................................................. PLUMBING INSPECTOR Check � e MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK lugCITY . 6� ��?�"' MA DATE . `r PERMITT# JOBSITE ADDRESS / ,� �� o OWNER'S NAME— P OWNER ADDRESS ..._ 4 TELL 7 5 — 51 FA TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ® RESIDENTIAL PRINT CLEARLY NEW:El RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES E] Non FIXTURES Z FLOOR— BSM 1 2 3 4 1 5 6 7 1 8 1 9 10 11 12 13 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 SINK4Cr LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES _ WATER PIPING3 . . _ OTHER 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 �= p LIABILITY INSURANCE POLICY E] OTHER TYPE OF INDEMNITYD BOND 0 OWNER'S.INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the A 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 accura the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be) c mplia ce I ertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME I Richard Bymes_Jr. =LICENSE# 15435_ SIS' A R MPEJ JPE] CORPORATIONQ# 3498.._. _ PARTNERSHIPQ# LLCEj# COMPANY NAME Nurotoco 1 of MA d.b.a Roto-Rooter ADDRESS F175 Ma le Street CITY Stoughton J STATE= ZIP 02072 TEL 781-297-7049 FAX 781-341-8817 CELL6W7- 12-4589 EMAIL Richard.Bymes@rrsc.com ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES The Commonwealth of Massachusetts Department of IndustrialAccidents m Office of Investigations 1 Congress Street, Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Nurotoco of MA d.b.a. Roto-Rooter Address: 175 Maple Street City/State/Zip:Stoughton,MA 02072 Phone#: 1-781-297-7049 Are you an employer? Check the appropriate box: Type of project(required): 1.❑ 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 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 g. ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.$ required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.E:] officers have exercised their I am a homeowner doing all work 11.❑■ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.0 Other comp. insurance required.] *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. :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 Expiration Date:4/1/2016 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 certunder the Zsndpenalfies of perjury that the information provided ab ve i true and correct. Signature: Date: �� Phone#: 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#: P Information and Instructions 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-contractor(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 burn 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 Camino-nwealth of Massachusetts Department of Industrial Accidents Office of Investigations 1 Congress Street, Suite 10.0 Boston, MA 02114-2017 Tel. # 617-727-4900 ext 7406 or 1-877-MASSAFE Revised 7-2013 Fax# 617-727-7749 www.rnass.gov/dia COMMONWEALTH OF MAS51HlJSETTS:C DIVIS.IONOF-PROFESSIONAL a Q'OF PLUMBEftS`>#CVfl GASF..I.TTE <` ISSUES THE FOLLOWI`Ids"'`L'i`C'ENS E«;:>:::< ".`" RE131 S�'E11=D AS A PLUMB!NG;CORP RICH D BYRNES e ='.> U#201`Oca OF 41k'SSACHUSETTS, .I NC I 368 SPRAWN "STSU R g;R`ID`GEWAT:E .=>-aMA 02379-11a 349:8<:_ 057o:t:./<1>6.><< 2o7go6 lr OMMONWEALTH OF MAS .&C ET S . .. 'I L• • - • • BOARD'OF { PLUMBERKS AND GAS FITTERS ISSUES THE FOLLOWING L1'CENSE„ L I CENSER AS A JOURNEYMANsPOONfBR R1CHAkD P BYRNES JR ` 0368 5 <� . ST. ' ti 801 GGEWAE.R::; MA 02379 7 2710' 0�/o.:t:.✓:;�:�.' _ :'>< 207905 �.. Ll �" COMMONWEALTH OF MASSACHUSEITSR.; <' • • - • • PLUMBER,L UMB E R. >>AiG GA S F:::.1...TT E#t:S<> ' ISSUES THE FOLLOW L I'rrEN5E L I CEUSS'D AS A MASTER PTCI 4F�ER1.. -q R E C#{ARD PBYRNES JR ; 368 SPFit, Lu .'<�R`IDGEWATE.R., AkfA `02 379 7 154>3 a 05'%o a::/:: 6 207904 I:::> A4coRo- CERTIFICATE OF.LIABILITY INSURANCZ E ATE IS ISSU 0311712014 MA >•,F �MII__A-'� L�AND L'ONFERS-NO:RIGHTS.