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HomeMy WebLinkAboutMiscellaneous - 40 Great Lake Street 40 GREAT OAK STREET 210/022.0-0048-0000.0 ! `Date.::................................................ OF r►OiiTM,� TOWN OF NORTH ANDOVER O � 9 Q ""°" PERMIT FOR GAS INSTALLATION 8`QACMU9f� ,�r Q This certifies that ...... ....:.*.......................... :...�u.... .. .... has permission for gas installs 'on .. � . .v ... - inthe buildings of.......... ...................:....................................................................... at...:..:r. ..........�....a `.. fL..... .:...:............ North Andover,Mass. Fee.. .`:.. Lic. No. ...... ...... /`T�.................................................... p. GAS INSPECTOR Check# 6 9363 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY J.Wh Andover MA DATE PERMIT# JOBSITE ADDRESS OWNER'S NAME --� V OWNER ADDRESS Same TELT- FAXI TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL PRINT ® ® RESIDENTIAL CLEARLY NEW: RENOVATION:El REPLACEMENT:❑ PLANS SUBMITTED: YESE NDE] APPLIANCES 7 FLOORS— BSM 1 1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER .BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER Replace 1 Gas Meter x INSURANCE COVERAGE I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 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. CHECK ONE ONLY: OWNERE] AGENT SIGNATURE OF OWNER OR AGENT I 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' co pliance with all Perti pnt provision ofthe Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME Joseph Marino LICENSE# 8736 V SINATURE MP Ej MGF® JP JGF 0 LPGI[j CORPORATION E]# 3285C PART' HIP[]# LLC®# COMPANY NAME: RH White Construction Co ADDRESS 141 Central St - CITY I.Luburn STATE=ZIP 01501 TEL508 832 3295 FAX 508-926-4347 CELL 508-832-4614 JEMAILLJMarino@RHWhite.com ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT#, PLAN REVIEW NOTES �2 d2IViNlWNiNSA[.TH OF MASSA`G:!$U 7 ' ' '.- • -•�1PLUl $ERS AND GASP- :•` • •' ` jT `r;=- -- f.IC, SE® AS'A-•Mf"a7R P, 1llltltR-''z 's -_ .19b U tv---•AHQUE"L tGENSE'T'd<"-= `u. .:,•-" ' J. No iNGTON 8T ' tfCfR_CES"TER ' MA 0' ,;. 0510 1/14 6`O =T::`;r:._• i,.;. , _.= 'C,®mfoo EAL.TH OF MASSAC'KNN g:'ri<S= _ _ - 1J'NfBERS AND GASFIT�"E`R*. t 1 ('CNS 'C1 AS A JOCJ.RNIrYMA(�l1.1111 '� c VES THE ABOVELKENSE iO?-'nY % ��_=Fi4�R�R7=NGTQN S.T• =�_-='= _ -;�__ .�..: >yB!T71 G% _=S'f E R �{A 1315`0`4=": :Z 0 9=` a: Y OS/01/14 r7 �•`_— -:.•Y:•.:.�a:. i i I A Q® CERTIFICATE OF LIABILITY INSURANCE P... 1 of 1 08/29/2013 THIS'OERTIFJCATE IS ISSUED ASA MATTER OF INFORMATION ONLYAND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT 13ETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the Poliey(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this ceIfleate does notconferrig hts to the certificate holder In Ileu of such endorsement(s), PRODUGgR CONTACT 99illiq p� Massackusotte, Ine. PHONE c/o 26 C"tury Blvd, NQ�F�ST) 877-9457378 NIAX R. 0. Box 'J05i9i -Mi.IL 88-467-2378 Netghville, TN 37230-5191INSURER(8)AFFORDING COVERAGNAIC fFINSVRED INSUREiA.,The Chartar Oak rino Znaany 25615-001R• K- White Construction Company, rnc. INSURERS:Travalgrs property Casuaof Am 25674-00341 Cmntral Street P. 0. Box 257 INsuRERc-xnti4>aal Union Piro rnsuny o£ 7.9445-001 Auburn, MA 01501 INSURER D;TrpvOlera indomnity Company 2565A-DO1 INSURER F; INSURER F. COVERAGES CERTIFICATE NUMBER.,20.187680 REVISION NUMBER; THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED,ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN I5 SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. II TO NSR TYpEpPIN3URANCE 40' SUB POLICY NUMBER POLICY EFF POLICYEXP A GENERAL LIABILITY LIMITS VTC20Co 977X9948-13 9/7./2013 9/1/2014 EACHocCURRENCE S_ 2,a00,ppQ X COMMERCIAL GENERAL qqM TORENTFp �REg_(Esocemenccl R 300=004 CLAIMS-MADE OCCUR MED EXP(Anyone pars6n $ 1p1000 i PERSONAL&ADV INJURY S 2 DEO,000 ATE � GEN'LAGGREGATF LIMITAPPLIES PER; GENERALAGGREGS 4 Q00,000 POLICY PRP LOG PRODUCTS-COMP/OP AGO 9 .000 000 ]3 AUTOMOBILE LIABILITY VTJCAP 977R955A-7,3 9/1/2013 9/1/201.4 OMI31NEo SINGLE LIMIT X ANYAUTO act dent g 2.000,OOa ALIO OWNED AUT08ULED BODILY INJURY(Perpetaon) $ NON-OWNED BODILY INJURY(Peraccidont) 6 X HIRtrDAUT05 X AUTOS Cv Defl PERTY S X X Cvxl I 'I eraccident C UMBRELLA LIAB X OCCUR $ $E8766140 /1/207,3 9/1/2014 EACHOCCURRENCF $ 000 000 X EXCESS UAD CLAIMS-MADE DED }; RETENTI0 AGGREGATE $ $_,000,000 10.000 D WORKERS COMPENSATION `�TRKUB 8205A185-13 9 S AND EMPLOYER8'11A6ILITY y N /x/2073 9/1/2014 X TAIYIJ U D ANVPROPRIETORrPARTNFRIFXECUTIVE NIA VTC2XUB A203,A71A-13 9/7/2023 9/1/x414 E.L.FACHACCIDENT T 1,000,000 OFFICERIMEMBFR EXCLUDED? frySrvland 6s,,nNH) E.L.DI8EA9E-EAEMPI,pyFE S 1,OOO,p00 U tS K11-I)N urd-Q-PI.RATIONS haiew F,I.,DISEASC.POLICVLIMIT S 1,000,000 I )FSC RIPTION OF OPERATIONS 11,4GATIONS I VEHICLES(Ar(ICII Acord 1t77,Addltnnal Remarks Sehvdula,I(more ep eco 1..quirad) :ERTIFICATE HOLDER CANCELLATION SHOULD ANY OF TWE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THF POLICY PROVISIONS. Evidence of Inmurance AUTHORI2915REPRESUNTATNE 001144297604 Tpl:1694012 Ge7:t.:20287680 ©9988m2010ACORDCORPORATION.Ali rights reserved. CORD 25(2070/05) The ACORD name and logo are registered marks of ACORD Date. .........�...f` ............. i OoRTl, °� •,� TOWN OF NORTH ANDOVER ° PERMIT FOR WIRING 8`QACHUS� Thiscertifies that ............................................................................................................................ has permission to perform r,)... ?.c��.� ................. wiring in the building of..........................J....?:....;.....................................................:................. �� at ........................................................ ................................:...,No Andover,Mass. / b-0Fee �!5........Lic.No. .. .... .............................:......................................... ELECTRICAL INSPECTOR" Check# C 1 y 114 _ Cfatnn:oatvaaCK o//t'a idac/tttiott-i jWZ:__ , OfficiUse Only rr// cc// Permit No'- T 2aparImenf ol5ro Soruicel BOARD OF FIRE PREVENTION REGULATIONSOccupancy and Fee ChecIced [Rev-11071 (leave blanic) APPLICATION FOR PERIU IT TO PERFORM ELECTRICAL'WORK PL All wodc to be performed in nccordance with the Massachusetts Electrical Code C),Sp CMR 12.00 ( SEPRINTININh'ORAL INF.RA,14TIOR9 Date: City or Town of: of(�, c� To the Insp�cto �Yires: By this application the undersigned gives notice o his or her intention to perform die electrical wort:described below. Location (Street&Number Owner or Tenant ✓ ftS Telephone No. h Owner's Address $ Is this permit in.conjunction with a building mit? Yes No ❑ (Checic A ro rintel3 )� pr r .Y) Purpose of Building ] t Utility Authorization No. Existing Service Amps ! Volts Overhead ❑ Undgrd❑ No.of Meters New Service Amps ! Volts Overhend❑ Und rd g ❑ Na. of Meters , Number of Feeders and Ampacity- Location and Nature of Proposed Electrical Wor1t: 17 1C, ��l Jeogmze,nae Com letion of the following table matj,be ivaived b),the Inspector of i1-re No.of Recessed Luminaires No.of Ceil.-�Susp.(Paddle)Fn as No. of Total No. of Luminaire Outlets No.ofFlat Tubs Transformers I�VA Generators IICVA- No.ofLuminnires Swimming Poo! Above ❑ In- ❑ o.o Emergency ig ting rnd. rnd. Bntte Units No.of Receptacle Outlets No.or0H Burners , ALARMS No,of Zones No.of Switches No.of Gas Burners No.ofDetectian and Initiatin>=Devices No.of Ranges No.of Air Cond. Tans No.of Alerting Devices No.of Waste Disposers lleatl'ump Number To11�V No.ofSeh-Contained Totals: = DetectionlAlertin Devices a No.of Dishwashers i Space/Area Flea ting KVV Local❑ Municipal Connection El Other No.of Dryers Heating Appliances I(W Security Systems:W No.of Wnter No.oNo.of Devices orGuivalent j Heaters KW f_ f ns No.Balo is Data Wiring: �1 No.of Devices or 11 uivnlent No.hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or E uivatent OTHER: k Ill. ! !� `i Estimated Value of leAttach additional detail ifdesimd ar as required by the Inspector of!•dire. c>l Work (When required by municipal policy.) [ Z Work to Start Inspections to be requested in accordance with IVIEC Rule 10,and upon completion. t ti INSURANCE CqVERAGE: Unless waived by[fie owner,no permit for the performance of electrical work may issue unies the licensee provides proof of liability in uFance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such cover is in force,and has exhibited proof ofsa a to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify: ��/A � P fY�) \\ 1 certify,itttdert/te pnirts an CJ r rtlties ofperdrytthe ifrftlnuat Itis applicatiotr is lrtte and coruplete. FERM NAM.