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HomeMy WebLinkAboutMiscellaneous - 14 Redgate Street Date. ./����f . TOWN OF NORTH ANDOVER p PERMIT FOR PLUMBINr# SSACMUS- This certifies that . . . . ./. .7�. � . ./.`A- *#7 . . . . . . . . . . . . . . . has permission to perform . . . . .,/J?<'..!. . . .4 .e... . . . . . . . . . . . plumbing in the buildings of . . . . . . . . . . . . .//�!. . . . . . . . . at . . . . . I�k- !' . . . . . . . . . . North Andover, Mass. `C Fee$ �°(). . .Lic. No./. /.S.-7. . . . . . . . . . . . . . . . PLUMBING INSPECTOR Check # 8240 I'd IN MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETTS ail {� ���� / S Building Location` Owners Name 1' /L 0/ Date e Permit# Type of Occupancy 05 Amount New Renovation Replacement 1:3 Plans Submitted Yes No ❑ FIXTURES x E~ O Z O A W � A a H z sL-W�E BASEUM ISE K-0(R / /4t 14 1 1 M FLOC i M FLOC t aM1-OCR M F1OC t sMHJDCR air# 71H aO [t s1H HJOCR (Print or type) Check one: Certificate Installing Company Name Corp. Address j O Fl Partner. usmess elephone Firm/Co. Name of Licensed Plumber: Insurance Coverage: Indicate the typc of insurance coverage by checking the appropriate 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 three insurance Signature Owner ❑ Agent 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 Pl mbi Code h 142 of the General Laws. l By: igna ure icense um er ' Title Type of Plumbing License ice! - City/Town is nse UMDer Master Journeyman ❑ APPROVED(OFFICE USE ONLY " Thae Commonwealth ofMassachusetts j t Department of,fndustrialAccidents 10r Office of Investi;ations 600 If asfzington Street Boston, MA 02111 r�+ Wnw Inas py1dia . 'Workers' Compensation lwitrance Affidavit: Buffders/ContractorsMiectricians/plambers A licant Information Please Print Le-ib Nallae (Business/Organiza6onfindividual): Address: City/State/Zig: Phone#: . Are you 8a employerY Cheek.the appropriate box- Type.❑ F am a employer with 4. Type of Prelim(required): Q 1 am a general contractor and I employees(full andlor pert-time).* have hired the sub-contractors 6. New construction ` 2.❑ I am.a.sole proprietor or partner- Iisted on the attached sheet.= 7• [❑Remodeling ship and have no employees These su&contzactors have .1 working for me in any capacity, workers' comp.insurance. 8' Q Demolition [No workers'comp.insurance 5. ❑ We are a corporation and its 9• Q Building addition 3.❑ required.] officers have exercised their 10•Q Electrical repairs or I am a homeowner doing all work right of exemption per MOL Plumbing additions myself[No-workers'co g Tepairs or additions mP• � �2, §1(4),and we have no insurance required.]t employees. [No workers' I2.Q Roof repairs comp• insurance required.] 13.Q.Other `fury appiicam that checks boat#t must also fill out the section below showing their workets'oiimpensatioti policy information t Homeowners who submit this affidavit indicating they ars itomg an work and then him outside contractors =Contractors that chest this box mtutattao�d an additions:sheet show mustsubmtt a new affidavit indicating such ittg•the mum of the sub-commcton and their worimrs'cottw.patio ini0rrU60TI. I asst an employer twat�prozi&Rr:workers'compearadan �nsrrranre or information. f HF employe m Befew is the policy and job sits . Insurance Company Name.- Policy ame:Policy#or Self-im.Lic.