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HomeMy WebLinkAboutMiscellaneous - 4 CiderpressM Date ......... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that .... e/ ... Aj. ...................... has permission to perform ..... / ................................. plumbing in the buildings of .... 4 at ...... Izk, ............ North Andover, Mass. Fed->'�"�!�?. Lic. No.. 7 ............................... Check �' /j/6 PLUMBING INSPECTOR 0 � > '-, -MASSACHUSETTS UWORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS pate Building Locationo Owners Name Q jai Permit Amounttff New Renovation 0 (Print -or type) Installing CompanyNamee Address _pGLL_._L Of Replacement 0 ' L�T17TTiD Tit C Plans Submitted Yes [] No L.J - -- - M/ �W`MM Check one: Certificate [_! Corp. .^ ElPartner. El Firm(Co. Name of.Licensed Plumber: Insurance Coverage: Indicate the of insurance cov ge by checking appropriate box: Liability insurance policy Other type of indemnity Bond ❑ Insurance Waiver: I, the undersigned, have been made aware that the licensee o£this applicatioL--A n does not have any one of the above three insurance Signature \' Owner El Agent I hereby certify that all ofthe 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 Massachus5 State C�pter 142 of the General Laws. Type ofPlumbing License .License um er Master V' Journeyman r ..• ons .o. (Print -or type) Installing CompanyNamee Address _pGLL_._L Of Replacement 0 ' L�T17TTiD Tit C Plans Submitted Yes [] No L.J - -- - M/ �W`MM Check one: Certificate [_! Corp. .^ ElPartner. El Firm(Co. Name of.Licensed Plumber: Insurance Coverage: Indicate the of insurance cov ge by checking appropriate box: Liability insurance policy Other type of indemnity Bond ❑ Insurance Waiver: I, the undersigned, have been made aware that the licensee o£this applicatioL--A n does not have any one of the above three insurance Signature \' Owner El Agent I hereby certify that all ofthe 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 Massachus5 State C�pter 142 of the General Laws. Type ofPlumbing License .License um er Master V' Journeyman r The Comnzonweczlth of ll,assachusetts DePatment of rndusftiffl Accidents Office of bivestigations ..600 Was]zingoton Street BOstOyz, 1L1 02I1I WWW-Mczssgov/dia Workers' Compensation Insurance Affidavit: gnUders/Contractors/ lectricians/Plumbers �Iicant Tnformafion Name (Business/Ora nimtion/lndividual): Address: City/State/Zip: Phone #: employer? Check the appropriate box: employer with 4. ❑ I am a ge7.eral contractor yees (full and/orpait time).* sole and I have hired the sub -contractors proprietor or partner- lquired.] Misted on •the attiched sheet I nd have no employees These sul}coli�ctors have g for meinany capacity. orkers' comp. insurance workers' comp, insurance. 5. ❑ We are a corporation and its d.] 3. ❑ am a homeowner doing work officers hake exercised their .I all myself [No workers' comp, right of exemption per MGL c. 152, §_1 (4.), and have no insurance insrance required.] t employees. [No workers' comp, in s„ rMcP, required.] ':�-ni' w.* p?ic.�nt +.hst :.I:�...UQ box.4� m•;st;?so fY'i,l e•�: fac ..ey-e� b , � Flnt�i EOWners Who 6 •C.. -e�I • W o ^.^g ` wor ms' Con=,.enc�,;nn Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ BmIdmg addition 10-DElectrical repairs or additions .11. D Plumbing. repairs or additions 12.❑ Roof repairs 13.❑ Other unmI ItI1S a daVIL lndlcatm they am .I ,.., r••••.•�-...- j;.z:::x g Cj � l .Hirt showing w ng th, then hire omide coatmeto, 16i submit a new athdavit lndimating such. - +contractors that chwk th;: boy must a�c3ed a,� additional sheet showinP the aame of the sub -contractors and their workers' comp. policy information. f am an employer that is providing workers' compensation insurance for niy employees Below is she policy and job site information, Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City Attach a eopyof the workers' compensation policy declara$.en page (shawirpg y/ to Policy expiration failure to secure coverage as required under Section 25A ofMGL c. 152 can lead to the imposition of criminal penalii of a d one up to $1,500.00 and/or one imprisonment, as well as civil penalises the form of a STOP WORK ORDER and a one of up to $250:00 a dap against the violator. Be advised that a copy of this statem Investigations of the DIA for insurance coverage verification It may be forwarded to the Office of I do hereby certify under the pains ¢nd penaifies of peri`31 th4rz the information provided above -is true and correct Official use only. Do not write'in this area, to be completed by city or town official City or Town: Issuing Authority (circle one): P'ermit/Ucense # Y. Board of Health 2. Building Department 3. City/ qwn Clerk 4. EIectricaI Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone'#: Information an. d 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, partaership,•assoeiation, corporation or other IegaI entity, or any two or more of the foregoing engaged in a joint enterprise, and including t ae legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association oo< other legal entity, employing employees. However the owner of a dwelling house having not more than three aparmmL ents and who resides therein, or the occupant of the dwelling house of another who employs persons to do mainte;mance, 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 bean employer." MGL chapter 152, §25C(6) also states that "every state or lo -cal licensing'agency shall withhold•the issuance or renewal of a license or permit to operate a' business or to moons ct 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 um -til 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) vvitb..no employees other than the re members or partners,. anot required to carry workers' comp a nsation ii' surance. if an LLC or LLP does have employees, a policy is required Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. .Also be stare to sign and