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HomeMy WebLinkAboutBuilding Permit #385-14 - 1211 OSGOOD STREET 10/23/2013 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: ✓`' Date Received Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION /Z// Qea e_ oC/ S7z'CC7- No►.T� �i,�doyes z,, /N�. Print PROPERTY OWNER 54- k LLC_ �! Print 100 Year old Structure yes 0 MAP NO: PARCELM- U ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT. PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: 5K-Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands 0 Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED:` / k) Identification Please Type or Print Clearly) OWNER: Name: LLL Phone: lei -7131 - 9Y37 Address: Z t3 � CONTRACTOR Name: NIA. Phone: Address: Supervisor's Construction License: Exp. Date: - 4 Home Improvement License: Exp. Date: ARCHITECT/ENGINEER 0114-. Phone: Address: Reg. No. FEE SCHEDULE.BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ lea° FEE: $ 3o CIA Check No.: a 07 D3 Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund 9 w.r. �g.. _ _ __g=__ _._ ' Si nature of A ent/Owner Sign of contractor Plans Submitted Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ Plans Submitted ❑ PlansWaived-11 -Certified Plot Plan ❑ Stamped Plans ❑ -TYPE ORSEWERAGE:DiSPOSAL Public Sewer ❑ Tanning/MassageBodyArt ❑. . Swimming Pools ❑ Well ❑. Tobacco.Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc- ❑ - _ .Permanent Dumpster on Site ❑ THE.FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE.APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS -CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS t y C?oning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit DPW To` o Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Mair Street . -Fire Departine!itsignature/date-. COMMENTS i Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions._ .Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL-Chapter 166 Section 21A-F and G min.$1oo-$10o0.fine NOTES and DATA— (For department use ® Notified for pickup - Date E Doe.Building Permit Revised 2010 ` Building Department The fol'-3wing is---a list of the required forms to be filled out for-the appropriate.permit to be obtained. Roofii,g, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract L3 Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire-Department prior to issuance of Bldg Permit Addition Or Decks ❑ BuildingPermit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) a Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the apw-al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be subm.tted with the building application Doc: Doc.Building permit Revised 2012 Location No. y Date /� 3 • - TOWN OF NORTH ANDOVER Jf Certificate of Occupancy $ Building/Frame Permit Fee $��-•"' Foundation Permit Fee $ Other Permit Fee $ TOTAL $�_•DC) Check#167 satyr - 2 Builtling Inspector Y cNeTH O p '11 O4n. r^``19 ,SSACIN`'ES CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Permit Number 385-14 Date: March 5, 2014 THIS CERTIFIES THAT BAKED ( 10 seats) THE BUILDING LOCATED ON 1211 Osgood Street MAY BE OCCUPIED AS _IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: Farrell Boghas 1211 Osgood Street Building Inspector Fee: $100 Receipt: 27036 Check :30750941-2 l NORTF� Town of 16 V• ��I I' r T �. h "h , ver, Mass, �wiae 1, COC NIC Kl WICK V ��AOR�1tED I`P���S S V BOARD OF HEALTH Food/KitchenPERMIT T LD �j Septic System lc'J ✓`� THIS CERTIFIES THAT ...........:...........................:.................................................. .................................. BUILDING INSPECTOR a .. Foundation has permission to erect buildings on .... ................... _.............................................CotiIe. .............. .... Rough to be occupied as ..............:.: :::......................... ............ ` ......�....