#: Expiration Date: ------------ Job Site Address: Attach a copy of the workers' com City/State/Zip: - peusation policy declaration page(showing the policy number and expiration d2te. Failure to secure coverage as required under Section 25A of MCJL 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 ss civil penalties in the form of a STOP WORK ORDER and a fine Of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the c cc of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pane and pernaidm of perjury that the in nrmabon m ' f p traded above is true and tore: rorrrzt St Date: Phone#: EOther only. Do not write in this area,to be con plaed or town o i �'�1' ffrxa( n: Permit/License# Issuing oriiy(circle one): Health Z Building Department 3.CiVrOwn Clerk 4.Electrics!Inspector 5. Plumbing Inspector on• "" Phone#: Inforrriation a nd Instructions Massachusetts General Laws chapter 152 requires all emp 3oyms 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'fbmping engaged in a joint enterprise,and includireg the legal representatives of a doceased employer,or the receiver ortntster•of an individual,partnership,associatioan or other legal entity,employing employees.'liowevQthe ownerof a dwelling house having not more than three apaements and who resides therein,or the occupant of the dwelling house of another who employs persons to do ma mtenance,construction or repair wdrk on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be im employer." MGL chapter 152,§25C(6)also states that"every state oar local licensing agency shall withhold the issuance or renewal ofa licence or permit to operate a business or *o conorect 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)state "Neither t1he commonwealthnor any of its political subdivisions shall enter into any contract for the perfortnarace of public work until-acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants r 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).mind phoge 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 rm*-ed'to carry workers'cco,rnpensation 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 mqueste 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•cd the Department at the number listed below. Self-m-suared compani-Should entero+= self insurance"Iicame number on the,appropriate I=. City or Town Officials Please be sure that the affidavit is complete and printed legibly. 7be 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 applicak Please be sure to fill in the permit/license number which w►-iII be used as a reference number. In addition,an applicant that must submit multiple permittlicanse applications in any given year,need only submit one affidavit indicating-current policy;inforrnation(if necessary)and under"Job Site Address"tate applic int should write"all locations in (city or town)."A copy of'the affidavit that has been Officially icially staimped or marked by the city or town may be provided to the applicant as of that a valid affrdavrt rs on file for fuiaae ifs or Iicenses. A new affidavit must be filled out each SPP proof ]?� year.Where a home owner or citizen is obtaining a license or permit not related to business or commercial verttta�e g al Y P'� �Y (i.e. a dog license or permit tro bum leaves etc.)said persor3 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 Commonwealth of Massachusetts Departmcat of Fzidustriai Accidents Office of Invest libations 600 Washington Street Bosfon, MA 02111 TeL# 617-727-4900 ext 406 or 1-9.77-MASSAFE Revised 5-26-05 Fax 4 617-727-770 wwwmass.gov/dia r , D Date. . . ... .. HORTIy t G=pha TOWN OF NORTH ANDOVER ti A PERMIT FOR GAS INSTALLATION 14 �,SSAC HUSEt This certifies that . . . e. has permission for gas installation . . . . A C:-�<. . . . . . . in the buildings of . . . �'. . . . �.! �. . . . . . . . . . . . . . at 4..j..