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Home My WebLink AboutMiscellaneous - 426 Main Street _T _ i Date. . . . .... . NORTIy 0* 4, TOWN OF NORTH ANDOVER 0 • PERMIT FOR GAS INSTALLATION SACHUS This certifies that . . .)9,#(- . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . has permission for gas installation . . ...l3 . . . . . . . . . . . . . . . . . . . . in the buildings of . . . . . . . . . . . . . . . . . . . . . . . . . . . . -tv at . . . .L/ G. . . 'J19/. . . . . . . . . . . . . . . . . North orth Andover, Mass. Fe' IA( Lic. No.. . . . . . . . G. S NSPEC rOR Check# 7070 i r� MASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS FITTING (Type or print) Date 01 21"0 Ly NORTH ANDOVER,MASSACHUSETTS �f e Building Locations �•`? ✓"D An d f/f f <( Permit# Amount$ Owner's Name New❑ Renovation Replacement Plans Submitted xrA zW a Z H m H w W o 7 a w x z a a a w o o F x G7 F Z H z F F W u c°q > L�, �w. WV a O Z d a d ¢ O O w a O [-• O x w D 3 D C7 a U a > A a F O SUB -BASEMEN T B A S E M ENT 1ST. FLOOR 2ND . FLOOR ,0 3RD . FLOOR 4TH . FLOOR 5TH . FLOOR 6TH . FLOOR 7TH . FLOOR 18T H . FLOOR (Print or type) Check one: Certificate Installing Company Name ti 1� 1 Gc �'1�Oc' l [:] Corp. Address C�6 (e.,S Pe I ya t1I Al# Partner. 6362 Musin Ta ep one COS- C156- of S- � Firm/Co. Name of Licensed Plumber or Gas Fitter �G( K! �<x tYl�j�c• �/ INSURANCE COVERAGE Check o I have a current liability Insurance policy or it's substantial equivalent. Yes No If you have checked yes,please indicate 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 142 of the Mass.General Laws,and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent 0 1 hereby certify that all of the 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 Derformed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts S at. s C94e142WCPt 142of the General Laws. B Signature of Licensed Plumber Or Gas Fitter Title By: Plumber �6 ��/ , City/Town Gas Fittericen�se Tum er ❑ Master APPROVED(OFFICE USE ONLY) Journeyman " The Commonweirith of Massachusetts Department of Industrial 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): j ` � /Gl/yJ U/% •F �/tCr�j i? Address: .� City/State/Zip: �� 7 �''� � �� Phone#: S_ 7 AFu an employer?Check the appropriate box: Type of project(required): 1• am a employer with '� 4. ❑ I am a general contractor and I mployees(full an part-time).* have hired the sub-contractors 6. ❑New construction 2. I am a sole proprietor or partner- listed on the attached sheet. 1 7• ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. [No workers comp. insurance 5. 9 Building addition p ❑ We are a corporation and its r required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11- Plumbing myself. ❑ g repairs or additions y [No workers' comp. C. 152,§1(4),and we have no 12.❑ oof repairs • insurance required.] t employees- [No workers' / / comp.in 13.[Other e �e t"e 7 ] / ,— p surance required.] � � �/r � v applicant that ChaclW box C muss also till out the section beim,sho"vin Herr won a s'compen-mwon Y l:e,`sto Patron 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 isproviding workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins. Lic.#: // �y M�r Expiration Date: A Job Site Address: `1' /414 �'/ S fl City/State/Zip: . All u j J5,Ij/S— 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 cer�fy u der the Mns nd naltie of perjury that the information provided above is true and correct. Si ature: J S Date: /G O Phone#: [[I. fficial use only. Do not write in this area, to be completed by city or town official ity or Town: Permit/License# suing Authority(circle one): 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 coinpliance 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 cerdficate(s)of q\ 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 r. 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 permittlicense 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-MASSAFE Fax#617-727-7749 Revised 5-26-05 www.rnass.gov/dia