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Building Permit #046-45 - 585 CHICKERING ROAD 7/15/2014
NORTH BUILDING PERMIT O`.1c gI ED ,6 91• �asy� .60 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit No#: CJ�/6 Date Received 7 r �gSSACHU`���5 Date Issued: 7 �5 ��� IMPORTANT: Applicant must complete all items on this page LOCATIOND GfJ I _Y\ J2--jtvV g JL711 14 A00Y2_ t`'1 ,� Print PROPERTY OWNER MIcO&L. ASI18A Print 100 Year Structure yes --MM) _. MAP PARCEL: ZONING DISTRICT: Historic District yes (C P Machine Shop Village yes dBD TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑ Two or more family 0 Industrial +Alteration No. of units: XCommercial �( V�tPrA ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: f9-,f Identification- Please Type or Print Clearly OWNER: Name: Phone: j, Address: Qf(0-1AX_ (rA-04I l4 0©0-ri. 1-1 Contractor Name: RIM 6 Rhone. Address: DI 6f n G14 ,_�DojJ� 12,0. MF 40JtJ Ma 01,6L(y Supervisor's Construction Licenser .--c Exp. Date: Z, Home Improvement License: 1 bCti t-b Exp. Date: a X 0,1,- ARCH ITECT/ENGI NEER 1,-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: $un, on1b FEE: $ -D Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to thegu ranty fund Signature of Agent/Owner Signature of'contractor Location No. Date r � . - TOWN OF NORTH ANDOVER • Certificate of Occupancy Building/Frame Permit Fee $ U Foundation Permit Fee $ Other Permit Fee $ TOTAL $ t Check# / `� j3 di g Inspector Plans Submitted Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL i [Well ublic Sewer Tanning/Massage/Body Art ❑ g Pools ❑ Swumnin ❑ Tobacco Sales ❑ Food Packaging/Sales [IPrivate(septic tank,etc. Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U i� FORM f I PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS I I CONSERVATION Reviewed on i Signature COMMENTS HEALTH Reviewed on Si natures- j COMMENTS L� C— 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 DPW Town Engineer: Signature: Located 384 Os FIRE DEPARTMENT - Temp Dumpster on site yes nO�good Street Located at 124 Main Street Fire Department signature/date COMMENTS 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 Call Email Date Time Contact Name Doc.Building Permit Revised 2014 Building Department artment The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses o Copy of Contract ❑ 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 ❑ Building Permit Application ❑ Certified Surveyed Plot Plan i ❑ Workers Comp Affidavit La Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products g All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building pp 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 stampthe decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doe:Building Permit Revised 2014 Maims North Andover Health Department Community Development Division July 14,2014 Shadi's Inc. Attn: Michel Asmar 38 Copley Drive Methuen,MA 01844 Re:Bathroom remodel Shadi's Restaurant, 585 Chickering Road,North Andover,MA 01845 Dear Mr.Asmar, The Health Department received your application to remodel the bathrooms at Shadi's I Restaurant dated July 14,2014.This plan has been approved with one clarification. The coving E in the bathrooms is to be a"curved base"coving.It cannot be a 90 degree angled coving,as curve allows for proper cleaning along the edges. With this approval,I am able to sign the building permit. Please let us know when the construction is finished,so that we may conduct a sanitary code inspection. At that time you should have mounted soap dispensers and paper towels or dryers installed.The"Employee must wash hands before returning to work"signs must be hung up as well. If you have any questions regarding this approval,please contact the Health Office. Sincerely, Susan Saw�ce ,REHS Cc:NA Buildin ept. 1600 Osgood Street,!North Andover,Massachusetts 01845 Phone 978.688.9540 Fox 978.688.8476 Web www.lownofnorthandover.com I Page Enter construction cost for fee cal - North Andover Fee Calculation j Construction Cost $ 403000.00 m $ - $ 480.00 Plumbing Fee $ 60.00 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 60.00 Total fees collected $ 700.00 585 Chickering Road - Shadi's 046-15 on 7/15/2014 Remodel Bathrooms NORT#1 Town of E ndover O - to No. "t _ z �h ver, Mass, y CONIC Hl MACK y1. �qS R-ArED V BOARD OF HEALTH Food/Kitchen PEIRMIT T LD Septic System THIS CERTIFIES THAT ' ��F� "✓ r/' BUILDING INSPECTOR has permission to erect .......................... buildings on,.�7��.J�..C.r. l...G. �.�:!�`:! . . ,,.,..,... .,,,., Foundation Rough to be occupied as ...........A1,1.. ..o.Y. -.�•x 7 .'!�.......19.��..r.... ...�..`....� ........... Chimney provided that the person accepting this permit shall in every respect conform to the terms o he 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 Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTIO STARTS Rough G .. Service ...........� ..... ........... .....'............................ BUILDING INSPECTOR Final 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. • S�TT�BD j�' . North Andover Health Department (ommunity Development Division July 14, 2014 Shadi's Inc. Attn: Michel Asmar 38 Copley Drive Methuen, MA 01844 Re: Bathroom remodel Shadi's Restaurant, 585 Chickering Road North Andover MA 01845 Dear Mr. Asmar, The Health Department received your application to remodel the bathrooms at Shadi's Restaurant dated July 14, 2014. This plan has been approved with one clarification. The coving in the bathrooms is to be a"curved base"coving. It cannot be a 90 degree angled coving, as curve allows for proper cleaning along the edges. With this approval, I am able to sign my building permit. Please let us know when the construction is finished, so that we may conduct a sanitary code inspection. At that time you should have mounted soap dispensers and paper towels or dryers installed. The"Employee must wash hands before returning to work" signs must be hung up as well. If you have any questions regarding this approval,please contact the Health Office. Sincere,, - 'Sus Sawyer, HS/RS Cc: NA Building Dept. 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 918.688.9540 Fax 978.688.8476 Web www.townofnorthandover.com 1 Page f � I UMassachusetts -Department of Public Safety Board of Building Regulations and Standards Construction SuperA isor License: CS-098632 IBRAHIM E GEH� 81 BIRCHWOOD ROAD_ - -METHUEN MA 01844, J,,G.,, � `• 'I tot Expiration Commissioner 01/01/2016 ��\ r�fr' lCcr�u�iieitruefr�l�r�"C�if�r�l�cc�c<:ie/f' _ Office of Consumer 1 f fairs&Business Regulation OME IMPROVEMENT CONTRACTOR egistration: 160016 Expiration-1----6/17/2016. Type: Individual IBRAHIM GEHA IBRAHIM GEHA 81 BIRCHWOOD RD.L METHUEN,MA 01844 Undersecretary LEW CORPORATION 1090 i3ristol,Rd,Mountainside. NJ 07092 Phone.:-(908)6548066Fax:(908).654-8669 t�rrtificate of Attendance-,and Suc3essful Completion ' Rehbvator Initial-English n •'Per 40 CFR Pat 745225 IBRAHIM GEHA 81 BIRCHWOOD RD.. -METHUeN,MA 01844 Identification Number:R--l-18342-10-02765 Goorse Date-0412,3/10 - -txatn Intion Dale 040-640 Cv;flrator Date.041260, 05110!10 f.