date the affidavit. The affidavit should be ret'u'neu t0 the Ci�� or �tiircn �ha� the ctiuttGauGn tvt the pe ranee s be re ,' i- ^•e Ty • r�aifiorli � i;ng. q.iesfed,'nat epareW°tiitof Industrial Accidents. Should yon have acv questions regardi=g the la_: or if you are m4hir ed m obtain a workers' compensationpolicy, please call the Department at the number fisted below. Self-insured companies should enter their self-insurance license number on the appropriate fine. , 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 peimitllicense 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 peranit& 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 ]ivesiigations would like to than 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, telgphone.and.fagnumber._.. The Commonwealh of Massachusotts. Department of fndugftial Accidents Office of JxN e&-0aateonus 600 W slvn_gtun Street Bastost, MLA 02111 Tel 0 617-727-490.0 ext 406 or 1-S ""/7-MASSAFE Fw� # 6.17-727-7749 Revised i -26 -OS WVMI-Mass._gov/dia Date... ...... TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that ... di. ol ... & /64 ..... f �( . ......... has permission for gas installation ........... . ......... in the buildings of ...... .... ...... at ............. North Andover, Mass. FeA/.() P ... Lic. No. . G�2-1r�PECTOR-- C lql heck # N LASSACKSETTS UN FORM APPLICATON FOR PERN TO DO GAS FITTING (Type or print) Date NORTH ANDOVER, MASSACHUSETTS Building Locations 2 Owner's Name New Renovation ❑ Replacement ❑ Plans Submitted 11 Permit # amount (Print or type)/ Ch k one: Certificate Installing Company Name UZ/1�4 Corp. Address Partner. Business Telephone MM'' Firm/Co. Name of Licensed Plumber or Gas Fitter 1&91 ,4 INSURANCE COVERAGE Check one- [ have a current liability Insurance policy or it's substantial equivalent. Yes No If you have checked yes, please in e the type coverage by checking the appropriate box. Liability insurance policy Other type of indemnity Bond Owner's Insurance Waiver: I am aware that the licensee does not have the .Insurance coverage required by Chapter 132 of the ; . 9 5 U.'/ S -1-3-(o Date.................................. TOWN OF NORTH ANDOVER PERMIT FOR WIRING .... tf -Pt'p This certifies that ........... k V/",v ... wtv., .t,/ ....... ........... has permission to perform .... TP . ..... qa&f . ......................................... wiring in the building of ..... ME- ....... 4.e� ................... at .......... q ... (fa)l. A. A.t? ........... . North Andover, Mass. Fee..3�� Lic. No. 3.t2kSe ......... A 2N� Check # !3-7f �� a.ummwiw�ar��r w �•ia��awru�cac� -------- --- ,-p---� Department of Fire Services Permit No. to Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/07] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 5 7 CD4R 12.00 (PLEASE PRINT ININK OR TYPE ALL INFORMATION) Date:— 0 City or Town of: NORTH ANDOVER To the Inspector of ices: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Owner or Tenant Owner's Address Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building Aj! r &n/ '')/(a, /J SLS �J Utility Authorization No. g7 h L%f,7�� Existing Service Amps Volts Overhead ❑ Undgrd ❑ No. of Meters New Service / W Amps Volts Overhead �_ Undgrd ❑ No. of Meters Number of Feeders and Ampacity 4/j1V d1"1 Srl,— V1 t, C (^/ q /Cly �y�,5 i4 r --o' .n r/ Location and Nature of Proposed Electrical Work: (G/L► < /.� / �:1/L. /l�>I,✓ hd/L► C_. Completion of the followinz table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑In- 1:1 rnd. rnd. o. o Emergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Detection and No. of Switches No. of Gas Burners Initiating Devices Ranges No. of Ran g No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Dis posers p Heat Pump Totals: Number ..I Tons * - KW ­ ** ........ No. of Self -Contained Detection/Alerting Devices No. of Dishwashers S ace/Area Heating KW p g Local ❑ Municipal ❑ Other Connection No. of Dryers Dr Y Heating Appliances KW Security Systems:x No. of Devices or Equivalent No. of Water KW No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP TelecommunicationsNo. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE K BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties ofperjury, that the information on this application is true and complete. FIRM NAME: ��dt�J /y�rcr� Lc (�...I �� LG%�c . LIC. NO.: Licensee: %����� / d r� A Signature LIC. NO.: (If applicable, enter "exenspt" in t e Yicense number line) Bus. Tel. No.: 179 Address: pi r- Alt. Tel. No.:9-79 50!2 .2.3S� *Per M.G.L c. 147, s. 57-61, security work requires Department of Pub is Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's Owner/Agent PERMIT FEE: $ 39J5 - Signature Telephone No. iii R 'f -�C O,g_�4 k C;�-V )IqIZ,7 Ott - II The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 4 s. www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lellibly Name (Business/Organization/Individual): K;r Address: 01 C/ City/State/Zip: / i d1/(�and— Phone #: 2,f 7f—,F An employer? Check the appropriate box: re ou a 1. a employer with f 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ 1 am a sole proprietor or partner- listed on the attached sheet. # 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.] officers have exercised their 3. ❑ 1 am a homeowner doing 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.] C14 e7 Type of project (required): 6. I construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.0 Plumbing repairs or additions 12. ❑ Roof repairs 13. ❑ Other *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 their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. f Insurance Company Name: Policy # or Self -ins. ,L�i`c. #: 0 L r e Expiration Date: d" Job Site Address: 7��/%/YS f ./f� y 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 certify ync#r,0e pains and penalties of perjury that the information provided above is true and correct. 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 #: