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TOWN OF NORTH ANDOVER.
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'`PERMIT FOR -GAS INSTALLATION
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1 5-10 GAS INSPECT
Check #
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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
City/Town: MA. Date: Via- Permit#
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Building Location:_ Owners Name: _ lad
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Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential IX
New: ❑ Alteration: ❑ Renovation: ❑ Replacementrig, Plans Submitted: Yes ❑ No ❑
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SUB BSMT.
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BASEMENT
1 FLOOR
2 NuFLOOR
Vu FLOOR
4 FLOOR
61H FLOOR
6 TH FLOOR
7 TH FLOOR
8 IH4—
FLOOR
Check One Only Certificate #
Installing Company Name: � ru'
,�/ El Corporation
Address: 4 City/Town:�;cl�t��. State: /'lam
El Partnership
Business Tel: Pbts---1`7gpy Fax:
0 Firm/Company
Name of Licensed Plumber/Gas Fitter: —1 aiAvaS
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yesin No ❑
If you have checked Yes, please indicate the type of coverage by checking the appropriate box below.
A liability insurance policy 9 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
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
Check One Only
❑ ❑
Signature of Owner or Owner's Agent Owner Agent
By checking this box ❑; 1 hereby certify that all of the details and information I have submitted (or entered) regarding this application are true and
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compliance with all PertinpM
ana inat au plumomg worK ano Installations performed under the permit issued for this application will be in
1 of the Massachusetts State Plumbing Code and Chapter 142 of the Geagral Laws.
Type of License:
By `® Plumber
Title
El Gas Fitter JZ Master nature of Licensed Plum6er/Gal Fitter
Cityrrown Journeyman License Number: l,! 1841-70
APPROVED (OFFICE USE ONLY) U LP Installer
The Commonwealth ofMassachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
kv www mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Name
Address: IUj
d
City/State/Zip:
Are you an employer? Check the appropriate box:
1. I am a employer with ___1_
4. ❑ I am a general contractor and I
employees (full and/or part-time).*
2. ❑ 1 am a sole or
have hired the sub -contractors
listed
proprietor partner-
on the attached sheet I
ship and have no employees
These sub -contractors have
working for me in any capacity.
workers' comp. insurance.
[No workers' comp. insurance
5. ❑ We are a corporation and its
required.]
3. ❑ 1 am a homeowner doing
officers have exercised their
all work
right of exemption per MGL
myself. [No workers' comp.
c. 152, § 1(4), and we have no
insurance required.] t
employees. [No workers'
COMP. insurance required.]
'Ary applicant that checks box 41 must also fill out the section b..', s:,,,.. ;.
Type of project (required):
6. ❑ New construction
7. ❑ Remodeling
8..❑ Demolition
9. ❑ Building addition
10.❑ Electrical repairs or additions
.11 - Plumbing repairs or additions
12.❑ Roof repairs
13.❑ Other
I Homeowners who submit this affidavit indicating they are doing all work —1 WU.Y compensation Polucy and then hireutside contractors must submiinformation. 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
informapolicy and job site
tion.
Insurance Company Name: C. VT- f --
'r ,. t S
Policy # or Self -ins. Lie. #:
Expiration Date: / , `1112—
Job
Z
Job Site Address: -;?q
City/State/Zip: �y
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.
Ido hereby certify un r the pains aan�d/ pen 'es ofperjury that the information provided above is true and correct
Si ature: It' /
Date:
Phone #: "
Official use only: Do not wr-ite in this area, to be completed by city or town official
City or Town:
Permit lAepnvp fE
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town CIerk 4. Electrical Inspector 5. PIumbing Inspector
6. Other
Contact Person:
Phone #:
-a
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 -contractors) 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 retied to the city or town that the app licaµon for the permit or license is being requested, not the Dep2rtment 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 bum 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 Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investibations
600 Washington Street
Boston, MA. 02111
Tel. # 617-727-4900 ext 406 or 1-8.77 MASSAFE
Revised 5-26-05 Fax # 617-72.7-7749
www-mass..gov/dia
7719
Date.. V ..�. .. ..�.... .
TOWN OF NORTH ANDOVER
PERMIT FOR GAS INSTALLATION
This certifies that
has permission for gas installation
in the buildings vo�f�. � I"1... °.�.�7....................... .
atm,..t... !.' ! : Q`%° .?!'� , North Andover, Mass.
Fee ? d:� .. Lic. No. Z zia... . �r4. .
_ GASINSPECTOF
Check # �V
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MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GAS FITTING
City/Town:MA. Date:,54 Permit#
Building Location: Owners Name:`t Q
Type of Occupancy: Commercial ❑ Educational ❑ Industrial ❑ Institutional ❑ Residential kf
New: ❑ Alteration: ❑ Renovation: ❑ Replacement: Plans Submitted: Yes ❑ No ❑
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SUB BSMT.
BASEMENT
1 FLOOR
2 N uFLOOR
3 FLOOR
4 FLOOR
5 FLOOR
6 FLOOR
7 FLOOR
I -H
8 THFLOOR
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Check One Only Certificate #
Installing Company Name:
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❑ Corporation
Address:V-Y(','ity/Town:
State:
Business Tel:x�2��i%✓j
Fax:
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El Partnership
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Firm/Company
Name of Licensed Plumber/Gas Fitter:
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INSURANCE COVERAGE:
I have a current liability,insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 Yes)Q No ❑
If you have checked Yes, please indicate the type of coverage by checking the appropriate box below.
A liability insurance policy 14 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
Massachusetts General Laws, and that my signature on this permit application waives this requirement.
Check One Only
Owner ❑ Agent ❑
Signature of Owner or Owner's Agent
By checking this box ❑; I hereby certify that all of the details and information I have submitted (or entered) regarding this application are true and
...W .,WQ. VI I1.1y fV jV WjCU9t; dnu u1dL an piumomg worK ana mstanations perrormed under the permit issued for this application will be in
_- •r••�••�� ...•.. W... �• •••�� N.....,.„.•+nuaad�nuaeus oidLr riuirmmng %,oue ana t napier T4z oT the tieneral Laws
Uy e of License:
By Plumber
Title p Gas Fitter 5 re of Licensed Plu ber/Gas Fitter
�J]� Master 55
Cit /Town Journeyman License Number: 1r2c)b
APPROVED OFFICE USE ONLY ❑ LP Installer
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