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Miscellaneous - 117 MAIN STREET 4/30/2018 (2)
� �' a D 117 MAIN STREET Complaint Detail Report Printed On:Mon Aug 19,2013 Complaint#: CT-2014-000014 Status: IClosed GIS#: 10294 Violator: Shahram Maghibi 4�Trr. o'r'+s Address: 117 MAIN STREET Map: Address: 18 DALE STREET • Date Recvd.: Aug-14-2013 Time Recvd.: 12:00 PM Block: ANDOVER,MA 01810 Category: Food Lot: Type: Commercial GeoTMS Module: Board of Health FDitrict: Trade: Restaurant Recorded By: Lisa Blackburn ing: Structure:WINE CONNEXTION Description _ Complaint: Jeffrey Goldman,617.840.8332 called to place a complaint regarding Chama Grill.He ate dinner there on Wed,8/7/13.He ordered a Mediterranean Salad with chicken.When he got home,he didn't feel well.He has had diarehhah and vomiting for a week.He visited Beth Isreal Hospital and is expecting results to come back today to see if he had food poisoning.He feels strongly that it was the salad that caused him to be sick and would like the Health Department to investigate. Comments: _ Inspector Assigned to Complaint: Contacts Contact Type Date Time Name Phone Best Time To Reach Recorded By Response Caller Aug-14-2013 12:00 PM Jeffrey Goldman (61.7)840-8332 Q Lisa Blackburn Forwarded to Health Inspector Actions Taken GeoTMS Module Status Date Time Response Type Action Taken Comments Board of Health REFERRAL Aug-19-2013 11:24 AM Follow-Up by Michele Grant spoke to Michele Grant complainant.Stool tests came back negative from hospital.No food poisioning.Case closed. Aug-16-2013 8:41 AM Follow-Up by Facility is clean.No open Michele Grant cuts on the cooks hands, chef was not there.Temps range from 34 to 38 degrees. GeoTMSO 2013 Des Lauriers Municipal Solutions, Inc. Page t of 1 Location No. -50 /D ' 3c/0 Date01 NORTH TOWN OF NORTH ANDOVER 9 Certificate of Occupancy $ ACMBuilding/Frame/Frame Permit Fee $ 1Ust Foundation Permit Fee $ Jher Permit Fee $ 3o a-) ''ll TOTAL $ Check #/�7 9.r" � 2341 R ildin lKspector -, NORTH � 2O ED TOWN OF NORTH ANDOVER p D� CO""..CK SIGN PERMIT ��SSgcKus���� DATE: September 20, 2010 PERMIT: S010-2011 THIS CERTIFIES THAT SAN-Lau R.T. First and Main Marketplace has permission to erect. Wall sign 3" deep all black aluminum letters - CONVERSE on 109-123 Main Street, North Andover MA 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. INTERNALLY ILLUMINATED SIGNS ARE PROHIBITED Inspector of Buildings Receipt: 23460 Amount Paid: $30.00 BUT1IITEI` -M c a I p a I a I i 0 a 5514 SA15lM1AAVEMIE NORRI HOLLYWOOD.CA 91601 PHONE 818.763.4798 GO FAX 818.763.5758 nV R Er JOB NAME 3"DEEP ALL BLACK ALUMINUM LETTERS LIT FROM ABOVE BY GOOSENECK LIGHTS SUPPLIED BY OTHERS C©WER5E n SIGN ELEVATION V ADDRESS: 109-123 Main Street Bldg.G Suite G2 3" North Andover,MA N I ME, I 9-3-10 I DRAWN BY. AK ALUM.CHANNEL LETTERS W/ SCALE: SATIN BLACK FINISH i ®L N.T.S. REVISED: ALL MATERIALS ARE U.L.APPROVED 9-18-10 NOTES:NO VISIBLE FASTENERS,DECALS,UL LABELS OR SWITCHES PAINT STANDOFFS AND ALL ELECT.COMP.TO MATCH STREFRONT APPROVED BY: 1/4"X 2"STUDS EPDXIED AND KEEPALL WITHIN LETTER MIN.2"FROM EDGE. INTO WALL(4 MIN.) WALL EXT. SIGN SECTION DRAWING#: 3 OF 3 Location lG 9- /a3 �- No. SD/4 '�o/ Date oto a a io f NORTH TOWN OF NORTH ANDOVER A Certificate of Occupancy $ • i Building/Frame Permit Fee $ s�cNUSE Foundation Permit Fee $ SiO/,/ pP,2,pl-r Other Permit Fee $ ,36.00 TOTAL $ Check # 23460 � = } Gilding Inspector � QRTp-1 , ovm of :: Andover O _t�___- LAKE o dover, Mass., COCHICHEWICK Sd ADRATED `ss BOARD OF HEALTH Food/Kitchen .PERMIT T D Septic System BUILDING INSPECTOR THIS CERTIFIES THAT . .............................................................................. Foundation has permission to erect........................................ buildings on ../, ..7...... ..7 Ala Rough _� ............ ..... ................................. to be occupied.as...........1�.......... �.`..I�'.!--.rtq. .......6. ..'.f..........�>�. -t.� ... 