•;: . ��� G ' LIC.NO.: Licensee: �� ,,�� Signature Hato e (if applicable,eat i emp t the 1f'cease number li - LIC.NO.: Address: �j tt./i,�f� ly1 � Bus.Tel.No.- .67e*PerM.G.L_c. 147,s.57-6I,security work uires reqDepartment of Public Safety"S"License: A1bL c.No.. 6�� OWNER'S INSURANCE WAIVER: t am aware that the Licensee does not have the liability insurance coverage normally x required by law; By my signature below,I hereby waive this requirement. I am die(check one)[]owner -= -Owner/Agen# ❑owner's agent Signature _ Telephone No. PERWT FEE.- $ / ' 'q�rn4 I C.! V V !V ki F C-i 1 V Li v V 1.: I �lal MASSACHUSETTS ckmiu� , BELOW FOR OFFICE USE ONLY PLAN REVIEW NOTES ELECTRICAL INSPECTION NOTES ELECTRICAL INSPECTION NO'T'ES FEE: $ PERMIT# ROUGH FINAL 019824 D&te � �gfLTb3 ' K TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that . has permission to perform . ./,2/1,..,,,,�i. R . . . . . . . . . plumbing in the buildings of. . j-././.P.' . . . . . . . . . . . . . . . . . . . . . . . . at .q.p. °'• . A-e-4 . . . . . . . . . . . . ,North Andover, Mass. Fe Q.�. . . Lic. No. P 3. 6. ,� PLUMBING VIS PECT Check# / /'f 3 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY v _ U � � MA DATE 2 _L? / I PERMIT# (�� JOBSITE ADDRESS CT., OWNER'S NAME POWNER ADDRESS �"�""''�'e TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL 0 EDUCATIONAL 0 RESIDENTIAL PRINT CLEARLY NEW: R RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NOD(. FIXTURES Z FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM ( -.._..-.__J DEDICATED GAS/OILISAND SYSTEM d DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER Td _1.'.__1 ._._,_.� ...__,_I � __...-.__! I ( d _! _ ....._.I ._._-._. _ 1 _-.......I DRINKING FOUNTAIN I -- I l d __._.J d -_.._...._A _____ _._._.._ ..-_...I _.__._...___d .-_.._-f _—w.1 __._.__! FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR)KITCHEN SINK LAVATORY 41 __-__-__f .-_--._._1 ....___.._! __,-_._..J _ ( ► _–___! ROOF DRAIN SHOWER STALL SERVICE/MOP SINK —d -__-_1 TOILET URINAL WASHING MACHINE CONNECTION __--.__i I ___-_J _.___-u.I WATER HEATER ALL TYPES WATER PIPING J==== ! J _........_ __._._ __.__._. J==== . I OTHER Sh ��- rr►¢ e ± ___I ..___._._- --_-_- ! d ___.._.. __.....----..` ....__.._( d -.__...__-► __I .___ f I ...._........ _ I F _._.-_I _ __I INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements.of MGL Ch.142. YES _.F NO _ IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY L, OTHER TYPE OF INDEMNITY Q BOND M__I 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 0 AGENT �Dd SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information I have submitted or entered regarding this application are tr and a curate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in co p• nc ith all ertine provis' of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME j LICENSE# [Y,; _ 3 I SIGNATURE IVIP -I JP[3 CORPORATIONB# - 3 Y- _]PARTNERSHIP P_.I#=LLC COMPANY NAMEDRESS CITYJ ,1ff a u STATE ; ZIP —D jT it TEL Q 7_P G 7(e D FAX _Q^- CELL ._75.7_ S EMAIL V1 c ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES 3 Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES The Commonwealth of Massachusetts Department ofIndustrial Accidents Office of Investigations qu 600 Washington Street Boston,MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): 2.y , Address: /�� Qy k 5 c( City/State/Zip:_)-i U ✓t-AJ9 Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.�am a employer with � 4. El am a general contractor and I ' * have hired the sub-contractors 6. ❑New construction employees(full and/or part-time). 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7 emodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. g, ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3111 am a homeowner doing all work right of exemption per MGL 11.[J Plumbing repairs or additions myself. [No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t employees.[No workers' comp.insurance required.] 13.❑Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. 