•' : : +�, -: - �'1 fail C �.1:':�l •7.". (J " - +r % a Unrestricted-Buildings of any use group.which contain less than 35,000 cubic feet(991m)of enclosed space. Failure to possess a current edition of the Massachusetts State-Building.Code is cause for revocation of this license. for,DPS Licensing information visit: www:Mass.Gov/DPS License or registration valid for individuI use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 10 Park Plaza-Suite 5170 Boston,MA 02116 i Not v lid without signature 71 x VDAC ace group WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY TYPE AR INFORMATION PAGE WC 00 00 01 ( A) POLICY NUMBER: (GSG2UB-4532P02-9-14) RENEWAL OF (GSG2UB-4532P02-9-13) INSURER: ACE AMERICAN INSURANCE COMPANY 1. NCCI CO CODE: 121 G5 I INSURED: PRODUCER: I G CONSTRUCTION LLC THE HOWE INS AGENCY 81 BIRCHWOOD RD 4 PUNCHARD AVENUE METHUEN MA 01844 ANDOVER MA 01810 Insured is A LIMITED LIABILITY COMPANY Other work places and identification numbers are shown in the schedule(s) attached. 2. The policy period is from 04-23-14 to 04-23-15 12:01 A.M. at the insured's mailing address. 3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers Compensation Law of the state(s) listed here: MA B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed in item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident: $ 100000 Each Accident Bodily Injury by Disease: $ 500000 Policy Limit Bodily Injury by Disease: $ 100000 Each Employee C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here: N COVERAGE REPLACED BY ENDORSEMENT WC 20 03 OGA f— a N D. This policy includes these endorsements and schedules: v o SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All required information Is subject to verification and change by audit to be made ANNUALLY. DATE OF ISSUE: 04-29-14 SC ST ASSIGN: MA OFFICE: ORLANDO DA ACE 24M PRODUCER: THE HOWE INS AGENCY 28XDK 007866 z. IN Policy Number:MPB2684H SrREEr AMERICA GROUP BUSINESSOWNERS COMMON DECLARATIONS MAIN STREET AMERICA ASSURANCE COMPANY 4601 TOUCHTON ROAD EAST,SUITE 3400,JACKSONVILLE,FL 32245-6000 I Item 1. Named Insured and Mailing Address Agent Name and Address I G CONSTRUCTION LLC THE HOWE INSURANCE AGENCY INC 81 BIRCHWOOD RD METHUEN MA 01844-4541 4 PUNCHARD AVENUE ANDOVER, MA 01810 I Agent Phone No. (978) 475-0400 Agent No. 200201 Item 2. Policy Period From: 05-30-2014 To: 05-30-2015 at 12:01 A.M., Standard Time at your mailing address shown above. Item 3. Form of Business: LIMITED LIABILITY COMPANY Item 4. In return for the payment of the premium, and subject to all the terms of this policy, we agree with you to provide the insurance as stated in this policy. This policy consists of the following coverage parts for which a premium is indicated. Where no premium is shown, there is no coverage. This premium may be subject to adjustment. COVERAGE PREMIUM Section I —Property $ 147 . 00 Section I I —Liability $ 1, 820 . 00 Inland Marine $ 175 . 00 Total Policy Premium: $ 2, 142 . 00 For Coverages subject to premium audit: Annual Audit Applies Item 5. Form(s) and Endorsement(s) made a part of this policy at time of issue: See Schedule of Forms and Endorsements V Countersigned: Date: By: Authorized Representative THIS BUSINESSOWNERS COMMON DECLARATIONS AND SUPPLEMENTAL DECLARATION(S), TOGETHER WITH SECTION III —COMMON POLICY CONDITIONS, COVERAGE PARTS, COVERAGE FORMS AND ENDORSEMENTS, IF ANY, COMPLETE THE ABOVE NUMBERED POLICY. BPM D 1 1207 INSURED COPY GCONSTRUCTION LLC Ibrahim Geha, General Contractor Commercial - Residential 81 Birchwood Road,Methuen MA 01844 Ph: 978.423.8397 Fax: 978.725.8591 Proposal Submitted to: HIC# 160016 CS#98632 Name: Shadi's restaurant/Michel Asmar Phone: 978-683-9559 Date: 07/11/2014 Job Location: 585 Chickering Rd.North Andover MA 01845 We propose to furnish all materials and permits and perform all labor necessary to complete the following: Restroom remodeling Demo Remove all interior wall covering, ceiling tiles and grids remove all existing plumbing Demo all existing electrical - Cut concrete floor for underground plumbing, when plumbing roughing is done close floor trenches with 6" concrete -Walls and covering Frame all walls per print with 3 1/2" 20 gage steel studs 1/2" moister resistant gypsum drywall over new studs and when needed,tape, sand,prime one coat and paint 2 coats Install bathroom walls per print with 20 gage metal studs Install 1/2" moister resistant blue drywall Install 4'the on walls grout and seal Tile Floors with porcelain tile, grout and seal Prime on coat and paint two coats above - Ceiling covering Install new grid system and 24"x24"Armstrong tile -All electrical to conform with state and local code -All plumbing to conform with state and local code -All tiles and accessories, restrooms fixtures, partition, lighting fixtures are to be provided and paid _ for by owner -Owner is responsible for fire sprinkler replacement heads and fire alarm Clean up and dispose of all debris in compliance with local and state laws No outside work is included in this contract I I Total= $40,000.00 I, Any alterations or deviation from the above specifications involving extra cost of material or labor will be executed upon written order for same, and will become an extra charge over the sum mentioned in this contract. All agreements must be made in writing. All of the work is to be completed in a substantial and work manlike manner for the sum of Forty thousand Dollars($ 40,000.00). Payment to be made as follows: � x.700 d $"�H;fi;ffDO upfront , �$ ;A89 90 I pt 0 0 t7 $ ;9980 after final inspection U t©,0vd`--- Authorized Signature Ibrahim Geha ACCEPTANCE You are hereby authorized to furnish all materials and labor required to complete the work mentioned in the above proposal for which Shadi's restaurant/Michel Asmar agree to pay the amount mentioned in said proposal and according to the terms thereof. --�' 7/,,/; y Signature Date w 1. H ' , i 4:� i 111 { 1 f 4 i � l -;-9 L ----0 ZZ-- , t 9 i l 00 pol t ss a C rlf . 1 . x 1 `... •9E { z 4 ii J f f ti Ill i 1 _ n F - 1 1 1 -E I I ff r7 �I I f1 � f ff 1 fI � r7 r7 ff If I f f jVU 7T MXSLi "S 1 4:i _R3 r7 sip 1; �.�Via:' 'll ' ivkt tl�v •4C? �7191vo`J 0fif11WE —'�9 t�tt��t�►5 i�'?ia 9=3� �'�,i 1'`!t7 qtr�.