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HomeMy WebLinkAboutMiscellaneous - 40 Harkaway }o � lael�w� BUILDING FILE 107 *3 7 Date... r TOWN OF NORTH ANDOVER aR0 PERMIT FOR PLUMBING 14U This certifies that .. d, has permission to perform.. ...................... .. . .......... . ............................... plumbing in the buildings of... /A,*de'-*****"*"*...... at.)..../...C.)..... ............................................. North Andover, Mass. Fee,Ah..N......Lic. No. ............ PLUMBING INSPECTOR Check# 4 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY MA DATE�� %�S/�PERMIT# JOBSITE ADDRESS �,/A n pc a f, rr 2 OWNER'S NAME arm __..� POWNER ADDRESS TEL /� ,�s f� 6X79JI FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL © RESIDENTIAL PRINT �/ CLEARLY NEW: 0 RENOVATION:® REPLACEMENT: 5; PLANS SUBMITTED: YES® NO© 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 DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM i _._._.._..J ._._. [ 1 .,.._ _J I [ J I t t [ __t DISHWASHER j I __.-_3 _..-.1 . ..... DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK --t ....._.._J _--I -j LAVATORY ROOF DRAIN _.__,._,l �__J ___� _____t ___-.{ _._1�.__. ._..._J ._.._ I � .__.._. __.._.-_j SHOWER STALL I .__._ 1 _[ � I t 1 _ I .__ ._ t 1 __- ----. .j ____I SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTMER ..._......J _._._..4 INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES 2r0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY 0[ BOND 0 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 _I 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 in compliance with all Pertin;Pprovislon of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'SNAMEt.c LICENSE# IGNATURE MP 0 JP 2, CORPORATION D# PARTNERSHIP D# ILLC COMPANY NAME ,rtt F-/ ; ADDRESS PUId CITY ,,,�► c � -STATE /1J f� ZIP ®E; ^y� TEL I FAX � � CELL _sSo• �4�71 EMAIL i I ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No /I I14 A0 THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# i PLAN REVIEW NOTES .�Jv d The Commonwealth of Massachusetts - Department of ffidustrigl Accidlints Office oflnvestzgaflons 600 Washington Street Boston,.MA 02111 vww.mass gov/ciia Workers'Compensation Insurance.Affidavit:BuiXders/Coni°actors/Electricins/Pliiinbero a Applicant Information Please Print Legibly Name(Businos/Organi'zation/Tndividual): IzA W,/,a .Address: T Phone M 66A 9 Aoa; cp Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction ez Zoyees(full and/or peat time)* have liked the sub-contractors 2. am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and'have no,employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. [l Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its 10.[Electrical repairs or additions required.] officers have exercised.their 3.[l X am a homeowner doing all work right of exemption per MGL 11.❑Plumbing.repairs or additions myself.[Eo workers'comp. c.152,§1(4),and wehaveno 12.❑Roofrepairs insurancere lied. employees.[Noworkexs' qu ] 13.E]Other comp.insurance required.] xAny applicantthat checks box#I mustalso fill outthe section bel6w showingtheir 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 sucl tContractors that check this boar must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. X man employer that is providing workers'compensation insurance for my employees Below is the policy and job site infarmation. Insurance Company Name:_ Policy#or Self ins.Lic.M. ExpirationDate: Job Site Address: City/statelzip: Attach a copy oldie workers'compensationpolley declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL o.152 can lead to the imposition of criminal penalties of a flue 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. X do Hereby cert&under thepains and Id s o fperjury that die informationprovided above is true and correct. - Sigiatare. Date. 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.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 oi:'hi m,• express crim-plied,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 leaving 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 Y emp to er." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license oxexmit too operate a business or to cons et p p txu buildings in the commonwealth for a applicant g � ny a pp 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 till out the workers,compensation r omp nsatzon affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),addresses)and phone numbers)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 notrequired qaired to ca nyworkers compensation.insurance. If an LLC or LLP does have employees.,a policy is required. Se advised that flus affidavit maybe submitted to the Department of Industrial Accidents for conf"umation 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 Ofizcials 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 thatmust submit multiple pennit/license,applications many given year,need only submit one affidavit indicating current Policy information(ifnecessary)and under"Sob Site Address"the applicant should write"all locations in .(city or town)."A copy of the affidavit that has b een officially stamp ed or marked by the city or town may be provided to the applicant as proof that a valid affidavit-is on file for future Hermits or licenses. .A.new affidavit must be fl1ed 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 burn 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 shpuld you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: Tho Commoawoajth o fMas a..chv-:SPtE1 Department ol:Xndustrial Acoldonta Mce ofIn.Vestzga-iona 6.0G WaMagtan St7reat Boston,MA 02111 tel,#617-7-21.7,49-00 at 406 Qx x-87.7-I1 A, AFE Revised 5-26-05 Fax 0 617-727-7749 i 011AINI0NWEALTFI DF_MASSWHi7SE • `PLllMBERS �� ASF 1TTItRS s ,J_ ISSUES THE FOLEOWING 4L=(CENSE s L I CENSIrf� SIS A JOURNEYMAN 1J�18ER a � fir, T#'Rk S S JARHADi l € ra 415 MA `t ST ` FF ' 4pSTAD NH 03841 �07