5................................................... Chimney provided that the person accepting this permit all in every respect conform to the terms of the application on file in Final 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 STARTS Rough G ..../v'-�'"Y ! .. ....... Service ........ ............ .......... BUILDING INSPECTOR Final Occupancy Permit Required to Oca cpy Building GAS INSPECTOR Rough f Display in a Cn isp1,1cu T1s Place on the- Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT f Until Inspected and Approved by the Building Inspector. Burner. Street No. SEE REVERSE SIDE Smoke Det. ©.e©O0 1 N G G _R A C_T O .�N C .� September 20,2010 Via US Mail Mr. Gerald Brown S Inspector of Buildings 1600 Osgood Street North Andover,MA 01845 Re: Converse-3rd Floor Renovation-Plans dated July 7, 2010 North Andover,MA RBC Project No. 10-821 Dear Mr. Brown, Converse(Manson Investments)respectfully requests a transfer of the North Andover Building ;Permit#053-2011dated July 13,2010 10 Republic Building Contractors Inc. Republic Building 'Contractors, Inc.will be completing this work for Converse and will therefore become the general contractor of record. The superintendent for this project will be Mr.Jim Burns.Jim's State of Massachusetts construction supervisor's license number is 045457. Please contact us with any questions or comments, or ifyou need any additional information in this regard. Thank you. rely, ep c Building Contractors,Inc. n J. Morris Prof et Manager Cc: cott Fairbanks,Converse(via e-mail) Jim Burns, RBC(via e-mail) 10-821 File Republic Building Contractors,Inc•491 Maple Street•Suite 103•Danvers, MA 01923•P:978.750.0099•F:978.750.8893•www.republicbuilding.com ..1MT August 6th, 2010 ARC ' s ARCHITECTURE ` Attention: Gerald Brown—Inspector of Buildings 1600 Osgood Street PLANNING ,µ North Andover,MA Re: Bldg"G"-First and Main Marketplace \ f; 107-127 Main Street INT OR SPAC ES. G North Andover,MA 01845 Dear Gerald, Architects Site Visit Report#10-01-SVR-1 Date of Visit: August 3rd,2010 Present on Site: General Contractor's Superintendant, Steel Fabricator, Masonry Contractor and Framing Contractor. Work in Progress: Framing temporary support walls, installing l new structural steel support columns and cutting of exterior masonry. P i ° X Problems Encountered: none. a ,\ General Comments; All work completed to date looks good and /' 1 `` appears to be in conformance with the Contract Documents. u mitted by, Patrick O.Finn,R.A.NCARB -Project Architect / Landry Architects (603) 890-6414 ` 1 Email: pof@landryarchitects.com ��re 389 Main Street Salem,NH 03079 T:603.890.6414 < a F:603.894.4358 www.landryarchitects.com Town of North Andover Building Department NORTH Of it�eD „°q'1'O 3`� a;' ••.° OL FO A 9sgACHUSEt Dear Judy, I have reviewed all the facts as well as the Decision from the Board of Appeals,regarding the issues and concerns of parking for The First and Main Plaza(109-123 Main Street Unit Gl) and have determined the following: 1. Request for a restaurant on this site would be allowed as a GB Zoning District. 2. Parking calculations for 4,927 square feet,restaurant requires 15 per/KSF GFA, 75 parking spaces are required. 3. Zoning Board of Appeals Decision(dated May 15, 2007)2007-0004A(shopping center) and 2007-0004B (kiosk) 4. Variance for reduced parking is for 172 spaces. The parking analysis provided is mainly during evening hours for the restaurant's patrons and employees. This would offset the need for relief, since many of the stores in the plaza are not operating during these hours. Therefore,based on the above facts and materials presented to me,I am of the opinion that the applicant has the necessary amount of parking required and is in compliance. The Building Department supports this petition. Sincerely Gerald Brown Building Commissioner and Zoning Enforcement Officer 9 6 u `.............................Date.... f NOR7M, 3?;•_:�`` "°cam TOWN OF NORTH ANDOVER p PERMIT FOR WIRING SACMUSE� This certifies that PT l.,l7 r has permission to perform ! ` T v P .... .......................................................................... wiring in the building of. ,2.�T...t. /r.IF7... ..h!'re.`........ AA�E . North Andover,Mass. Fee.. 0vL25� Lic.No��.