�1 'Z"��J'�Z' -_! c ' 2 - 3 I �I L C I Cl ID Jc ID -7-------------- -e --/------------- WOMEN MEN 0 " Jol II II - � -------------------------------------------- II LODDT Y ----------- - ELEV ;.M :y„v NORTH �L�o 3? �. ; o a cocac"twicM �A°RA Ok? 9SSAC HUS�� TOWN OF NORTH ANDOVER Sign Permit Date: January 11, 2010 Permit Number: S25-2010 THIS CERTIFIES THAT EDAR CREST—MARY CLAIRE_KENNEDY Has permission to erect a REPLACEMENT ROOF SIGN On 585 CHICKERING ROAD provided that the person accepting j this Permit shall in every respect conform to 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 Internally Illuminated Signs are Prohibited ,p Receipt# �' Amount Paid Inspector of Buildings SIGN PERMIT APPLICATION 1600 Osgood_Street Building 20, Suite 2-36 TOWN OF NORTH ANDOVER Site Owner uz, C((m K e, , Applicant_&Y, C'Gu l- lees,p t/ Tel(�-7?) Site Address S'g S' Size of Proposed Si gj i5 ,k ' 7 May Parcel Illumination: (Not illuminated b) Internally illuminated How attached: a) Against the wall c) Externally illuminated b) Roof ✓ c) Ground Materials: d) Other Proposed Colors: Background 13 Q__'� Lettering /S Costof Sign Border Note: No permanent/temporary sign shall be erected, or enlarged until an Required Attachments: application on the appropriate form furnished by the Sign Office has been Photographs of building filed with the Sign Officer containing such information including Material sample photographs,plans and scale drawings, as he may require, and a permit Color sample for such erection, alteration, or enlargement has been issued by him. Site or Plot Plan (Required for all free-standing signs) Such permit shall be issued only of the Sign Officer determines that the Drawings of proposed sign sign complies or will comply with all applicable provisions of the By- Other, specify Sa -► _c est Law. Will sign overhang any public road or walkway Yes O No (v� If Yes, Name of Agency who will provide liability insurance: AN INCOMPLETE APPLICATION WILL NOT BE ACCEPTED DATE FILED: 1.0 Receipt # Check# Revised 10.31.2006 Form Sign Permit Application SIGNATURE OF APPLICANT Date........................1.................... RT TOWN TOWN OF NORTH ANDOVER 0 9 PERMIT FOR WIRING 88�►cmug� nn This certifies that .... ....�S,0 2,j. §k G ........................................................................................ has permission to perform .......��i . ............................................................................ wiring in the building of............. v. a.� .t...`?.......................................... .. .. ..: at ...................... ........................!.c~�...•Q '2t �� ,North Andover,Mass. .......................................... Fee...q.'a........Lic.No.1-...z ............................................................................... ELECTRICAL INSPECTOR Check# `' ' 7 1 Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. • Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] leaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT W INK OR TYPE ALL INFORMATION) Date: 3 - 6 — Z d! 3 City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersigned_gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) Owner or Tenant Mie-[-J2( A SM A4Z S1Jt4,b Telephone No. Owner's Address �(_ Q ea ttt ( D1 J4 N,1+14y-ed M 0,. Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box) C Purpose of Building Utility Authorization No. Existing Service?Oy Amps a d /AYO Volts Overhead[9-'Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters " Number of Feeders and Ampacity i Location and Nature of Proposed Electrical Work: le LJ J R 44-d), Completion of the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ce% Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- ❑ o.o mergency Lighting rnd. rnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones No.of Switches No.of Gas Burners No.of Detection and Initiatin Devices No.o g Tons g No.of Ranges No.of Air Cond. Total Nf Alerting Devices Heat Pum Number Tons KW No.of Self-Contained No.of Waste Disposers P ...... .. ....................._............................_... Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KWLocal❑ Municipal ElOther Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or E uivalent " OTHER: ed / Attach additional detail if desired,or as required by the Inspector of YYYres. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: S—b-2 J t-3 Inspections to be requested in accordance with NEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE [BOND ❑ OTHER ❑ (Specify:) X certify, cinder tlZe ams andpenalties o perjury,flta t e information on this applicatio is true and complete. FIRM NAME: . -f 1D-?J21- - S LIC.NO.:d;t CJ V 61L$ Licensee: n�rclL�.� S�•�yl it (-�) Signature LIC.NO.: W) (If applicable,enter "exe pt"in the license number line.) / Bus.Tel.No.• '27-�" 51.)l Address: , Q � l kry /I�9cfoo&JJ GeN't ./7 ►r etl4Alt.Tel.No.:�7�'3��'-�4(,/y *Per M.G.L c. 147,s. 75 61 security work requires Department of Public Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent. Owner/Agent PERMIT FEE.$>kq— Signature Telephone No. 1 ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the provisions of M.G.L.c. 143,§3L,the l� permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166,§32,an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L.c.143,§3L. Permits shall.be limited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ' ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012. ❑ Rule 8—Permit/Date Closed: ***Note:Reapply for new permit ❑ ❑Permit Extension Act—Permit/Date Closed: Trench Inspection Pass 0 Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: I Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: " Pass F?1 Failed Re-Inspection Required($.)❑ 1 Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass 0 Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSPECTION: Pass M Failed Re-Inspection Required($.) ❑ Inspectors Comments: l3 2 —S— V—Z/— cac Inspectors Signature: Date: DEB WEINHOLD ...TOWN OF MERRIMAC,MA. .......dweinhold@townofinerrimac.com ' 1 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 s� www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organizati6n/Individual): S k—ya-f f 6�-9 f t S-e 12 c44 ccl v Se oe vt .,�n4 Address: 31 City/State/Zip: 7N (1'e'-1 Phone It: t Q- (° O"3 Are you an employer?Check the appropriate box: Type of project(required): 1. Are am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.El am a sole proprietor or partner- listed on the attached sheet. ? E]Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition workingfor me in an capacity. workers'comp.insurance. Y p n'• 9. ❑Building addition [No workers' comp.insurance 5. El We are a corporation and its required.] officers have exercised their 10. Iectrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers'comp. c. 152, §1(4),and we have no 12.❑Roof repairs insurance required.]t employees. [No workers' comp.insurance required.] 13.❑ Other Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. Dontractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site zformation. isurance Company Name: olicy#or Self-ins.Lic.#: Expiration Date: 3b Site Address: City/State/Zip: Atach 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 ne 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 f up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of ivestigations of the DIA for insurance coverage verification. do hereby certigpifnder the painsd ,pn!pmal s of perjury that the information provided above is trite and correct i nature: Date: 3 2!J13 hone#: I -2 Official ttse 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#: 1 V � 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 of 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 1877-MASSAFE Fax#617-727-7749 .evised 5-26-05 www,mass.gov/dia r. r COMMONWEALTH OF MASSACHUSETTS r F OF ELECTRICIANS AS A REG JOURNEYMAN ELECTRt ISSUES THE ABOVE LICENSE TO: FREDERICK R SKAFF '-III m 29 ROLLING MEADOWS '*LN + ` HAVERHILLI, SMA. 01832-88 2440E E 07/31/13 814883 GENERATOR APPLICATION DATE: 0/6//.3 LOCATION: ' Czi �v- OWNERS NAME: GENERATOR kw NO INSTALLATION OR GROUND DISTURBANCE BEFORE APPROVALS* CONTRACTOR: PHONE NUMBER: ELECTRICAL ELECTRICAL. :) RESIDENTIAL :COMERCI TEMPORARY LOCATION OF GENERATOR: *ZONING DISTRICT: *CONSERVATION APPROVAL Date �0./z 3�! byl'Ii IU),�G TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION This certifies that .'. >> `�`.�/"�. . . Y\.4.�►� !1 has permission for gas installation . . . Ge,\,cc-o—r . . . . . . . . . . . . . . . . in the buildings of. . 1"'0 �� e . . . .� X'"��. . . . . . . . . . . . . . . . . . . . at . . . �. '�. . .C.�'" .Yc ,North Andover, Mass. Fee Lic. No. �.�?:�.6. . . . . . GASINSPECTOR Check# kq-7 �( 3 83 ,0 MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY lt(b G Y MA DATED- PERMIT# JOBSITE ADDRESS l OWNER'S NAME OWNER ADDRESS TE ---VAXtP TYPE OR OCCUPANCY TYPE COMMERCIAL( EDUCATIONAL ® RESIDENTIAL El PRINT CLEARLY NEW:RENOVATION:[j REPLACEMENT: ! PLANS SUBMITTED: YES[]_{ NO I APPLIANCES 7 FLOORS— BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE FRYOLATOR — _ FURNACE GENERATOR _ _� _... I �.J L>�--� =I ..�_J .----. _. �_ _- [�-I_ I _ I -� _.1 GRILLE INFRARED HEATER LABORATORY COCKS ( I l r-- ._ J I -�- I {_. _J I i MAKEUP AIR UNIT OVEN POOL HEATER T { T ROOM/SPACE HEATER ROOF TOP UNIT _— TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATERi- OTHER F --J _-_ INSURANCE COVERAGE 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES 10 NO Q IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAG CHECKING THE APPROPRIATE BOX BELOW , LIABILITY INSURANCE POLICY OTHER TYPE INDEMNITY BOND --I 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 r-711 AGENT _C]__f SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true a cur to to a best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will b I' a wi I rtinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the Ge ral Laws. PLUMBER-GASFITTER NAME� - ( ! LICEN�SE# C SIGNATURE MP�1 MGF[]I JP ® JGFE] LPG] CORPORATION ARTNERSHIP©# LLC J#= COMPANY NAME: _ ADDRESS 0C A-02 CITY —jj STATE ZIP TEL - -FAX CELL EMAIL GO ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES 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 Legib Name(Business/Organization/Individual): iA- N t'CG Address: 3 lige llve)t J7L ' City/State/Zip; 7`,4^ Phone#: �!19�J ?Ya--,z- Are Y0 " Ayo n employer?Check the appropriate box: Type of project(required): 1.re I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have}tired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. �• ❑Remodeling ship and'have no employees These sub-contractors have _ 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its 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 repairs or additions myself. o workers' comp. c. 152, 1(4),and we have no Y [N P § 12.0 R epairs insurance required.]i- employees.[No workers' 13. Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they aie 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 is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. /v/ Nf Policy#or Self-ins.Lie.#: 1 'I p R q 3 7 Expiration Date: Job Site Address: ��S 116 City/S to/Zip: /V 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 dohereby azndpealoes ofperjury that the information provided above is true and correct. Signafore: r/ / (, Date: Phone#: 6 4 S � 17j� 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 - - a Contact Person: Phone#: y 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-contractors)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 Depirtment has provide: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:Ysed as a reference number. In addition,an applicant that must submit'muitiple 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 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 Revised 5-26-05 Fax#617-727-7749 www.mass.govldia 76J4 Date.. /'? .......... NOR7ly pf ,.ao °,ti0 or '' °� TOWN OF NORTH ANDOVER ' PERMIT FOR GAS INSTALLATION SA US This certifies that . . . .4!�r f. �J.��' . . . . . . . has permission for gas installation z . . !.14 . . . in the buildings of . . . . f�! ./`. . . . . . . . . . . . . . . . . . . . . . at �. .�. . . . . .��+.�. �. . . , North Andover, Mass. F e (, .�.&. Lic. No./.Q�d .. .. . . . ..1. GAS INSPECTOR Check# / �(, MASSACHUSETTS UNIFORM APPUCATON FOR PERNHr TO DO GAS FPI'HNG (Type or print) Date NORTH ANDOVER,MASSACHUSETTS Building Locations permit# �n 'lftS M A� mount$ � Owner's Name New❑ Renovation ❑ Replacement Plans Submitted F1 x x O ' H x t W pq W v 04 cn F WC W O •7 O z F W W m Z G. Q W ? coq Cr W H (Fj a v� A .Tr O �+ f=. A Ch UO a° � A w F O SUB -BASEM ENT BASEM ENT 1ST. FLOOR 2ND . FLOOR 3RD . F L O O R 4TH . FLOOR 5 T H . FL 00 R 6TH . FLOOR 7TH . FLOOR STH . FLOOR I 17T (Print or type) // ,I 1 Check one: Certificate Installing Company Name �c i4A'JX/� rQ140 YI.P orP• —' e� Address ku ❑ Partner. Business Telephone ❑ Firm/Co. Name of Licensed Plumber or Gas Fitter INSURANCE COVERAGE Check one: . I have a current liability Insurance policy it's substantial equivalent. Yes ❑ No❑ If you have checked Yes,please ind' e 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 p 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 installations performed under 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. Signature of Licensed Plumber Or Gas Fitter Title ® Plumber as Tit City/Town ❑ Ga er Licthse Number aster APPROVED(OFFICE USE ONLY) ❑ Journeyman Date. . . . . . . . . . . . . TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING SSACow 1 This certifies that . . . . . . . . . . . . . . . . . . . has permission to perform . . . . �ff ��G: . . . . . . . . . . . . . . . plumbing in the buildings of . . ..�11ti ! S. . . . . . . . . . . . . . . . . . . . at� . . . S. . . . . . !1 �(�L.'