`. . . . . . . . . . . . ., North Andover, Mass. Fee IKO. . . Lic. No.. 1.5­�/�57. .7 . . . . . . . . . . . . . . . . . . .SPECTOR Check# 5 69 ,; t MASSACHUSETTS UNIFORM APPLICATON FOR PERMUf TO DO GAS FITTING (Type or print) Date 1� �o NORTH ANDOVER,MASSACHUSETTS Building Locations �2LfCfG �� Permit# / Amount$ f o- Owner's Name New❑ Renovation ❑ Replacement ❑ Plans Submitted ❑ x w w w p U z z C z W O W W w p O p F z F W F E• y O z O z O vFi x x o x3 c U °a > A a " H o SUB -BASEM ENT B A S E M ENT 1ST. FLOOR 2ND . FLOOR 3RD . FLOOR 4TH . FLOOR 5TH . FLOOR 6TH . FLOOR 7TH . FLOOR 8TH . F L 0 0 R (Print or type) Check one: Certificate Installing Company Name / /, LY ❑ Corp. Address U ❑ Partner. d v? usmess a ep one (ay 2,_ c/ ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter mAij INSURANCE COVERAGE Check o I have a current liability Insurance policy or it's substantial equivalent. Yes No❑ If you have checked yes,please' icate the type coverage by checking the appropriate box. Liability insurance policy E 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 Mass.General Laws,and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent ❑ 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 C t 1 2 of the General Laws. By: Signature of Licensed Plumber Or Gas Fitter �. Title ❑ Plumber f L/S 7 City/Town ❑ Gas Fitter License Nurnoer ❑�aster APPROVED(OFFICE USE ONLY) ❑ Journeyman ..< %.uirr✓naj2wa'a f fff of Mmacluae#s Dpartrnerzt of l'Rtlrccirial Accident It �f tee of Invesfigations t,l 1 600 ffr=hh;oan Street c Boson, MA 62111 Workers' Compenafion fns' w s��,ov/dna A. 'cant Information. sur'nnce A ffir;$vi Banders/CoatraeforLmecbicians/PiQmbers Please Print Lem-bl Name��sl�rgasiz�on/inaividtta!>• _ Address: - CityLSta�/Zip; - Phtme#: . F3.1331 an employer?Cimk.the apPeoPriste boz: a employer with 4. Q I am a Type ofProject(t•equirep: ge�nerai comractor end I .loyees(full and/or part-time.* have 6. New co.asole.. 1 Dred the subcamtsac�ors ❑ nstructionPrOPn�cr Partner- iisiad ori the attached sheet 3 7. - andhavano employees _ Thome ❑Remodeiiag ing fior me in sub-cortttS haveany cmpa ity. work=-slcom i g' Q»emtiiition' workers comt • ' p msum=. 9• QButldiP ice5• Wz ar"- $.aorpotatiom and its ng addition requh, DMO= have exercised theira homeowner !O.Q �TeP�m'additions doing alt work Sion of exam on Q Piurrtb'lf'[No•work=' Pn par MOL I I. ing Tepair�or additions anc.•regnir ed].t�P, e, 1 S�, §1(41,.and,we have no I2. OmPj�'e;es [No workor�' Q hoof repaka ;Any ap Nestle Comp• insumce required..] I3.Q.p� submi box'#I m+ra also fits out tha reaEian beiow showing&'W.orirotd'cot�eetimt poi hdbmatioa, _ ;Any who sdbmit osis affidsvh indicating pies,an sin . Z(:aahaamrs that check fbis box tousle as additroaei fivmg �ilc tired then ohs outside contn;ctors moist Shea-,showat�g.the nems of the mt:. submit a new affidavit � l ol%oJi a ro er ..r Mots and tiecir worm'ccs.., infou. fob J' ra�sn�daicng:war-k ' rr sersc. rt n e m�J'Taves nd lel . Insurance Company Name: Policy#or SW--ins, Lie.#: - job SiteAr3dress: Expiation lie: Attsch it copy of the workers''c�, Crt3'�tatCJZip: mPeusation Poky declaration Page(showin;the policy number and e Faihtre to secure coverage as required under Section 25A of xpimfioa fine up to S1,50QA0 and/or one-year im MOL c. 152 can lead to the imposition of criminal penahim of up to 2250.00 a p�omn�'as wolf Es civil penalties in the form of a S7Y}p y,�p O of a Invasin against'the violator. Be advised that a copy.of this statement �ER�a fine gations of the DIA'for insmsnce coverage verification. may he forwarded to tic pffitw of I do hereby certify render the pains and peRaid=of pedivY llfiat the infnrmm�ioa m 5i P vie' d above is trrce and aorreci Phone#: Date: 4fficiQl Me only. Do not wrae is tfris arr q to be m+npFeted P do or town oficid Crty or Town:: Issuing Aathority(circle one): Peruut/Licnase# I. Hoard o-Health Z RoMi� De 6.Other Department I City/Town•Cleric 4. Eiectr;�Inspector S.Plumbing Iaspecfor Contact Person. Pbooe#: Massachusetts General Laws chapter I S2 mquires all amp ioyars to provide workers' compensation for thoir employees. Pursuant to this statcite,an wrioyee is defined as"..:every person in the service of another under any contract of hirr, Cyr iin li oral or t express cd, written. 1 P . . An a nq&yer is&-fined as"an ind vidue;parte..