�� ........... r. . r ............RICAL INSPE Check # 1�_�. L Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. Occupancy and Fee Checked VVJ BOARD OF FIRE PREVENTION REGULATIONS Rev. 1/07] leave blank) 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 IN INK OR TYPE ALL INFORMATION) Date: August 24, 2010 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) Building"G" - 107 - 127 Main Street- First and Main Marketplace Owner or Tenant First and Main arket Place Telephone No.508-962-1541 Owner's Address Same Is this permit in conjunction with a building permit? Yes R No El (Check Appropriate Box) Purpose of Building Strip Mall Utility Authorization No. 9428823 Existing Service Amps / Volts Overhead ❑ Undgrd❑ No.of Meters ' New Service 800 Amps 110 / 208 Volts Overhead❑ Undgrd ® No.of Meters 3 Number of Feeders and Ampacity Install new 800 amp Underground Service,feed from existing Transformer Pad. Location and Nature of Proposed Electrical Work: Install new Fire Alarm Equipment,Receptacles and Lighting Completion o the ollowin table maybe waived b the Inspector of Wires. No.of Recessed Luminaires No.of Ceil.-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- E] No.of Emergency Lighting 16 rnd. grnd. Battery Units No.of Receptacle Outlets 18 No.of OR Burners FIRE ALARMS No.of Zones No.of Switches 5 No.of Gas Burners No.of Detection and 9 ti Initiating Devices No.of Ranges No.of Air Cond. 5 Tons Tot20 No.of Alerting Devices No.of Waste Disposers Heat Pump Nutuber Tons J.K_ W_____._.____ No.of Self-Contained Totals: Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal El Other Connection No.of Dryers Heating Appliances KW Security Systems:* No.of Devices or Equivalent No.of Water Kms, 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 Equivalent OTHER: $40,000.00 Attach additional detail ifdesired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: 8/24/10 Inspections to be requested in accordance with MEC Rule 1.0,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:) I certify,under the pains and penalties ofperjury,that the information on this application is true and complete. FIRM NAME: High-Tech Electrical Contractors Inc. LIC.NO.: A11889 Licensee: Michael J. Pallazola Signatur LIC.NO.: E28416 (If applicable,enter "exempt"in the license number line.) V I Bus.Tel.No.• 978-768-7322 Address: 239 Western Ave. Essex, Ma. 01929 Alt.Tel.No.: 508-962-1541 *Per M.G.L c. 147,s.57-61,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 Signature Telephone No. PERMIT FEE: $ i �.c.� f� , 1 �� l or Y 7 Y 'ScNuSft CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Permit Number 260-2011 Date: October 25, 2010 THIS CERTIFIES THAT THE BUILDING LOCATED ON 122 Main Street North Andover MA 01845 Converse MAY BE OCCUPIED AS retail store IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: San Lou Realty Trust 122 Main Street North Andover,MA 01845 Building Inspector Fee: 100.00 Receipt: 44666 L ORTH Town of Andover 0 -o dover, Mass., �. C OC NICHE WICK V S0BOARD pP � t�77 ` BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR S��r � G� /{��/ mss, THIS CERTIFIES THAT.................................:................................ ....... ................................................................................... Foundation IA114 ! S' has permission to erect........................................ buildings on ... ........ ....... Rough to be occupied as............ .1....!.. :.... ......... � 1�(��`� 'f cr................................................ Chimney provided 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 Inspection, Alteration and Construction of � 7` 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 STARTS ugh�,�« ��..... Service ................. .......................�'^�-..;::.................................................. ce BUILDING INSPECTOR In •�z lo--L� � 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 D FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Det. , l� , SEE REVERSE SIDE Smoke Det.L ` �� D GENERAL BUILDING NOTES/CHECKLIST-NOT LIMITED TO ITEMS BELOW POST ALL LOT NUMBERS,ADDRESS, AND PERMIT(COPY 0K)..or no inspections INSPECTIONS: (Minimum) Excavation , Footing, Foundation, Frame, Insulation, Final. FOOTINGS: Continuous Full 2x4 Keyway Continuous strip footings for interior columns FOUNDATION: Rebar as required Anchor bolts or straps Damproofing Foundation drain-pipe/stone/fabric filter/cover and outlet connection. FRAME:Fireblock-over girts/plates between floor joist Penetrations for plumbing, heat,elec, etc. Walls at stair stringers. Windbrace corners and center bearing partitions. Size ridge to provide full bearing at rafter cuts. Hip and Valley rafters-watch bearing at walls. Ridge&Hip-Provide proper connections. Cathedral roof rafters provide proper connections and use"Hurricane Clips"tie to plate. Stair stringers-watch cuts and heal support. Joist hangers-fully nailed w/hanger nails. Sill plates 2-72X6(1 PT)w/sill seal. Girls-solid brick or steel plate bearing at foundations '/"air space at sides in foundation pockets. Lateral bracing at ends. Certified calculations. required for Beams/LVL's Trusses. Solid bearing support for Headers/Beams etc. Check headroom clearances-stairways, under beams Attic Access. (min.22x30 w/3'headroom above). Crawl space access. (min. 18x24). Bath exhaust fans to have metal duct to exterior(not in soffit). Firecode S/R wood frame of"0"clearance fireplaces&stoves Window Schedule or Every Habitable Room Must Have: Natural light equal to 8%of floor area. %of required glazing shall be openable. Bedroom s.required min.20x24 egress window or door. Vent attic spaces-"proper vent", soffit and required ridge vents. Firecode under stairs if used for storage FIREPLACES: Separate permit required. Inspections at Footing-Smoke Chamber-Finish Smooth parging,clean joints, 8"solid @ combust. DECKS: Lag to house, provide flashing. Rails min. 36" high, Baluster max space 5"on center. Over 8'above grade, use 6x6 posts w/lateral bracing. Lag all posts and rails. Pier footings down 48", Conc. pad at stair base. FINISH: Handrails returned to wall/newall post. Guardrails required alongside open cellar stairs. Exterior grading complete. Certificate or occupancy required prior to occupying structure. Temporary Stairs required for inspection. Re-inspection fee- $30.00(Be Ready). Certificate of occupancy required prior to occupying structure. 9 6-ut .. ........ TOWN OF NORTH ANDOVER PERMIT FOR WIRING rMUS This certifies that ..... ........ . ............. has permission to perform ..X�4H:...... X.......40� e. wiring in the building of......�'V.A,.,dZ..< IC....................................... at..... el............................. .North Andover,Mass. .................... Feek2.S ......... Lic.No.............. ....... Check # -rU z M 4rR'�'/ ,,�,� 6+x!!1/r/C7d1QM�elAH,B9 QP/I O'��gg��8140➢a,g��b6� ------ --- --J e Permit No. fzlge� DepartMePBtr` ������ �������� 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(NEC), 527 CNa 12.00 (PLEASE PRINTW INK OR TYPE ALL INFORMATION) Date: o c 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) Telephone No. _,3' ;Q - Owner or Tenant Owner's Address dL �-- S�•' ��''�� Is this permit in conjunction with a building permit? Yes No Q_ (Check Appropriate Box) ❑ Purpose of Building i L Utility Authorization No. Volts Overhead Undgrd❑ No.of Meters Existing ServiceN% Amps New Service 4k__ Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: 1,�s„�I[ATrav �+ Completion of the following table may be waived by the Inspector of Wires. ti No.of Total No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans ..Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA Above In- o.o mergency ig ing No. of Luminaires Swimming Pool rnd. rnd. Batter Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Detection and No.of Switches No.of Gas Burners Initiating Devices Total No.of Alerting Devices No.of Ranges No.of Air Cond. Tons Heat Pump umber. Tons••..