. . . ? , Norah Andover, Mass. Fee/10. .i d .Lic. No.. Check x / C� S PLUMBING INSPECTOR MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBIN (Type or print) NORTH ANDOVER,MASSACHUSE S �� 'e Date T �� Building Location Owners Name /'� �Y Permit# Amount ~ 1 .w Type of Occu anc /{"& - ---� New ri Renovation Replacement Plans Submitted Yes E No ❑ FIXTURES ,--� H J w v� SLRFSVE M RA%MENr lS�FIOQR i I za HIDOR 3M FIAQR FIOM SM HOM 6M FLOOR 7M FLDOR gm FLOCl<2 (Print or type) /�„�/ CO^ Check one- %1114,4 Certificate Installing Company Name Kfj/ AddressAV partner. Business Telephone Finr/CO. Name of Licensed Plumber: Insurance Coverage: Indicate the ty insurance coverage by checking the appropriate box: Liability insurance policy Other type of indemnity Bond ❑ Insurance Waiver: I,the undersigned,have been made aware that the licensee of this application does not have any one of the above three insurance Signature Owner ❑ 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 installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the assachusett State P1 ng Code and Chapter 142 of the General Laws. amm By SignaWte ui Lic,ensea rmmoer Title Type of Plumbing License City/Town icense INUMDET Master Journeyman ❑ APPROVED(OFFICE USE ONLY any 7 ��CxuN CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Permit Number 764-2011 Date: July 712011 THIS CERTIFIES THAT THE BUILDIlIIG LOCATED ON 585 Qhick&ing Road, N6rth Andover MA 01845 Shadi's Restaurant and Lounge MAY DE OCCUPIED AS restaurant IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: ShadiN Ibc. 585 Chickering Roar! North Andover,MA 01845 4— Building Inspector Fee: 100.00 Receipt: ��� '7 1 ORTH Town of � _ O Andover . dover, Mass.,LAKE • COCHICHEWICK �• 7�A0RATED `sS BOARD OF HEALTH Food/KitchenPERMIT T D t Septic System BUILDING NSPECTOR THIS CERTIFIES THATS. ..... .... A... ...... 10111AERV........................................................................................ Foundation has permission to erect........................................ buildings on ...... ���..... .1r�..�.�r .. .1� ....IZ4• Rough to be occupied as.....TS-o-Ad....oc....... ..... ..... ......................................................... Chimney provided that the person accepting this permit shall in every respectr6iorm to the terms of the application on file in F 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 INSPE TO VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Fin ���0� /164/4PERMIT EXPIRES IN 6 MONTHS 100 UNLESS CONSTRUC O t�RT' ELECTRICAL INSPECTOR Rough ........... ........ ......................................................................................... Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Fina No Lathing or Dry Wall To Be Done 71-AE DEPARTMENT- Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. SEE REVERSE SIDE ,i -. • Location -' No. L� J/ Date r MpRTry TOWN OF NORTH ANDOVER ; 41 - • , Certificate of Occupancy $ �----- r Building/Frame Permit Fee $ ------ �i Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 4�J/ �j s G " fguilding Inspector EXPLANATION AMOUNT 2084 �r� SHADI'S INC. DBA SHADI'S RESTAURANT MY Pim eNon a�Bu ess 585 CHICKERING RD. 54-7297-2114 NORTH ANDOVER,MA 01845 IUNT U� DOLLARS CHECK i ) CHECK AMOUNT IATE TO THE ORDER OF DESCRIPTION NUMBER $ `1 SALEM 1.0� CO-OPERATIVE BANK - PSALEM.NEW HAMPSHIIIE II�00 20184111' 1: 2 111, 7 297710 53 L4669lie NUMBER COMMONWEALTH OF MASSACHUSETTS BHP-2004-0276 North Andover FEE Board Of Health $50.00 DATE ISSUED Mango Grille and Limbo Bar January 01,2004 ------------------------------- ---------------------------------------------------------------------- NAME --------------------------------------585 Chickering Road NORTH ANDOVER, MA 01845 - - - ----------------------------------------------------- ------------------------------------------------------- ADDRESS IS HEREBY GRANTED A Dumpster LICENSE Duster This permit is granted in conformity with the Statutes and ordinances relating thereto,and expires December 31,2004 unless sooner suspended or revoked. RESTRICTIONS: Atlantic North; 800.445.1318; Weekly Pick-Ups Board Of ----------------- ----------------------- Health ----------------- ----- - NOTES: Contact: Thelma C.Phelan; 978.688.4746 ------------------------- ------------------------------------------------------------ Location W iw No. `-� Date 1 tORTN TOWN OF NORTH ANDOVER � Oft� o �,ti0 p Certificate of Occupancy $ Building/Frame Permit Fee $ CHU E Foundation Permit Fee $ � s�cNus t ,- Other Permit Fee $ �Q Sewer Connection Fee $ Water Connection Fee $ TOTAL $ �� Building Inspector 7M Div. Public Works r;tt.%f[T NO. APPLICATION FOR PERMIT TO BUILD — NORTH ANDOVER, MASS. PAGE 1 MAP 4-40. LOT NO. 2 RECORD OF OWNERSHIP IDATE BOOK ;PAGE ZONE SUB DIV. LOT NO. I LOCATION One T �� PURPOSE OF BUILDING LX,&READy!5-E- OWNER'S NAMENO. OF STORIES SIZE OWNER'S ADDRESS`.j p�0-141 agp Q.,N& ^M. BASEMENT OR SLAB �G n ARCHITECT'S NAME II ` 1 ,p Kof SIZE OF FLOOR TIMBERS IST �7 2ND 3RD BUILDER'S NAME C U ej<y (tet;f'El ZC &tDAe, 7"12.lJC iOD�! SPAN DISTANCE TO NEAREST BUILDING DIMENSIONS OF SILLS f DISTANCE FROM STREET POSTS DISTANCE FROM LOT LINES-SIDES REAR GIRDERS AREA OF LOT FRONTAGE HEIGHT OF FOUNDATION THICKNESS IS BUILDING NEW SIZE OF FOOTING % IS BUILDING ADDITION /CO�ry MATERIAL OF CHIMNEY IS BUILDING ALTERATION ye$ 4 P/i p,�,C�`� IS BUILDING ON SOLID OR FILLED LAND S�CrA WILL BUILDING CONFORM TO REQUIREMENTS OF CODE ,/`7L`� IS BUILDING CONNECTED TO TOWN WATER BOARD OF APPEALS ACTION, IF ANY X IS BUILDING CONNECTED TO TOWN SEWER IS BUILDING CONNECTED TO NATURAL GAS LINE y`✓�,r- INSTRUCTIONS 3 PROPERTY INFORMATION LAND COST SEE BOTH SIDES EST. BLDG. COST `, Be PAGE 1 FILL OUT SECTIONS 1 - 3 EST. BLDG. COST PER SQ. FT. EST. BLDG. COST PER ROOM PAGE 2 FILL OUT SECTIONS 1 - 12 SEPTIC PERMIT NO. ELECTRIC METEPS MUST BE ON OUTSIDE OF BUILDING 4 APPROVED BY ATTACHED GARAGES MUST CONFORM TO STATE FIRE REGULATIONS PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR DATE FILED / BUILDING INSPECTOR SIGNATURE OF OWNER OR AUTHO D K4 NT IF E E OWNER TEL.1/ �R-bGti�lf PERMIT GRANTED CONTR.TEL.N 19 CA ®oQ 75(0 CONTR.LIC.# H.I.C.# nm e -s. .•t_ BUILDING RECORD 1 OCCUPANCY 12 SINGLE FAMILY STORIES THIS SECTION MUST SHOW EXACT DIMENSIONS OF LOT AND DISTANCE FROM MULTI. FAMILY OFFICES LOT LINES AND EXACT DIMENSIONS OF BUILDINGS. WITH PORCHES. GA- APARTMENTS RAGES, ETC. SUPERIMPOSED. THIS REPLACES PLOT PLAN. CONSTRUCTION 2 FOUNDATION 8 INTERIOR FINISH CONCRETE - 3 1 2 13 CONCRETE BL K. PINE _ BRICK OR STONE HARD-DAS —_ _ PIERS PITER _ DRY WALL _ UNFIN. 