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HomeMy WebLinkAboutMiscellaneous - Exception (95)i Dater/./,!12 TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that has permission for gas installation ... &i�t ,. 641.4 ....6,4 n .. (U ."J. in the buildings of. j4 tV..1�.�: ,.�� j2 .0 ....................... at ....P..e w <Y ............... . North Andover, Mass. Fee. �,.�)1 U d . Lic. No... ........................ ... GASINSPECTOR Check # NEd I W400 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK • CITY MA DATE PERMIT # yt9� - JOBSITE ADDRESS _ OWNER'S NAME G OWNER ADDRESS S - - - - • TE ---------- FAX TYPE OR PRINT OCCUPANCY TYPE COMMERCIAL 0EDUCATIONAL .1RESIDENTIAL �- CLEARLY NEW: [l RENOVATION: El REPLACEMENT: [j -- PLANS SUBMITTED: YES 0 NO 0 APPLIANCES Z FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER) CONVERSION BURNER COOK STOVE - I - i - J ._ J T 1 - -_-J _ J : - l __ T ,f DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR FURNACE GENERATOR GRILLE _ _ INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN. POOL HEATER ROOM / SPACE HEATER _.�. - f - - - _ .. ROOF TOP UNIT J __.J --j ..... �- �� - �n. T _.__ -_ f _ _.._. I :. �I _.. _._ TEST I - .11 I L J — 1-._�I UNIT HEATER UNVENTED ROOM HEATER WATER HEATER _ _._L l^� 1 I _ J �Y -_ .f _ ,. OTHER �_ J L__-] I _ J - I I ----J _1 — INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES ONO D 1 IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY [a— OTHER TYPE INDEMNITY Ej 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: OWNER © AGENT [�( SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best I my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in co i nce th all P rtinent pr", he Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER GASFITTER NAME_l/ vyc _ -� LICENSE #J3-._� GNATURE MP 0 MGF 01 JP El JGF LPG] .__f CORPORATION �# �( _ f PARTNERSHIP# LLC []#= COMPANY NAME: ✓/-moi �.►.�^___._._.-{ � ADDRESS CITY `� V < , y tJ�� STATE ZIP ITEL r `1 J FAX CELL/'EMAIL _.._ ., _—__ :— H o H U a W � N a z� O y� W r W � � ~ W cnw W c a CW7 o a a a U J a M Q � w x w I-- w H °z z 0 H U W a t�7 C�7 1 11 The Commonwealth 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): Address: City/State/Zip: Phone #: Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ 1 am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. I ship and have no employees These sub -contractors have working for me in any capacity. [No workers' comp. insurance required.] 3. ❑ 1 am a homeowner doing all work myself. [No workers' comp. insurance required.] t workers' comp. insurance. ❑ We are a corporation and its officers have exercised their right of exemption per MGL C. 152, §1(4), and we have no employees. [No workers' comp, insurance required.] Type of project (required): 6. ❑ New construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.0 Electrical repairs or additions 1 l.❑ Plumbing repairs or additions 12.0 Roof repairs 13. ❑ Other *Any applicant that checks box # 1I L 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. tContractors 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 %reformation. Insurance Company Name: 'olicy # or Self -ins. Lic. #: Expiration Date: .ob Site Address: City/State/Zip: kttach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a ine 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 Tup to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of nvestigations of the DIA for insurance coverage verification. do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. ignature: Dat. - 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): L 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-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) 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 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 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,mass.gov/dia �M0 Crawford U.S. Property & Casualty Robert Pageau, AIC, Director New England Service Center February 14, 2011 Town of North Andover Health Department 1600 Osgood St, Suite 2-36 North Andover, MA 01845 Notice of Property Loss Under M.G.L. 139, Section 3B RE: Policy Number: HP2519944 Insurer: Merrimack Mutual Fire Insurance Company Named Insured: Anthony C & Suzanne E Antinoro =rTM, Type of Loss: Burglary/Theft �1v Location: 28 Dewey St, North Andover, MA 01845 Loss Date.: 02/07/2011 FW i p toil Our File Number: 1789624 Dear Sir/Madame: TWdR! OF NORTH AN 00VER !