-...................... ..... Chimney provided that the person accepting this permit shall in every respect conform to the terms applica ion on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and ;Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough 41;' L&-j� 1 PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION ARTS Rough j� Service ............. ..... .c.::........... ....... ......................... BUILDING INSPECTOR } GAS INSPECTOR i Occupancy Permit Required to Occupy Building Rou h Display in a Conspicuous Place on the Premises - Do Not Remove Fi76._/ No Lathing or Dry Wall To Be Done ARE DEPARTMENT Until Inspected and Approved by the Building Inspector. rner Street No. - v Smoke Det. SEE REVERSE SIDE 0 SO 00r -77 !1 IM x„: A �- 120 in Ben Moore Sherwin Williams Fresh Butter#290 Commodore Blue t"J M��y� so 00 T Baked date 2/27/14 0 THE SIGN CENTER n,-o sign center g designed by K Hansen 40 ORCHARD STREET,HAVERHU,MA 01630 ��6iSiJIIUU 1211 Osgood Jt, North Andover MA file name Baked Building Sign V4.plt YY//iSiJ111iL! Sales Associate Matt Rothwell details 36" x 120" Panel Dimensional Letters & Vinyl Graphics NORTH own of t EAndover o No. 3is- 11i * 1"t b h , ver, Mass, COC� NICKI WICK A `V S V BOARD OF HEALTH Food/Kitchen PERMIT T Septic System .�/Y er'r� f� i' �. 0 nt n BUILDING INSPECTOR THIS CERTIFIES THAT has permission to erect .......................... buildings on `.... `5 ................................. Foundation Rough to be occupied as ........1...`.: ................�..... � .. .... �::....!.1...;.:..//..... ..................................... Chimney provided that the person accepting this permit shall in every respect conform to t e terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION ARTS Rough ....�....... ....... .G�.::.............��..-.�..�. .......................... Service ' Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. SEE REVERSE SIDE I °<NO STN ti •� r �SStcxus itg' SII CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Permit Number 385-14 Date: March 5, 2014 THIS CERTIFIES THAT BAKED ( 10 seats) THE BUILDING LOCATED ON 1211 Osgood Street MAY BE OCCUPIED AS _IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: Farrell Boghas 1211 Osgood Street """ea Building Inspector Fee: $100 Receipt: 27036 Check :30750941-2 The Commonwealth of Massachusetts City\Town of North Andover Certificate of Inspection In accordance with 780 CMR,Chapter 1 (The Sixth Edition of the Massachusetts State Building Code) and Chapter 304 of the Acts of 2004 (an Act to further enhance fire and life safety),this temporary certificate of inspection is issued to the premise or structure or part thereof as herein identified. Identify Name of Establishment Certificate No. Issued to BAKED 385-14 1211 OSGOOD STREET Certificate Located at Expiration March 2015 Use Group Allowable Classification(s) RESTAURANT/BAKERY Occupant Load 10 SEATS i Certificate of inspection is hereby issued by the undersigned to certify that the premise,structure or portion thereof as herein specified has been inspected for general fire and life safety features. This certificate shall allow for the temporary use as herein described and in conformance with any and all conditions as identified below. It shall be framed behind clear glass and\or laminated and posted in a conspicuous place within the space as directed by the undersigned. Failure to post the certificate,failure to comply with conditions or,tampering with the contents of the certificate is strictly prohibited. Conditions of Temporary Use Name of Municipal Andrew Melnikas,Fire Chief Name of Municipal Gerald Brown,Bldg. Insp. Date of March 5,2014 J' Fire Chief Building Commissioner Inspection 1 Signature of Municipal Signature of Municipal Date of March 5,2014 Fire Chief Building CommissionerIssuance ,GZ�v� The Commonwealth of Massachusetts City\Town of North Andover Certificate of Inspection In accordance with 780 CMR,Chapter 1 (The Sixth Edition of the Massachusetts State Building Code) and Chapter 304 of the Acts of 2004 (an Act to further enhance fire and life safety),this temporary certificate of inspection is issued to the premise or structure or part thereof as herein identified. Identify Name of Establishment Certificate No. Issued to BAKED 385-14 1211 OSGOOD STREET Certificate Located at Expiration March 2015 Use Group Allowable Classification(s) RESTAURANT/BARRY Occupant Load 10 SEATS Certificate of inspection is hereby issued by the undersigned to certify that the premise,structure or portion thereof as herein specified has been inspected for general fire and life safety features. This certificate shall allow for the temporary use as herein described and in conformance with any and all conditions as identified below. It shall be framed behind clear glass and\or laminated and posted in a conspicuous place within the space as directed by the undersigned. Failure to post the certificate,failure to comply with conditions or,tampering with the contents of the certificate is strictly prohibited. Conditions of Temporary