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HomeMy WebLinkAboutMiscellaneous - 179 Elm StreetOf <HORTN 1ti • o O 9 ,SSACHUS� This certifies that Date/�/�/`5.. . TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING has permission to perform ....V' /-::. r" ...% . r. :' 1. Vit../....... . plumbing in the buildings of .................................. at ... �.%`7. x.`1<.. S .14 ........... , • • , North Andover, Mass. Fee.)��....Lic. No.% )-) f.3. ....... �,�-/ �—..... LUMBING INSPECTOR Check # Z Y , 8268 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building Location 1-7q M Sf Owners Name 71 Type of OccupancyJ?e S ,ce,T n a Date 40//o Permit # 9 y Amount ) a , New Renovation Replacement Plans Submitted Yes No i'i TYTT TD L, o (Print or type) / Check one: Certificate Installing Company Name J L �/is P�UIh�j��7 end h2nJ'h� Cor13 p. Address �© ct QI�Jt S % . % oc�o+Se�+a/ /0 61,0 1'i L] -Partner. 17R'' q77' o� S usmess Telephone Firm/Co. Name of Licensed Plumber: Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity 11Bond ❑ 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 IOwner E] Agent n 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 Plumbing Code and Chanter 142 of the C:PnPral T nixie By: Title City/Town APPROVED (OFFICE USE ONLY Type of Plumbing License 15Sin License Numoei Master F Journeyman ❑ The Comman►sealtk ofMassachusetts Depat'tment of Industrial Accidents Office of Investigations 600 Mashington Street Bmaston, MA. 62111 www n�sS.gOV%dJa . Workers' Compensation Im4mce Affidavit: Builders/ContractorsMiectricians/Plumbers miiicaat Information Ntune (Business/prgataiZation/Individual): Address: City/State/Zip: Phone #: . Are you an employer? Check the appropriate box: I • ❑ I am a employer with 4, ❑ I am 8 general contractor and I Type of pre}ect (required): employees (full and/or * part-time). 2. ❑ I am .a.soie proprietor. or have Mired the sub -contractors listed 6. ❑New construction partner- Sand have no employees on the attached sheet 3 '£hese 7. Q Remodelarg working for me in any capacity, [No workers' comp. insurance su}}-contractors have workers' comp. insurance. 5. ❑Weare a 8. Q Demolition 9. ❑ Building addition required .) 3 ❑ I am a homeowner doing corporation and its officers have exercised their 10.[] .Electrical repairs additions ail work myseIt [No -workers' comp. right of exemption per MGL c 152, § 1(4),'and we have no l I Z Plumb- ,. Ing or additions insurance required.] t .employees. [No workers? 12•❑ Roof repairs ". *Any nppiicettt that checks bo>lr # I moat also flit comp. instmartcxrequired..] I3.70ther out t Homeownthe section ow showing their workers' bonrpensatioo ers wimp submit this affidavit indic sting they ads Goin belall _ ZCorrtractors that check this box ser►d then has oras#de contractors policy infomzatioa muat'submit mustetteahea an aitditiamra! sheet shawl a new affidavit ind,cafng such. &g. the name ofthe sub-cmmwtors and their workers' CCm^,^. r Fc .^ Po infiffm ion. j seri ane p J,e. tai G ..."' infannado2 p ; «- g:workers' comPensatu►n �nrurancefor eery e"Floyem Below fs the , Po J and job site . Insurance Company Name: ' Policy # or Self -ins. Lic. 9: Expiration Date: Job Site Address: City/statt lZip: Attach a copy of the workers', compensation policy declaration page (showing the poficy Failure to snumber and expira6oa date ecure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal fine up to $I,500a and/orone-year imprisonment; as well as civil penalties in the form of a STO WORK ORDER and otine f a of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the invesEigations of the DIA for insurance coverage verification. office of ! do hereby certify under the pains and penalties of perjwy that the roormation information p vtded above is dace and corrEd, WJcial use only, Do not write in this area, to be con fla ed by cily or town official City or Town: Permit/License # Issuing Authority (circle one): I. Board of Health Z Building Department 3. b. Other City/Town Cleric 4. Electrical Insp.:.... Inspector S. Ping Contact Person• Phone #: Information a nd Instructions' Massachusetts General Laws chapter l52 requires all emp Sayers 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, assadia6cm, corporation or other legal entity, or any twa or mom of the%regoing engaged in a joint enterprise, and includir•tg'the legal representatives of a deceased employer, or the receiver ortrustee-of an individual, partnership, association or other legal entity, employing employees-. Nowever the owner of a dwelling house having not more than three apa-rtments 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 eruployment be deemed to bean employer." MGL chapter 152, §25C(6) also states that "every state os- local Picensing agency shall withhold the issuance or renewal of a license or permit to operate a business or *o construct bniidings in the commonwealth for any applicant who has not produced acceptable evidence.of compliance with the insurance' coverage required." Additionally, MOL chapter 152, §25C(7) states "Neither Cine commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work emdl - acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the corrtracting 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). a-nd phone number(s) along with their certificate(s) of , insurance. Limitrd Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not rec*-edito cavy workers' compensation insuranm. Van LLC or LLP does have empioyees, a policy is required. Be advised.that this affidavit may be submitted to the Department of Industrial i Accidents for confirmation of insurance coverage.. Also '6e 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, notifie Department of Industrial Accidents. Should you have any .questions repo -ding the law or if you are required to obtain a workers' compensation poiiey, please.c:all the Depam rtent at the nurnber. listed below. Self m�ured ChritpSrliPc eta^!ld e!++ *ham self-iFisutnnoe liCeMe Dumber on the'appr opiiate line. City or Town Officials Please be sure that the affidavit is complete and printed legzbiy. The Department hes 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 permiMicense number which %%-iII In used as a raferencc 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 writ t "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 of that a valid affidaOt is on file for future applicant as pro permits or licenses. Anew 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 bum leaves etc.) said pers6n is NOT required to complete this affidavit The Office of investigations would hike to.thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a ca11. The Depw rent's address, telephone and fax number. The Commonwealth of Massachusetts Depar t cat of IndustW Accidents Office of Investigations " 600 Washington Steed Boston, MA 02111 TeL # 617-727-4900 east 406 or 1-9.77-MA.SSAFE Revised 5-2645 Fax # 617-727-7744 www.mass.gov/dia