`i1P0111;11�E CERTIFICATE HOt�ER.'THIS NOT�AFFIR1MTI/Ef.Y'OR•NEGATIVELY•AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, THIS VERTIFICATE,OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S). AUTHORIZED `REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. '. IMPORTANT: It the certificate holder Is an ADDITIONAL INSURED.the POIICy(Ies)must be endorsed. K 8118ROGATION IS WAIVED,subJect to the teens and n110vconditions of the POIIGYendor.certain policies may 1+equlre an endorsement A statement on thN cer0fi�does not cc' rights to tttA certifleat�a holder in Iteu of such endorsem s PRODUCER CONT MARSH USA INC. ' 'SM VINE STRIET.SURE ISO' PHONE A CIMCM Y1,011 4520wk 2 Ade:alndme6 oeltregltarsb wm , 400408•RRSGGAUIN 14.15' IN EMS)AFF It a ME 00045 f A:OldRaplBllo X109 co NAIL N BISURED . 24147 15-ROT04WOTERSER1110ESCMVANY INs11RER1:NFA WA SfOUGH70N, 175 MAPLE ,NA NA 02072 m I mR C:M �7els 23 Cslrtlparry 612 Al ' . • •' a e.: .' COVERAf3E3 CERTIFICATE NUMBER:' ' CLFo-00ullm"'I REVISION NUMBER:3 THIS IS TO CERTPY THAT THE POLICIES OF INSURANCE.LISTED•BELOW HAVE BEEN ISSUED TO'THE INSURED NAMED ABOVE FOR.THE POLICY PERIOD INDICATED. NOTVWHSTANDiNG ANY REQUIREMENT.TERM OR�DITIDN OF ANY CONTRAOT OR OTHER DOCUMENT WITH RESPECT TO CY P THIS CERTIFICATE MAY•BE ISSUED OR MAY PERTAIN.THE INSURANCE iAFFORDED BY THE.POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDRION8 OF SUCH POLICIE$.LIMrrS SMOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. TYPE OF Mem A • 06nsim IAakm32 uN1R$ 00101404P =5 X CeI ERCW pENERAL LIABY ITY EACHOCf�jRq i MAN CL0464 m ©OCCUR. s ISO" Exh i . 5.00I PEReoNAiaADvIMAm s 2M.= EN L AOOREOATE LBpr ApPLIEB PER GENERALAGGAEOA s "MM X1 BucyM a Loc PaooilCTs-ccnrPrcPAc;o s 6,000,001 A . AUTOMOBILE LIABRny MWIB21957 + x ANI/ASO• 04/0mOw,• 09fO=5 5== jkmAUTO. SCHEDULED eODILYNJURY(WPwam) s x HIRWAUTOS x Alrf�ED BOO1ky1NjL1Ry0'arao0wwm i uMBRELLA LIIIe ' OCCUR a E>c�ss Lw CLI10dS TAlI1DE. EACH OCCCIRRENCE i AQtiREOATE i IDED 'A TVORKERSCOIIPBiSAT10Mi AND ENPLOYERw NAsLny TATO• C .a DICWDE07 YN. N/A 4 09101/1015 . . EsL:EACH A(CWW O� f 1,000 ■ daaelbi under. /1014 '. 0410112015OFOM a6K-EA8WPL0ym s 1A00,000 EL DISEASE•POLICY LINNT s 1 .000 DEOCIO"M OF OPERATION/I LOCATNINS I VEWLES.(Af1aa6 ACORD 101.AddMwW RenpAu schedule,Tlaoon apae�b nequlroQ) EVIDENCE OF INSURANCE. CERTIFCCATt:HOLDER CANCELLATION ROTO-ROOTER SERVICES COMPANY 175 MAPLE STREET SHOULD ANY OF THE ABOVE DESCRIBED-POLICIES BE CANCELLED BEFORE STOUGHTON,NIA 02072. THE EXPIRATION DATA- THEREOF, NOTICE WILL BE DELIVERED R9 ACCORDANCE WITH THE POLICY PROVISIONS.- AUTHORIlEO MMESENTATIVE. Of M3f*h USA bra ManashI Mukherjee •�,s,qp ACORD 26'(2010105 01988.2010 ACORO CORPORATION. All Tights reserved. t;1 The ACORD n8Mwand logo:are rsgistered•jnmrks of ACQRD aM MASSACHUSETTS PROPERTY INSURANCE UNDERWRITING ASSOCIATION Two Center Plaza Boston,Massachusetts 02108-1904 (617)723-3800 Ma Only(800)392-6108,FAX(800)851-8424 6/6/2009 Form of Notice of Casualty Loss to Building Under Mass.Gen.Laws,Ch.139,Sec.36 RECEIVE® NORTH ANDOVER HEALTH DEPT. NORTH ANDOVER TOWN HALL JUN 1 0 '009 NORTH ANDOVER MA 01845 TQWN OF NORM H ANN) 3V R HEALTH p PARTMENT Re: Insured: WILLIAM A.SILK Property Address: 132 KINGSTON ST.NORTH ANDOVER,MA 01845 Policy Number: 0980947 Type Loss: Water Damage:Plumbing Systems Date of Loss: 05/25/2009 Claim Number: 264101 Claim has been made involving loss,damage or destruction of the above captioned propert,which may either exceed$1000.00 or cause Massachusetts General Laws,Chapter 143,section 6 to be applicable. If any notice under Massachusetts General Laws,Chapter 139,Section 3B is appropriate,please direct it to the attention of the writer and include a reference to the captioned insured,location,policy number,date of loss and claim or file number. MPIUA Claims Division CMA00021