Use Name of Municipal Andrew Meh-ilcas,Fire Chief Name of Municipal Gerald Brown,Bldg. Insp. Date of March 5,2014 Fire Chief Building Commissioner Inspection Signature of Municipal Signature of Municipal Date of March 5,2014 Fire Chief Building Commissioner U/��jM~ Issuance Location ' .,J No. 00 — Date Il X t i r • TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee J! $ '"' TOTAL $ Check# ',1 '9 Building Inspector NORTH 0�I't 1'I G 0, h �� " p TOWN OF NORTH ANDOVER 11ey yoR `°`rID ATtD K. SIGN PERMIT r �y �SSACHUS�� DATE: November 18, 2016 PERMIT: 011-2017 THIS CERTIFIES THAT Harry Kanellos has permission to erect a sign on 1211 Osgood Street a 36x120 sign " Est 2016 Bella's Roast Beef Pizza Seafood Subs Salads provide that the person accepting this Permit shall in every respect conform to the terms of the application on file in this office, and to the provisions of the Codes and By-Laws relating to the Sign Regulations in the Town of North Andover. Violation of the Zoning of Sign Regulations, Section #6, Voids this Permit. INTERNAL ILLU INATED IGNS ARE PROHIBITED Inspector of B ildings Amount Paid:$30.00 Check#1317 Receipt 31216 SItGN 1P RMIIT APP1LU CATIION 1600 08900all Street BuRding 20,Sake 2-36 TOWN OF NORTH ANDOVER Date: Name of applicant who is purchasing the sign 96L(04S 1 N C Site Owner A22 yG/7 7y/ '3-2 k 2 • i Phone#of applicant who is purchasing the sign Site Address. /2// OSGvop Name of sign company_�O/�f✓y S Gti 7CCH Phone# � Size of Proposed Sign '-3G -c 12O BU2 J! Parcel � Illumination: a Not-illuminated How attached' Against the wallInternally illuminated Ro® � c)Ground c)Externally illuminated d)Other Materials. ,4 U;Folie e(__ Proposed Colors: ]Background Q 1A c►- fettering W W Pt-- Border I c,f Cost of Sim O OReauire Photographs s ofb building 1`V'2 No permanent/temporary sign shall be erected,or enlarged until an Photographs of building ' application on the appropriate forth furnished by the Sign Office has been filed ColoMaterial sample with the Sign Officer containing such information including photographs,plans Color sample and scale drawings,as he may require,and a permit for such erection,alteration, Site or Plot Plan(Required for.all free-standing signs) or enlargement has been issued by him. Such permit shall be issued only of the Drawings of proposed sign Sign Officer determines that the sign complies or will comply with all Other,specify applicable provisions of the By-Law. Will sign overhang any public road or walkway Yes( ) No(/ If Yes,Name ofAgency who will provide liability insurance: AN INCOMPLETE APPLICATION WELL NOT BE ACCEPTED DATE FILED.--//-/ Y Receipt# Check# Z,3/ 7 Revised 10.31.2006Form sign Permit Application SIGNATIIZ OF APPLICANT APPROVED BY - i r° Ar'W I6 BEII ROAST pro.; b � 16 >1 1 ti¢' ti 36" x 120" alupanel flush mount to building i (] f V%ORTh 1 o . BUILDING PERMIT ,.i��`�~�° "•��a� TOWN OF NORTH ANDOVER $.- : APPLICATION FOR PLAN EXAMINATION " Permit NO: Date Received "w-°, •.-. - �` SS�CHt7�+E Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION / ! Print PROPERTY OWNER N. S.A"• /ZOEAT2C -S_ LC..C Print MAP NO: PARCEL: ZONING DISTRICT: EHistoric District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family [I Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: -'s] Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic []Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer l� I-7 p Ir Identification Please Type or Print Clearly) OWNER: Name: - . vpE�2TT E� LLC Phone: (;f7 74)/ gZk2- Address: 7 0 L g- .0 D 0 L.E?o,v ew C3/ CONTRACTOR Name: /-� Phone: qZY QPY CSO Address: 3 Supervisor's Construction License: Exp. Date: Home Improvement License: Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE.BOLDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ 0, 60 FEE: $ 3� Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund Signature of Agent/Owner Signature of contractor a , Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATEAPPROVED Eli PLANNING & DEVELOPMENT x 111�UK 6 910 COMENTS �k�on CL-D CONSERVATION ❑ ❑ COMMENTS DATE REJECTED DATE APPROVED HEALTH ❑ ❑ COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit Located at 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date COMMENTS a Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— (For department use) ❑ Notified for pickup - Date Doc.Building Permit Revised 2012 Date�.L I I (.,0........ 