3 BASEMENT AREA FULL FIN. B M'TAREA _ y, 1/2 1/ FIN. ATTIC AREA _ NO B M T FIRE PLACES _ HEAD ROOM MODERN KITCHEN 4 WALLS I 9 FLOORS CLAPBOARDS B 1 2 3 DROP SIDING CONCRETE WOOD SHINGLES EARTH _ ASPHALT SIDING HARD'✓'D _ ASBESTOS SIDING COMMC:N VERT. SIDING ASPH.TILE _ STUCCO ON MASONRY STUCCO ON FRAME BRICK ON MASONRY ATTIC STRS. & FLOOR _ BRICK ON FRAME CONC. OR CINDER BLK. STONE ON MASONRY WIRING STONE ON FRAME _ SUPERIOR I� POOR ADEQUATE NONE 5 ROOF 10 PLUMBING GABLE HIP BATH 13 FIX.) _ GAMBRELMANSARD TOILET RM. 12 FIX.) FLAT I I SHED WATER CLOSET _ ASPHALT SHINGLES LAVATORY WOOD SHINGES KITCHEN SINK _ SLATE NO PLUMBING _ TAR & GRAVEL STALL SHOWER _ ROLL ROOFING MODERN FIXTURES _ TILE FLOOR TILE DADO i 6 FRAMING II 11 HEATING WOOD JOIST PIPELESS FURNACE FORCED HOT AIR FURN. i TIMBER BMS. &COLS. STEAM STEEL BMS. & COLS. HOT W'T'R OR VAPOR WOOD RAFTERS AIR CONDITIONING RADIANT H'T'G UNIT HEATERS 7 NO. OF ROOMS GAS OIL B'M'T 2nd _ ELECTRIC lar 13rd 11 NO HEATING ORT O VM of over y 4' i �- I y `art y dover, Mass., kEcemaEg_ l cQ 191 LAKE T A- COCHICHE WICK '7 PP P ' �CDn`ATED C� BOARD OF HEALTH s Food/Kitchen Septic System PERMIT T i BUILDING INSPECTOR THIS CERTIFIES THAT..R.Pt444...�M�1 ....5 4 P..Lt ...�..+�4.C..................................................................... Foundation has permission to-a"..0^r,........................ buildings on ...�,a..1.S�...CAfC.KRR-W.�.....�.�.�.�.��............................. Rough im to be occupied aPx s4m&.••:f41�.�F�d1G1a...ApAcm....-s ....�r?!14r. (,..1.4, .. (w.N►.............. ..... 5....... Chimney 2 sr8 s� h� " provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final j 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 EXPW 6 MONTHS ELECTRICAL INSPECTOR UNLESS CON TR rI Rough ... .......... ........ ................................ ...... .... .. . ....................... Service BUILDING INPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough ,. Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done Until Inspected and Approved by the Building Inspector. FIRE DEPARTMENT Burner PLANNING FINAL CONSERVATION FINAL Street No. Smoke Det. SEWER/WATER FINAL DRIVEWAY ENTRY PERMIT COMMONWEALTH bEPARTMENT OF PL&iLiC SAFETY OF ONE ASHBORTON PLACE top00000iaowrem MASSACHUSETTS' BOSTON,MA 02108 . N ooafhStataerlldl" oe%rrwooat/on EXPIRATION DATE O � C O N S T R LICENSE EVISOR a+8/M41110tlTION 09/14/1995 EFFECTIVE DATE LIC-N0. FOR PROTECTION AGAINST RESTRICTIONS THEFT, PUT RIGHT THUMB NONE 00613011993 0OC756 „ PRINT IN APPROPRIATE 6B�UC E E WHITE g BOX ON LICENSE. SS 024-46-7326 HA4PSTEADUNH 03841 , MUSt1I RAU PHOTO(BLASTING OPR ONLY) I 00 NOT VALID UNTIL SIGNED BY LICENSEE AND OFFICIALLY t JUL 12 19"25 HEIGHT: STAMPED-OR-SIGNATURE OF THE COMMISSIONER DOB: ' 0� Uno 9/14/1955 a a Q THIS DOCUMENT MUST BE :�L4 ` SIGN NAME IN FULL ABOVE SIGNATURE LINE CARRIED ON THE PERSON OF I N TURE OF LICENSEE THE HOLDER WHEN EN. Al%?fla OTHERS AL THUMB PRINT GAGED THISOCCUPATION. ER FWW'PN 1 I \ ,r FI U I71 t L D.1.N -- _C R i C_KL.FJI NC_-.C4 N ��M t N.k v_n'?. Fl XS:T_l1�lG- �,1L,21 Z_13ER-v�.. b —. —L—LI �i �IS'TING 5x�_t13cRw� r t I -- IST1 6- bY, T- I3EAm -- - f IV U 3i' 8 vnVT '� I A Ll ,x10 1 I '� Imo ieso _i�5e a I THE COMMONWEALTH OF MASSACHUSETTS t - �'S �,Sr `4 TOWN OF NORTH ANDOVER In accordance with the Massachusetts State Building Code, Section 106.5 this CERTIFICATE F 3 O INSPECTION IS ISSUED TO... MANGO GRILLE AND LIMBO BAR I CERTIFY THAT I have inspected the premise known as MANGO GRILLE AND LIMBO BAR Located at 585 CHICKERING ROAD in the TOWN of NORTH ANDOVER, COUNTY OF ESSEX Commonwealth of Massachusetts. The means of egress are sufficient for the following number of persons: BY STORY Story Capacity Story Capacity i sT 126 Place of assembly Capacity Location Place of assembly Capacity Location or structure or structure Place of assembly Capacity Location Place of assembly Capacity Location i or structure t. or structure : t. 16177-2003 March 7, 2003 March 7, 2004 Certificate Number Date Certificate Issued Date Certificate Expires Building Official COMMONWEALTH OFMASSACHUSETTS TOWN OF NORTHANDOVER 27 CHARLES ST ` APPLICA TION FOR-CERTIFICATE OF INSPECTION 1V V� Date Fee Required(Amount) Z/11)/- No 7 11)/ �— O No Fee Required Accordance with the provisions of the Massachusetts State Building code, Section 108,15, I hereby apply foi Certificate of Inspection for the belo�a'-named premises toca#ed t-the °llo�a'ing ad&.ess' Street and6- 3 /� Number /�1;cls 4)c, 9`/) ' Name of j Premises i ►76 6 Cote-f U E In b 24 04150 Purpose-for for which Premises is '0r—L � _��il Snnrt. rc t13 agencies: Location ` r*�---��1 4� M � A e No. Date r �a� _ Don Of 1 0 1fnM u4PP_, am of ti-A n 1)ov-: Of MORTq, TOWN OF NORTH ANDOVER n Telephone Certificate of Occupancy $ s��M�s Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ G5e� ITLE Check # kn /0 V DA r 16177 Building InspectcriZ FerM 01845 PLEASE NOTE: Application form with accompanying FEE must be submitted for each building or structure or part thereof to be cert 3) Application and fee-must be-received before-the�cer-ti fikate will-be issued. 4) The building officials shall be notified within ten (I0) days of any change in the above in ormation. CERTIFICATE# EXPIRATION DATE: FORM SBCC-3-74 REWSEB 2199 jmc TOWN OF NORTH ANDOVER INSPECTOR'S NAME OFFICE OF THE INSPECTOR OF BUILDINGS MICHAEL MCGUIRE INSPECT40N-REPORT FORM LASSIFICATION PASSES INSPECTION ye�dno 0 DATED OWNER BUILDING NAME OR-NO. � 0 C', f2c t STREET LOCATION TYPE OF OCCUPANCY {day Care-Center D fid.-0 Ica* B -Gym E Apt. 0 School 0 Common V�ictualer's Liquor 0 Place of Assembly 0 Other (\`F 01 ti OCCUPANCY NUMBER knclude-stories-# and-occupancy per4loor- use-reverse side EXISTINGS EXIST SIGN I -�-yes r10 u LIGHTED EXIT SIGNS -eperable � �� -no -0 EMERGENCY LIGHTING SYSTE M operable dry cell 0 wet cell SPRINKLER SYSTEM operable gage pressure yes no SMOKE DETECTOR operable yes 1�r no FIRE ALARM SYSTEM -e)oratien-date -Yes -no ANSUL SYSTEM �l dj yes no 0 FIRE ALARM SYSTEM operable 0 municipal 0 yes 0 no 0 ELECTRIC EQUIPMENT PROPERLY PROTECTED yes `r no 0 EGRESSES LAWFULLY-DESIGNATE unobstructed -yes(4- -no 0 STAIRS PROPERLY RAILED �1`�('V yes 0 no 0 HALLS AND STAIRWAYS LIGHTED N(C\ yes 0 no 0 RADIATOR GUARDS yes 0 no 0 COMPUE-S HANDICAPPED PFRSONS!oW %TV -no � FIRE RESISTANT CURTAINS OR DRAPERIES HOW HEATED _ �C NO. FIREPLACES yes D no BOILER ROOM CONDITION VENTILATION © (Z- UTILITY LUTILITY ROOM CLOSETS NUMBER OF GRADE FLOOR MEANS OF EGRESS DOORWAYS NUMBER OF SEPARATE STAIRWAYS ACCESSIBLE PER STORY /y A SHOPS 4 FOR INSPECTOR USE ONLY Revised 2/99 iMc MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or Print) NORTH ANDOVER,MASSAC SETTS .Q f�✓!