-rship,as %-_%6H ion,corporation or other legal entity,or any two ormore of thtlamping engaged in a joint enterprise,and includi"g the legal rtpreserttafivex of a iircaesod employer,nrthe receiver ortwstx,of as individual,partnership,assot- c>ln or other Iogal-amity,eanploying employees. •Aowmthe owner-of a dwelling house having not more than three apa_T1==is and who resides therein, or fire occupant of tim dwelimg house of another who.employs persoru to do ma.i•ntxmmmce,construction orrepair wdrlc oa such dwelliaghot= or on the grounds or building appurtenant thereto shad nat b===of sucb eepioymert be ds~cued to be an empiW=." MOL chapter 152,523C(6)also states that"every state are local 6cansing agency shall withhold the issu$nceoc renewal of a liceese or permit to operate a business or t m construct bulWnd p in the commonwealth for any app ieanf who has not produced weeptable evidence o*Peompganee with the.iosarancx i overage required" Additionajly, MOL chapter 152,623CM status"Ncitbcr tJbc'commranwesith nor any of its political subdivisions shall enter into any cxmtraet for the perfbn=ee ofpublic word- until•aceeptaile evidence of coinpilisi cz with the insur =- requirCrr=tts.of this chapter have bean prod tD-fim canct rac tiing authority." ApPiicsnta .. Please fill out the workers'.ccmtpartsation.affidavit completely,by ehecicing the boxes that apply to.your situation and,if necessary,supply sub-cotrtzactnr(s)ni wne(sl addTMKc5):acrd phone nurnbc;(s)along with their c :rtificair(s)of insurance. Limited Liability Companies (LLC)err Limited Liability.Pwt=ships(LLP)with no employees othedum the mesnbars or,partners,arc not rztluurd,to carry workers'cni.Tnlyensation holu mx. Van LLC or LLP does-have employ=,a policy is required. Be advise=d that this affidavit may be submitted to the De:pi rtmerl of Industrial Accidents for confirmation of insurance coverage.. Also.13ve sure to sign and elate time affidavit. The affidavit should be.ratcane:d to the city or town that the application for he peimii or Ticcese is being requested,natt a Dapsrimpa of Industrial Acaidnnts. Should you have-any questions.reP -fig the law or if you aro requimd m obtain a workers' oomtpe:nsat ion policy,please-call the Departncent attlm-nuxmbar.listed below, Self-insured companies should entrrtheir se+lt�UUUn X=c lic:nsz number on Sre'appropi lutes ileac. City or Town t7ffeesia% Please:be arae that the affidavit is complete and printed legibly. The Depminient has provided a space lit the botmm of the affidavit for you to fill out in the event the Ofti=of Investigations has to contact you regarding die appli=t PkRise bo wet to ffii in the perrnit/license numbw which be used as a reference number. In addition,an applicant that ffrust submit multiple paumit/iicanse applications in eery given year,need only submit one affidavit indic;s ing-Marent '. policy•information(af necessary)and under"Job Site Address"ihr applicant should write"all I= diom in (city or town)."A Dopy oftlre affidavit that has bean,officially starriped or marked by tiro city or town maybe provided to the appiicant as proof that a valid affidmAt is on Me for f4tire permits or iiccames. A now affidavit must be Meal out each year.Whers a home:owner or citizen is obtaining a Tic== or pzxmit not related to any business or aomme-cial venhae (i.e. a dog lic:==or permit to bum leaves adz.)said persori is NOT.r oquired to-compietz this effidaviL The Ofnnca of Invextigations would lila to thank you in advance for your cooperatim and shouldyou have any questions, please dw not,hem to give us a call The De partm=r's address,teelephont and fax number: The Commonw=x_-jth of Nfassachum= D part n=9 of 1xidustial Ac.6d=its Officeorf EXPE26:21fions _ 600 mash lepton Street Basfvn, MA 0,2111 TeL f 617-72-74900 cart 406 or 1-8.77-MASSAFB lL.visod 5-26-(15 Fax;9 61 7-727-7748 www.mass.gov/dia "