'i i2 ;) �NOp7�y, TOWN OF NORTH ANDOVER 9 PERMIT FOR PLUMBING ,ss'�CMUS�S � nn,^, This certifies that iy /�.r� ..... ........................................ ........................................... .... .......... ..n........ has permission to perform.....j...`�'`' ..�....A�..-q.,!.............................. plumbing in the buildings of..:(� &- I- 1�� 1 �I R........................... ....................................... at....�....... �� ��`�c�r r�. North Andover, Mass. Fee„10(�- ....Lic.No. ! �1... ................................................................................. PLUMBING INSPECTOR Check# �_� MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY� `�` MA DATE y/SIG PERMIT# �0 3 5 - a0 JOBSITE ADDRESS /2// 056010 S1 OWNER'S NAME �-/,/z.,y SCA w.e//oS POWNER ADDRESS 7 D;Y e y i),7- m q a, g.-It TEL 617 -711 k i kz FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ❑ RESIDENTIAL❑ PRINT CLEARLY NEW:❑ RENOVATION:[1r REPLACEMENT:❑ 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/OIUSAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN Z INTERCEPTOR(INTERIOR) KITCHEN SINK 3- LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WAI tR HEATER ALL TYPES -r WATrR PIPING s 0TH R INSURANCE COVERAGE: I have a current liabilityinsurance 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 K 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 Massachusetts General Laws,and that my signature on this permit application waives this requirement. SIGNATURE OF OWNER OR AGENT CHECK ONE ONLY: OWNER ❑ AGENT ❑ I herebycert' that all of the details and information 4Y t n 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 Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME LICENSE# j 8IGNATURE MP 0 JP❑ CORPORATION[N#32cct, PARTNERSHIP❑# LLC❑# COMPANY NAME g&4nt;-f, bYv74gr-�S ADDRESS 3 CITY Iii �P.�2M STATE qA ZIP Djgq� TEL (T2 ?347`2jg3 FAX CELL EMAIL � Datei � I � ..... .............. NORTH TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION 88�CHU55 M This certifies that ........ ....................!. -.... .! ' !`- . '. ............................. has permission for gas installation ....:'.. �' ,-.,!� �....... in the buildings of.......�7 �V'. ,.�......i...:.�.. rr.. .^........ (f ............................. u • North Andover Mass. Fee.. .. ........ Lic. No. ..7 '............................................ Check 4 GAS INSPECTOR �� ��-7 I I MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY: W014% A11JCA _* MA. DATE: S PERMIT# S JOBSITE ADDRESS: / r)d 036'01D _S:7- OWNER'S NAME: /1A Z,2 Y GOWNER ADDRESS: 7 Q,x eY Q%L .,g o/`i yr-TEL: 6/7-211 %1Z-'2- FAX: TYPE OR OCCUPANCY TYPE: COMMERCIAL[ EDUCATIONAL ❑ RESIDENTIAL❑ PRINT I CLEARLY NEW:❑ RENOVATION:[0-'REPLACEMENT:❑ PLANS SUBMITTED: YES Ee/NO❑ APPLIANCESZ FLOOR- Bsmt 1 2 31 4 5 6 7 1 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR 1 FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCK MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER I I INSURANCE COVERAGE I have a current liabilft nsurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES �KN0 ❑ If you have checked YES,please indicate the type of coverage by checking the appropriate box below. LIABILITY INSURANCE POLICY Ir OTHER TYPE INDEMNITY ❑ BOND ❑ OWNER'S INSURANCE WAIVER:I am aware that the licensee oes not have the insurance coverage required by Chapter 142 of the. Massachusetts General Laws,and that my signature on this p6rmit application waives this requirement. • CHECK ONE ONLY: OWNER ❑ AGENT ❑ SIGNATURE OF OWNER OR AGENT F 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 Ender the permit issued for this application will be in compliance ' all Pertinent provision of the Massachusetts State Plumbing Code and Chapter'142 of the General Laws. .I PLUMBER/GASFITTER NAME:Mary' ! .W LICENSE# 1 355 SIGNAT RE COMPANY NAME: ADDRESS:3 &rfs+ 5r CITY: 4 JSTATE, ZIP: G[t'1 4 5 FAX: (If 97k TEL:$ S,3G`"ZI 9 3 CEL ?36- Z/ i 1*3 EMAIL: MASTER JOURNEYMAN❑ LP INSTALLER FI COR .3a PARTNERSHIP❑# LLC❑# Department,ol'Industrial Accidents Office of Investigations ' 1 Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): A J f 1 C© J'S'>Vz)44V44d— Address: _ ��A S i— City/State/Zip: /'Y1!, rJJ J-e-40-� Phone#: Areyouan employer?Check the appropriate bog: Type of project(required): 1.2 1 am a employer with .3 4• ❑ I am a general contractor and I employees(full and/or part-time). have hired the sub-contractors 6. ❑New construction 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g. ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp.insurance.