� Date /d Building Location Permit# X50 Amount Owner MaZ4 e,/A f`RQ � New 0 Renovation 0 Replacement Plans Submitted Yes 0 No FIX��aTIJRES rf W. SUMEW M 1LDCR M ELOCR 3RD FLOCK 4IH IIDCR 51H HD[K Date. :• • •�• Certificate rP TOWN OF NORTH ANDOVER trier. NORTh i � PERMIT FOR PLUMBING v/Co. r • _ ,SSACMUS� -- 1 . . . . . . . . . . . This certifies that . : • • • • • • • • • • • ' ' es not have any one of the above has permission to perform plumbing in the buildings of . . . • ' • • . North Andover, Mass. at . . . . . . . . . on are true and accurate to the Fee/-'. - Lic. No:. . . . . . . ' ' ' r this application will be in ✓` PLU'M' BING INSPECTOR of the General Laws. Check # 85 ` 7 � �_�� ��,,,__}.�--------�viaster Journeyman t� A i The Commonwealth of Massachusetts Department of Industrial Accidents Office of investigations Uf .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: zo nL City/State/Zip: _ ����� ,iy1�- Phone Are you an employer?Check the appropriate box: Type of project(required): L❑ I am a employer with 4. El am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. F-1 New construction 2.❑ I am a sole proprietor or partner- hstedtin the attached sheet. 1 7• ❑Remodeling ship and have no employees Thse sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. [No workers' comp. insurance 5. We are a corporation and its 9' E]Building addition required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11-0 Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.] t employees. [No workers' comp.insurance required.] 13.❑Other *Anyapplicant that checks box#1 must also fill out the section below show: g their worr_ers'compmsatior.policy information. *Any 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 is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:_Z�/J/zh Policy#or Self-ins.Lic. #: ,�/� _���j�.C� � f Expiration Date: Job Site Address: / City/State/Zip: Attach a copy of the worker 'compensation policy declaration page(showing the policy number and expiration ate). 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 ce under the pains and penalties of perjury that the information provided above is tr a and correct Si atur _ /�/lt�-- i) 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): L Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: y , 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 15.2, §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 1-8.77-MASSAFE Fax#617-72.7-7749 Revised 5-26-05 www.mass.gov/dia i ICommonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. 1 Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [R BOARD (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code C),*7 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: V ai 1-3 City or Town of. NORTH ANDOVER To the InspeLtor Af Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) Owner or Tenant o v Telephone No. Owner's Address saw f Is this permit in conjunctionw' h a building permit? Yes EK No ❑ (Check Appropriate Box) Purpose of Building M Utility Authorization No. Existing Service Amps / Volts Overhead❑ Undgrd❑ No.of Meters New Ser V _ ~ Iters Number, Date....Z / Location; ................ ..... &ORTPI I L TOWN OF NORTH ANDOVER �ITot 1rofWires. No.of o p PERMIT FOR WIRING KVA No.of I �"..: : KVA . y No.of I) ;�s°•.... ftting $�cHva� No. of 13 -T of Zones 1 This certifies that ...........v...0� L- Z./..................................................... No.of S� ..... . .. n No.of f has permission to perform .........j'�.TCJ ............................... .................................................. wirin in the building of........................�--� q�71/l:&S............................................... ' No. of R g g .........��• Ices S9 S�l,//C i rcJ, ......,North Andover,Mass. ❑ Other No.of at ......................................fir . /.I. .......... No. of D Fee f 2. ........Lic.No. .!... � :�. ......... ................ .......................... No.of W ELECTRICAL INSPEcroR trivalent Cheek# ' trivalent No.Hydi (irm . '� f1 /7 ent " OTHER i U trival_-- Attach additional detail if desired, or as required by the Inspector of Jnres. Estimated Value of lec ical Work: '—J (When required by municipal policy.) `Vork to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE CO GE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify,under the painsand penalt' f pe 'ury,that t1 i oration on this application is true and complet . FIRM NAME: , �.. iJ b� LIC.NO.: Licensee: U _ Si na ure LIC.NO.: (If applicable e er e pt"i�rz.the lice�e zr be li e.) Bus.Tel.No.: Address. ( Alt.Tel.No.: *Per M.G.L c. 147,s.51-6 1,security or re uires De artment of Public Safety"S"License: Lic.No.� OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent. Owner/Agent PERMIT FEE: $ Signature Telephone No. ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance-with the provisions of M.G.L.c. 143,§3L,the permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed j 1 on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166,§32,an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L.c.143,§3L. Permits shall.be limited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012. ❑ Rule 8—Permit/Date Closed: ***Note:Reapply for new permit❑ ❑ Permit Extension Act—Permit/Date Closed: Trench Inspection Pass 0 Failed Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed Re-Inspection Required($.) ❑ Inspectors Comments: 1 Inspectors Signature: Date: ` PARTIAL ROUGH INSPECTION: Pass M Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH PECTION: Pass Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: 1 Inspectors Signature: U,- ��, ,� Date: FINAL INP TION: Pass M Y Failed Re-Inspection Required $. ❑ Inspectors Co m Inspectors Signature: 0 Date: DEB WEINHOLD ...TOWN OF MERRIMAC, MA. .......dweinhold@townofinerrimac.com b` The Commonwealth of Massachusetts - Department ofIndustrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www mass gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly /` Name(Business/Organization/Individual): L_ J So a 7�7 Address: 5 G l !tZ 91 City/State/Zip: p Phone#: Are u an employer?Check thea propriate box: Type of project(required): 1. I am a employer with 4. ❑ I am a general contractor and I 6. ❑NeW construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet.$ emodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. El We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.01 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]t employees. [No workers' comp.insurance required.] 13.❑Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they aie doing all work and then hire outside contractors must submit a new affidavit indicating such. r tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. lhld Insurance Company Name:. Policy#or Self-ins.Lic.#: n Expiration Date: L'(, 1 p Job Site Address: �) v t 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 DTA for insurance coverage verification. 