�7DEPARTMENT Crawford & Company is the independent insurance adjusting firm hired by Merrimack Mutual Fire Insurance Company to investigate the above captioned property loss on behalf of their insured, Anthony C & Suzanne E Antinoro, presently residing at 28 Dewey St, North Andover, MA 01845 Under Chapter 139 of the Act of 1977, you are hereby notified that a claim payment of more than $1,000 is expected. If any notice under MGL, Ch. 139 Sec. 313 is appropriate, please contact the undersigned immediately. We thank you in advance for your assistance in this matter. Respectfully, CRAW ORD & COMPANY Adam Lucas Property Adjuster CC Town of North Andover — Office of Treasurer/Tax Collector Merrimack Mutual Fire Insurance Company EXCELLENCE IN EVERYTHING WE TOUCH 204 Second Ave ■ Waltham, MA 02451 0 Tel: 866-641-8175 0 Faz: 800-651-3743 0 www.trawfordandcompany.com Date.... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that......... \7 ....................... zze---z ..... has permission to perform ............�e.cp ....... ......... . .1 ..... wiring in the building of .............. JE.. ...... P .... I!1-11- ....... MAlk �41 ..... at ...... ....................... . North Andover, Mass. Fee... Lic. No.'.4'v�-3 ........... 4i - r ............. .. .......... Check # ELECTRICAL 5634 J JIM UU1y1Ly1U1YYVVJUA13Ur�nrs.�arrt,ay.usl�� �••w/ 2 , DEPARTYVIF1 TOFPUBLICSAFEN Permit No. ts� J BOARDOFFMPREVEMONREGUL4HONSS27(. 2l2:(XI APPLICATION FOR PERMIT TO PERFO. ALL WORK TO BE PERFORMED IN ACCORDANCE WITH THE MASSACHUSSTS (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Town of North Andover The undersigned applies for a permit to perform the electrical work describe/below. Occupancy & Fees Checked 1 ECTWCAL WORN CODE, 527 CMR 12:00 Dat 3 / Y10 To the Inspector of Wires: Location (Street & Number) Z Fr LJQe4l CN, -,IT Owner or Tenant Pio Owner's Address S 4-,n le Is this permit in conjunction with a building permit: Yes No (Check Appropriate Box) Z� ( Purpose of Building S( Utility A�Itorization No. Existing Service Q Amps /L6 / L V Volts Overhead nUnderground IZI No. of Meters New Service 00 Amp:VW INO Volts Overhead Underground No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work P.12d/I CC i0C J?w —e No. of Lighting Outlets No. of Hot Tubs No. of Transformers Total KVA No. of Lighting Fixtures Swimming Pool Above Below Generators KVA ro ground No. of Receptacle Outlets No. of Oil Burners No. of Emergency Lighting Battery Units No. of Switch Outlets No. of Gas Burners FIRE ALARMS No. of Zones No. of Ranges No. of Air Cond. Total Tons No. of Detection and No. of Disposals No. of Heat Total Total Pumps . Tons KW Initiating Devices No. of Sounding Devices No. of Dishwashers Space Area Heating KW No. of Self Contained Detection/Sounding Devices Local Municipal Other No. of Dryers Heating Devices KW Connections No. of Water Heaters KW No. of No. of Signs Bailasis No. Hydro Massage Tubs No. of Motors Total HP I OTHER• r Iharesulxrtiiad !! INSURAN X BOND r7 OTHER (Please Sper�j+) � w,11 �sl( Wodcrostatt!� hnpedmDateReWMd Rou�ghj'� S'igled undte rTie Paj�Y� 49/�✓`L t C (Q �d'ft C RRMNAN E Lic megum Vc/br®" Signaaae —+Aw !LNI ryouhmchal®d Estirn*dvaileofEbc" Walk $ Final Lioa>seNa ,�y / �2.T Liww?e b BusirmTd Na ?7f ALTeINa OW OCSINSURANCEWMVER I dutheLivawdommthmtheir>siaamwmVailsakswWegtrivalentasr gmadbyMassadmmCg WLaws arcl that rrry sigr�hae rn the pelrritapp)rcation wanes this regtlicarlalt. (Please check one) Owner Agent Telephone No. PERMIT FEE $ .. signature of Owner or Agent