7 Homeowners who submit this affidavit indicating they ate 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. C Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: 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 requiredunder 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 herebycert' nd the pains and penalties of erjury at the information provided above is true and correct. Si ature: Date: -7 ! Phone 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.EIectrical Inspector 5.Plumbing Inspector 6.Other - - - Contact Person: Phone#: 4 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 ofpublic 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 returned to the city or town that the application for the permit or license is being requested,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 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 permittlicense 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 Investigations 600 Washington Street Boston.,MA 02111 Tel,#617-727-4900 ext 406 or 1-877,!MASSAFB Revised 5-26-05 Fax#617-727-7749 www.mass.gov/dia - _ M .d .i . .�..Zvi.♦ ..- -.� _ wT Date LEW TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that .K. :J: . 5.A . . . . . . I . . . . . . . . . . . has permission for gas installation . . 5.7`x.1/ . . . ... .1 f in the buildings of. . ./�11.�P."�. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . at . . ''1 . . .fa.� !� . . .�� . . . S. . . . . ,North Andover, Mass. Fee .-3(�, . . Lic. No. . :7�. . 'i . . . GASINSPECTOR Check# 1 LI 7 8613 -� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK rA CITY h#_ _.. ..r�_� �-�- ._ MA DATEV_757 PERMIT# JOBSITE ADDRESS _ OWNER'S NAME GOWNER ADDRESS TE TYPE O OCCUPANCY TYPE COMMERCIAL(�( EDUCATIONAL �]j RESIDENTIAL CLEARLY NEW: A RENOVATION:0 REPLACEMENT:( PLANS SUBMITTED: YES E NO Q APPLIANCES 1 FLOORS, BSM 1 2 3 1 4 1 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER =—__- COOK STOVE _ .n J l-s.nA - DIRECTVENTHEATER DRYER FIREPLACE FRYOLATOR FURNACE - GENERATOR GRILLE - INFRARED HEATER LABORATORY COCKS _. _ MAKEUP AIR UNIT : OVEN POOL HEATER ROOM/SPACE HEATER r_. — ! -.— -•_—, ! - .._...: — - . I_. _. I�___. — — -- -- -- ! ROOF TOP UNIT - TEST UNIT HEATERAl UNVENTED ROOM HEATER WATER HEATER . v___ = __. OTHER INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES la10 (�__I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY (a— OTHER TYPE INDEMNITY BOND I__f 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 �7__i AGENT �I SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true d accu ate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in com an wi II P rtinent pr vision the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUM BER-GASFITTER NAME�( .,,,, LICENSE#n- ( GNATURE -- MP El MGF —j JP Pj JGF�_{ LPGI CORPORATION[ # 3 ( PARTNERSHIP D#=LLC[--]I#� COMPANY NAMES-1, ADDRESS CITY u 0_✓ - A4,4- _--J1 STATE�ZIP TEL 7 F G G-D z FAXCELL 1 ( (EMAIL ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES t, n The Commonwealth of Massachusetts Department ofIndustrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): 9 ',_7_4 s Address: 1-90 s-5 y City/State/Zip: )stg= / ji„cam Phone#: S -7 F-6 Ro e 7- Are pa an employer?Check the appropriate box: Type of project(required): 1.ETI am a employer with 1/ 4. ❑ I am a general contractor and I 6. E]New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7• F1 Remodeling ship and'have no employees These sub-contractors have S. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 1011Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.[No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]i employees.[No workers' 11bother comp.insurance required.] *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 thepolicy and job site information. Insurance Company Name:._)il. Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: LI U G-P�044 City/State/Zip:`)l 4 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder 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 cert' un r the pains and penalties o perjury that the information provided above is true and correct. - Si ature: Date: Jl Y 13 Phone#: 5 -2 zU 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#' 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 returned to the city or town that the application for the permit or license is being requested,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 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 Investigations 600 Washington Street Boston,MA 02111 I TeX,#617-727-4900 ext 406 or 1-877rMASSAFE Revised 5-26-05 Fax#617-727-7749 wwwmass,govldia