* Electrical repairs or additions required.] 5. ❑ We are a corporation and its 10.❑ p 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4),and we have no 13.❑ Other employees. [No workers' comp.insurance required] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. I Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. lContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. lam an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: &Cj, Policy#or Self-ins.Lie.#: S RAd 0!!�-3 7 d Expiration Date:_ 3/d y 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 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 cern under thegains and enalties 2_f eEdugthat thein ormation provided above is true and correct Si ature: ... _ - - _ .___ Date _:.------— — ----' Phone#: 9—3 o5 - Z,(5; 3 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#: ' DATE(MM/DD/YYYY) '`����® CERTIFICATE OF LIABILITY INSURANCE 3/17/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND 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 BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(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 certificate does not confer rights to the certwficate holder in lieu of such endorsement(s). PRODUCER CONTACT Eva Ca exon NAME: P EA Stevens Company, Inc. PHONE (781)322-2324 F No):(781)397-7672 389 Main St. E-MAIL ADDRESS:evac@eastevensins.com P. 0. BOX 188 INSURERS AFFORDING COVERAGE NAIC# Malden MA 02148 INSURERA:Hartford Fire Insurance Company 19682 INSURED INSURER B:Safety Indemnity Insurance Company 33618 Magnifico Brothers Plumbing Heating INSURERC:Twin City Fire Insurance Company 29459 & Gas Fitting, LLC. INSURER 0: 31 Forest Street INSURER E: Middleton MA 01949 1 INSURER F: COVERAGES CERTIFICATE NUMBER:CL1631608744 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 IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE A DL U POLICY EFF POLICY EXP LTR POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 TO A CLAIMS-MADE [i]OCCUR OCCUR _bAMAGES( RENTED 300 000 PREMEa occurrence � $ 08SRAUQ5370 3/24/2016 3/24/2017 MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY F;,7 jE� F-1 LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT E, accident $ 1,000,000 B ANY AUTO BODILY INJURY(Per person) $ ALL OWNEDX SCHEDULED 5053635 3/24/2016 3/24/2017 BODILY INJURY(Per accident) $ AUTOS AUTOS PROPERTY DAMAGE X HIRED AUTOS X NON-OWNED $ AUTOS Per accident A X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 EXCESS LIAB CLAIMS-MADE 08SBAUQ5370 3/24/2016 3/24/3017 AGGREGATE $ 1,000,000 DED X RETENTION$ 10,000 $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVEE.L.EACH ACCIDENT $ 500,000 OFFICERIMEMBER EXCLUDED? N/A C (Mandatory in NH) OBWECRJ9050 3/24/2016 3/24/2017 E.L.DISEASE-EA EMPLOYEE $ 500,000 ff yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION berry@berrymechanical.com SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Berry Mechanical Services, Inc THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 3 Milton Way ACCORDANCE WITH THE POLICY PROVISIONS. Georgetown, MA 01833 AUTHORIZED REPRESENTATIVE I- Thomas Cares, Jr/EC ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 26(2014/01) The ACORD name and logo are registered marks of ACORD INS025 otrlenrn ,< COMMONWEALTH�0 p-- 3 . .A.... . .. �w ` Ze;"'AS CHUSETTS BOARD OF PLUMBERS AND GASFITTERS ISSUES THE FOLLOWING LICENSE REGISTERED AS A PLUMBING CORP ow t+ w MARK MAGNIFICO MAGNIFICO BROS PLB&HGT,GAS FITTI t 31 FORE-ST ST � y{ 3 MIDDLETONMA 01949-2015 .., � I - 3266 05/01/16 ,. - ir - —,�- 204565 COMMONWEALTH OF MASSACHU3 iiTS BOARD PLUMBERS AND GASFITTERS ISSUES THE FOLLOWING LICENSE LICENSED AS A MASTER PLUMBER - :¢ a MARK B MAGNIFICO t,+ W ; 31 FOREST STREET -"` \: W 'il DDLETON MA 01949-2075 13559 05/01/16 �.: CC! !�lIIONWEA��T" -•� * ; _ ,ASSA ~. ri, _ USE:TTS OAR B ' D OF PLUMBERS AND GASFITTERS ISSUES THE FOLLOWING LICENSE r .. LICENSED AS A JOURNEYMAN PLUMBER i t4ARK B MAGNIFICO Z .L 31 FOREST ST Z MIDD tE7'OM MA 01949-2015 • 002 0 - 5%01 16 yl f•. t • x a tt V. 3} 7/72016 Date: July 07, 2016 20210 This is an e-permit.To learn more,scan this barcode or visit northandoverma.viewpointcloud.com/#/records/20210 I TOWN OF NORTH ANDOVER lil '0 PERMIT FOR WIRING i D This certifies that Demetrios Dalianis has permission to perform Bella's Liberty Bell Restaurant wiring in the buildings of Harry kanelos at 1211 OSGOOD STREET , North Andover, Mass. Lic. No. 13648 1/1 I