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Home My WebLink AboutMiscellaneous - 59 Hitching Pst Date.e.iZ &ORToq 0 TOWN OF NORTH/AOVER TIO • PERMIT FOR GAS I ALLATION SACHU This certifies that . . . . . . . . .. .. .. .. .. . . . . . has permission for gas installation . . . . . . . . . . . . . . . . . in the buildings of -4 at North Andover, Mass. Lic. No-??.6;'i . . -7' ' - - - - --- - - - - - GAS IN*S'PECT. Check# 606 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) 0G61e, Mass. Date _ a® Permit # d Building Location f1Y�C Jrti��" Owner's Nameo;35W//d�1'/ ` N AND 0 r1ex Md rf Type of Occupancy New Renovation ❑ Replacement ❑ Plans tans Submitted: Yes ❑ No ❑ LuU WW � ¢ O $ m � a O W w °� ¢ O D O ~ W J ¢ cn C7 W w = U) Z Cn Q ¢ > w Lu H z W H z w W W ¢ W ~ W ~ = co ¢ > HLU a w > ¢ w z ¢ ¢ a m O 8 w ¢ O w V ¢ 2 O 0 2 u 0 C7 -j 0 ¢ > � a ►- O SUB-BSMT. BASEMENT 1ST FLOOR 2ND FLOOR 3RD FLOOR 4TH FLOOR 5TH FLOOR 6TH FLOOR 7TH FLOOR 8TH FLOOR Installing Company Name kt- Check one: Certificate # Address 3 y G 9 S T ❑ Corporation {�411 F2 0 / r ❑ Partnership Business Telephone 7 '5�-_ `� g 3 ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter Al 4T7 r'U/ i'1'I fib- /%/C INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142. Yes ❑ No 2� If you have checked yes, please indicate the type coverage by checking the appropriate box. A liability insurance policy. ❑ Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that tl-e 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 1:1 Agent ❑ I 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 installation performed under the permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. By Type of License: I I Plumber Title I l Gasfitter Signature of Licensed Plumber or Gas Fitter City/Town I] Master 7 G License Number APPROVED (OFFICE USE ONLY) [/Journeyman �O, BELOW FOR OFFICE USE ONLY FINAL INSPECTION SKETCHES NO. PROGRESS INSPECTIONS FEE MERCURY TEST FINAL INSPECTION APPLICATION FOR PERMIT TO DO GASFITTING NAME & TYPE OF BUILDING LOCATION OF BUILDING PLUMBER OR GASFITTER LIC. NO. PERMIT GRANTED DATE 19 GAS INSPECTOR The Commonwealth of Massachusetts j Department of Industrial Accidents cp Off ice of Investigations iiliif 600 TN'ashina,ton Street Boston, MA O2111 c www_mass.gov/dia . Workers' Compensation Insiu-ance Affidavit: Builders/Contractors/Electricians/Pimbers Applicant Information. Please Print Leeibl Name T n/Individual) Address: City/state/Zip: � `p Q o g3 d- Phone �' Are you an employer?Check the appropriate bo z: I.❑ I stn a employer with 4, Type of project(requires: ❑ 1 am a general contractor and T employees(full and/orpart-time).* have hired the sub-eorutzactots 6. Now construction 2 lam.asole proprietor or partner_ listed on the attached sheet,x 7. ❑Remodeling ship and have no employees These sub-contractors have working far me man $ Q Demolition y capacity. workers' comp.insurance. [No workers'comp.insurance 5. ❑ We are a corporation and its 9• Q Building addition 3.Qrequired.] officers have exercised their 10•Q Electrical repairs or additions I am a homeowner doing all work right of exemption per MGL I I.dumbing repairs or additions "(� myself.[No-workers'comp, C. 152, §1(4),and we have no insurance.re required.] 12.❑Roof repairs q I .employees. [No woriCors' COMP. insurance required_] 13.0.0ther `Arry appiicattt that checks bo><'#!must also fill out the section below showing their workers'Coro t Homcownets who submit this aff+davk indicating they are loin a►1 Pensetion Policy information, g of g work and then hire the ntrwetars musf submit a now affidavit mdiaatiag ouch - - ;Contractors that chest this box must arrreeeteed an additional sheet showirgthe�p of the sub-co nttactors and their workers'cerr.F•FDti�'in€omistion. i am an employer brat is pro g:workers'compensation insurance or nformation f nr employees: Be71ow is the policy and job site Insurance Company Name— Policy ame ' Poli #or cy Self--ins.Lic.#: Expiration Bate. 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 required,under Section 25A of MGL c. 152 can lead to the i fine up to$1,500.00 and/or one-year imprisonment,as we 11 ss civil penalties in mposition criminal penalties of a number the form of a STOP WORK ORDER anti 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 undcr the pains and penalties of perjury that the information provided above is true and torted Si tare: Dam11k; 6 q Phone#. _ l JcW use only. Do not write ur Phis area,Gn be completed by city or Iowa offirxaL City or Town: Permit/License# Issuing Authority(circle one): L Board of Health 2. Building Department 3.City/Tovvn Clerk 4.Electrical Inspector S. Plumbing Inspector 6.Other Contact Person• Phone#: `•Rn Information a nd Instructions Massachusetts General Laws chapter 152 requires all emp 3 overs 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,assodiation,corporation or other legal entity,or any two or more of the'forcgoing engaged in a joint enterprise,and includirig 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.thiin three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do mauntenance,construction or repair work an such dwelling house or on the grounds or building appurtenarn thereto shall not because of sucb employment be deemed to be an employer." MGL chapter 152,525C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of license or permit to operate a business or *o 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).mind phone munber(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 requiredito 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 i*rsL+i'd crmp"�i�chn�ild e..,rT+J,r;r 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 permitflicense number which A-ill 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 ofthe 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 Off=ice 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 Departnent's address,telephone and fax number. The Commonwealth of Massachusetts Department of lmdnstriW Accidents Office of Lnvestibations 600 Washington Stmt Boston, NIA 02111 TeL 9 617-7274900 east 406 or 1-977-MASSAFE Revised s-26-05 Fax 4 617-727-7744 wwwmass.gov/dia