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HomeMy WebLinkAboutMiscellaneous - 2 Saunders Street MAW Date... �. ..�.�.` ................. OF'►ORTM,� TOWN OF NORTH ANDOVER " q"= PERMIT FOR GAS INSTALLATION s'�CMU56 Thiscertifies that ................................................................................Q.............................. has permission for gas installation .........4 Ps in the buildings of..5C-�. ."ie 2 .......................................................................... at....2-.. `'`..^ .....c—� -'`�. ........., North Andover, Mass. Fee--??.4......... Lic. No.2.1.g� 5 � ....... ....... ............................................................ GASINSPECTOR Check# 6 r �+ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK rZ' CITY MA. DATE PERMIT# �10 JOBSITE ADDRESS j OWNER'S NAME L—IZ—V-r—aet� GOWNERADDRESS: TEL: FAX TYPE OR PRINT' OCCUPANCY TYPE: COMMERCIAL[IEDUCATIONAL ElRESIDENTIAL CLEARLY NEW:❑ RENOVATION:❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES[I NO❑ FIXUTRES 1 FLOOR Bsmt 1 1 1 2 1 3 1 4 5 6 7 8 9 1 10 11 1 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST "f1NIT HEATER UNVENTED ROOM HEATER ;WATLEREATER 0 l INSURANCE COVERAGE I have a current liabili insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ] NO ❑ If you have checked YES,please indicate the type of coverage by checking the appropriate box below. LIABILITY INSURANCE POLICY T OTHER TYPE INDEMNITY ❑ BOND ❑ OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER ❑ AGENT E] hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and accurate to the best of my Knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. P LUMBER/GASFITTERNRME: I Peter J Crane LICENSE#F21805-1 SIGNATURE COMPANY NAME: Crane`s Plumbing & Heating ADDRESS:1 70 Douglas Street CITY: I Haverhill I STATE: r1A ZIP: E01830 FAx TEL: 978.771.1155—�CELL:1 978.771.115 EMAIL: annacrane.ac@verizon.net MASTER❑ JOURNEYMAN[3 LP INSTALLER❑ CORPORATION ❑#=PARTNERSHIP❑#=LLC❑#0 The Commonwealth o,f tl4'assachasetts .Deparbnent o,f1nd4s1Y1g1 Accid&Js . , Office v,f-ruvestigaflons 600 Washington Street Poston,MA 02111 vwwmassgov/ciza ers. Worker . . 'Comp engationInsurancec�adt:S�c�erg/Co)atractoro/FXectriciansiTliiikTL Applicant Wormation Please Print Le�ibXv Name(Businessiorganization&dividual): �- Address: -� Cx /State/z . Phone#: / Are you:an employer?Check the appropriate box: Type of project(required): 4• ❑1 am.a general.contractor and l 1,[� am a employer with- t 6. [l New construction mployees(full and/oxparEtime).* haveliiredtheffah-contractors 2. T am a sole proprietor or par[ner listed on the attached sheet: 7• n Remodeling These sub-contractors have 8. [[Demolition ship and`havena•employees worlang forme in any capacity, workers'comp.insurance, g• Building addition [No workers'comp.insurance 5. ❑We area corporation and its 10.[]Electricalrepairs or additions required.] officers have exercised.their 3.[] Z am a homeowner doing all work right of exemption per MGL 1Q]Plumbingxepairs or additions myself Vo workers'comp. c.152,§1(4),and wehave n.o 12,P Roofxepairs insuxaucerecluixed.�� employees.[No workers' 13.[]Other • comp.insurance required.] Anyapplicautthatchecks box#I 'compensationpoHoyinformation. Homeowners who submitthis affidavitindicatingthey ire doing altworlc andthen hire outside contractors must submit anew affidavit indicating such. xContractorsthatchecktbisbo mnstattachedanadditionalsheetshowingthe,nameofthesub-contractorsandthokworkers'comp.policyinformation. I am an employeN that is providing workers'compeiisation insurance formy employees- B61OW b thepolicy ani j©�i site in,fux'madon. Tusurance Company Name% Policy#or Selz ins.Lxc.#: Expiration Date: lob Site.Address: City/State/Zip: .Atiach,a copy of 00 workers'comp enation-policy declaration page(showing-fae policy number and expiration.crate). Failure to securer coverage.as required.under Section 25A ofMGL o.152 can.lead to the imposition of criminalpena10 of :fte up to$1,500.00 and/or one year impo� risnent,as well as civilpenalties in the form of STOP.WORT ORDER and a fne of up to$250.00 a day against the violator: B e advised that a copy of this statement may be,forwarded to the Office of investigations of the ATA for iiasura ac .coverage verification. .ado Hereby Berta undertitepains aand penaltles of penury that Me information,provided above is true and correct. - S' afore: Data: 7 I'lzone#: OfflciaZ ease oily Do not write in this area,to be eompleted by city or town official City or Town: Permit/License 0- Issuing Authority IssuingAuthority(circle one): Z.Board of Health 2.BuildingDepartment I CityNown Clerk 4.Electrical Inspector 5.Plumbing Inspector f.Outer - - - Information and Instructions , Massachusetts General Laws chapter 152 xeq*es alt employers to provide workers'compensation for their employees. Pursuant to ties statate,an employee is defined as"•.