4 do hereby cert u e tlt pa sand penalties ofperjury that the information provided abo a is trite and correct. Si ature: 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 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-contractors)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 Commonwoaltlt of Massachusetts Department of l dustrial Accidents Office of Investigations 600 Washington Street Boston.,MA 02111. Tel.#617-727-4900 ext 406 or 1-877,7MASSAFB Revised 5-26-05 Fax#617-727-7749 www.naass,govldia 1 O O L 3 Date...3............................. e NORTI{ o� TOWN OF NORTH ANDOVER p PERMIT FOR WIRING ,SSACNUSE� This certifies that ........... f. has permission to perform ....... ... .` �— /. ............ ..3................ wiring in the building of.... 5 at.. �.........��� ........ ....... .........., ,(..�...-... ,North Andov ,Mas Fee f,5..v......... Lic. No.�l ....../...�<°, /.. ...... ...�yr�:.�. L ELECTRICAL INSPE R Check !1 J 6-�_U C.ourrrtnteutaa[Uc o� adiac�ttSo ! Official Use Only Permit No. �9 oUoparfnnonf a�.}irn Saruicw _ Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] Ot:nveblani:) ` APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK S ASI work Lobe performed in accordance with the Massachusetts Electrical Code(ME?),5WCMR12.00 (PLEASE PRINT 1NINIi OR TTPEIN=0 -,rAT10jV Date: City or Town of: (� To the Inspe 10 of ffrires; By this application the undersigned gi es notice of his or in noon to perform the elec icpl work described below. Location(Street 3c Number) 1(j �yzIn 14 Owner or Tenant S [&,sTm/410 Telephone No. Owner's Address Is this permit in conjunction witn;l il�d' permit? Yes No ❑ (Check Appropriate Box) Purpose of Building TA, i2l)►� Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Und rd g ❑ No.of Meters New Service Amps / Volts Overhead❑ Und rd g ❑ No.of!Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrienl Wort: COm letian ofthe ollf tVin table may be wah1ed by the Ins ectar of 1.11ires. No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Tans No.of Total Transformers ICVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- E] o.a merge , ncy rging rnd. rad. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners o.of Detection an Initiating Devices No.of Ranges No.of Air Cond. TOW No.of Devices Tons g No.of Wnste Disposers Hent Pump Number ITons N o.of e-1 oniainai1 Totals: f Dpiection/Alerting Devices No.of Dishwashers SpacdArea Heating ICW Local❑ Municipal ❑ Other Connection No.of Dryers Renting AppliancesSeeuri ICW No. Systems,.- y Devices or Equivalent No.of Water IC1Y No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or E uivnlent No.Hydromassage BathtubsNo.of Motors Total HP elecommunientions Wiring No.of Devices or Equivalent OTHER: .t oad'additional detail if desired,or as required bj,the Inspector ofIl Tres. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion_ INSURANCC RAGE*. -waived-by-the=owner;no=permit farthe=performance of electicat work=mey=ls"sue unless ................._:._....W.........�.. �=COPE �•- the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof ofsame to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I cerci fy,render lite pal»s a» alties of er'rtry lhat the it fa »ati�tt,ou this application is lrtte airtl complete >i ERM NAME: u 4 r C LTC.NO.: , Licensee; Signature ArzLIC.NO.; Address:ble,entgrj' pt' r e icens rttunberline.} Bus.Tel.No: jv-11 JA/ �K- Att.Tell.No: *Per M.Q.L.c.147,s!57-61,security work re4uizles Department ofPubfte Safety"S"License: Lie.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent. Owner/Agent Signature Telephone No. rPERM7T FEE:S 1-5-0 �/< p RESIDENTIAL-MINIMUM PERMIT FEE $25.00 COMMERCIAL-MINIMUM PERMIT FEE $50.00 1) New Dwelling w/service up to 200 amp $220.00 NEW CONSTRUCTION AND ALTERATIONS �(nv Need Utility.4uthoiri.ation Number on Form 1)Per 1,000 square feet construction space / a) Each additional 100 amperes capacity or fraction $20.00 Mitumunt phts temporary senice or other sen4ce charge $100.00 b)Each additional meter $10.00 2)Service change(first 100 amperes or fraction,one meter) $10.00 c}Each additional panel $25.00 a)Each additional 100 amperes capacity or fraction $30.00 S 2)Service change or underground service b)Each additional meter $25.00 Need UtilityAuthorization Nymbei-on Form 3)Repair and maintenance permit a) One meter up to 100 amperes capacity or fraction $40.00 a)Blanket Permit,up tp two electricians $150.00 b)Each additional 100 amperes capacity or fraction $20.00 b)Per pair of electricians over two $50.00 c)Each additional meter $10.00 4)Panel Change;Circuit Breaker,each $25.00 3)Feeders or sub feeders,each 100 amperes capacity or fraction $5.00 5)Feeders or sub feeders,each 100 amperes capacityor fraction thereof $15.00 4)Temporary Service-Need Utility,4uthoilzalion Number of Fora: $25.00 6)Temporary Service $100.00 5)Additions and Alterations: 7)Motors,per hp or fractional part thereof $2.00 Maximunt Fee $220.00 GENERATORS a)Panel change;Circuit breaker $20.00 1)Including photo-voltaics and other gererating equipment er KVA $1.00 b)Additional meter $20.00 2)Transfer Switch $25.00 c)Repair to service $20.00 3)Sub-panel $25.00 6) Swimming Pool 4)Uninterru table power systems,per KVA $1.00 a) Above ground $25.00 5)Batteries over 100 ampere hours, per cell $1.00 b) In ground $50.00 TRANSFORMERS(NON-UTILITY OWNED) 7) Major Appliances 1)Per KVA $1.00 a)Air conditioners and heat pumps $40.00 2)Vaults and equipment,each $25.00 b}Alarm systems $40.00 3)Ducts,conduit and conductors c)Built-in ovens;Counter-top units $10.00 (associated with padmont transformers) $25.00 d)Dishwasher;Disposals $5.00 a)Each manhole $10.00 e)Gas or Oil burners $20.00 b)Each handhole $5.00 f)Hydro-massage tubs;hot tubs $20.00 4)Primary feeders,each(over 600 volts,non-utility owned) $25.00 g)Ranges $15.00 5)Capacitors per KVA $1.00 h)Sewer Eject Pump $25.00 MISCELLANEOUS i)Washers;Dryers $15.00 1)Carnival equipment,each $50.00 j)Water heater $30.00 2)Signs, each $25.00 lc)Water heater with off-peals or rate meter $20.00 3)Office f tmishin s,per circuit(relocatablepartitions) $10.00 I)Other $20.00 4)Commercial Swimming Pool $100.00 8) Outlets,Switches,and Smoke devices $1.00 5)Data/Telecommunications 9) Heat devices and Space heaters $1.00 a)including first 10 devices $30.00 10)Generators b)each additional device $1.00 a) Including photo-voltaics and other generating equipment,per tcvA $1.00 6)Alarm System(smoke and security) b)Transfer switch $25.00 a)including first 10 devices $60.00 c)Sub-panel $25.00 b)each additional device $1.00 11)Low voltage wiring(Data and Tele-communications wiring)per device $1.00 OTHER I)VAV Boxes $20.00 RE-INSPECTION FEES-Residential and Commercial $25.00 SPECIAL MACHINERY,EQUIPMENT OR SITUATION, CONTACT THE ELECTRICAL INSPECTOR FOR FEE Paul Kennedy-978-623-8306 Electrical Permit Fees May,2010