•every person E the service of another under any c6tract of hire; MOSS orimplied,oral orwritte0l An.erqloye is defined as"an individual,partuership,association,corporation or otherlegal entity,or anytwo oxmoxe of the i oxego�ng engaged in a joint enterprise,and includingthe legalrepxesentatives ofwdeceased ernployex,,or fire receiver or'rtaistee ofan individual,partnership,association or other legal entity,employing employees. Sowevex the owner of a dwelling house having notmore than three apartments and who resides therein or the occupant ofthe dwelling h ouse of another who employs persons to do maintenance,construction ar repair work on such dwelling house or on the grounds or but&g 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 Ideal lie-ening agency shall withhold the issuance or renewal of a license or permit to operate a business or to coustmet 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 ofpublic workuntil acceptable evidence of compliance with the insurance requirements of this chapter have b con presented to the cpntracting authority," Applicants Pleas-0:0 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�honenumber(s)alongwzththeir certifxcate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partuersbips(LLP)with no employees other than the members orpartners,axenotrequiredto canyworkers'compensation insura co. Si anLLC orLLP doeshave employees,apolloyis required. Be,advisedthatthis afddavitmay be,submittedto the Department of Tudustrial , Accidents for condxmation of insurance coverage. Also be sure to sign and date the affidavit: The affidavit should be retamedto the city or town thatthe application forthepermit or license is beingrequested,riot the Department of Industrial Accidents. Shouldyou have any questions regarding the law or if you are xeq*ed to abtain,a*arkers' compensationpoliey,please call the Department at the namber listed below. Self insured companies should enter their • self insurance license number on the appropriate line. City or Town Offfelals Please be swo thatthe affidavit is complete andpxinted legibly The Department has provided a space at the bottom of the affidavit foxyou to fill out in the event the Office of Tnvestigatlons has to contact you regarding the applicant Please be-sure to fill in the permit/11cense number Whichwill be used as a reference number, Th addition,an applicant thatmust submitmmultiple,permit/11cense applications la any given year,need only submit one afftdavit indicaffig current PORGY information(ifnecessary)and under"Job Site Address"the applicant shouldwrite"all locations in (city or tawix):'A copy of'tlie affidavit that has been officially stamped or marked by the city ox town may be provided to the applicantaspzooffhatavandafftdavit•ison:Ilei'orf'utmopemzitsorlicenses• Anew afddavitmustbaflledbut each year.Where a home owner or citizen is obtaining a license ox permit not related to any business or commercial venture (i.e.a dog license orliexmit to bum leaves etc.)said person is NOT rogpired to complete this affidavit. The Office of fnvestigations would like to thank;you in advance for your cooperation and should you have anyquestions, please do trot hesitate to give us a call. The Department's address,telephone anal faxnumber: TEQ Coxaeat2 0sac?vP DcpaxtmeAt o.l'Wu Wal Accident (exec of][Avesaga tan 604 Waft&n TO,0 617-72t,4900 0A 406 Qx 1-477-MASS F _ Revised 5-26-05 Fax 9 617-727-7749 ' v��v4�'.�aS�,g4�fcT�a • ,><: COMMONWEALTH OF MASSA Eel io 9612:2061 • BUARDrO)* PLUMBtRS"'AND GASP t>TERS>` S.SU::E:S-.-THE F 0 LL OW'[N'IG"IICENS::< > L k C'£ I,S EU AS ,A...;JOURNEYMAN, UMB in fR J C R A.N.E:.,;::::::.: 70 DOUGLAS ST >> HA ERH : :L<::: ::;;.: MA 1 .3.:...:.:.,74