•,._••KW No.of Self-Contained No. of Waste Disposers Totals: " ' "' Detection/Alerting Devices MunicipalOther No. of Dishwashers Space/Area Heating KW Local❑ Connection El Security Systems: No. of Dryers Heating Appliances KW No.of Devices or Equivalent No.of WaterNo.of •No.of Data Wiring: KW Ballasts No.of Devices or Equivalent Heaters Signs Telecommunications Wiring: No.Hydromassage Bathtubs No.of Motors Total HP No.of Devices or Equivalent OTHER: ,4ttach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: 2FOt. (When required by municipal policy.) Work to Start: D p Inspections to be requested in accordance with NEC 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 cover -e is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE [�BOND ❑ OTHER ❑ (Specify:) I certify, under the pains acid penalties of perjury,that the information on this application is true andcomplete. G LIC.NO. ' : FIRM NAME: [ ,v Licensee: 6vAriat 16 ;Y Signature ,/ LIC.NO.: (If applicable, enter "exempt"in the license number line.) Bus.Tel.No.: 01, `rt Address: N eu7s-74-,vv T'wj y1Q. �'zv /?1--r— Alt.Tel.No.: *Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lie.No. OWNER'S INSURANCE WAVER: 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 Owner/Agent Telephone No. -PENT FEE. $ J 2 S Signature The Commonwealth of Massachusetts Department of Industrial.Accidents Office of Investigations 600 Washington Street Boston,MA. 02111 www.mass.gov/dia ,,.'r 9a Workers' Compensation Insurance Affidavit: Builders/Contractors/E1 Please Print Le bl Applicant Information Name(Business/Organization/Individual): i � d � Address: 3 4 City/State/Zip: Phone#: ��%�� 2%3 //z`/ — Are you an employer?Check the appropriate box: Type of project(required): 1.EJ Tam 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 listed on the attached sheet. 7. ❑Remodeling 2.❑ I am a sole proprietor or partner- ship and have no employees These sub-contractors have 8. ❑Demolition kers' comp.insurance. 9, Building addition wor p working for me in any capacity. ❑ [No workers' comp.insurance 5• ❑ We are a corporation and its 10.E]Electrical repairs or additions required.] officers have exercised'their right of exemption per MGL 11.E]Plumbing repairs or additions 3.❑ I am a homeowner doing all work c. 52,§1(4),and we have no 12.❑Roof repairs myself. [No workers comp. insurance required.]t employees. [No workers' 13.00ther 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 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 j / Policy#or Self-ins.Lic.#:_� `3-,/3,)kExpiration Date:^�_ / /Al Policy igw�r '<'2 0 City/State/Zip- Job Site Address: 01-C /����/f'% !y �' 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 certify under the pains andpenalties of perjury that the information provided above is true and correct. Date: 10 b Ile, Si ature: r 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 CIerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Date. ............................. NOR71y Of,«1O{.1'4C o� TOWN OF NORTH ANDOVER PERMIT FOR WIRING 4o SSACHUSE� This certifies that ....... . ...C....... .................... .`. ..........��( �. has permission to perform/r .?.7`�.. ....Z .......... P .. wiring in the building of........ .................................... at .............................................. .North Ando r,MM/. Fee.2 Lic.No. .!T .. ., .... /�y� ELECTRICAL INSP E? R Check # d L4U/111I1U11LrVVa1&11 UA - � - Department of Fire Service Permit No. 467Z_ Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev- 1/071 (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 LN INK OR TYPE ALL INFORMATION) Date: CA-a N– p City or Town of. NORTH A"OVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the�el g[rical work described below. Location(Street&Number) ` icia. �� N Owner or Tenant elephone No. Owner's Address a ' Is this permit in conjunction wit a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building 9,eko� N Utility Authorization No. Existing Service Amps Volts Overhead❑ Undgrd ❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: �,����G CP C_P Qs Completion of the following table may be waived by the Inspector of Wires. No.of Total No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA Above In- .0 mergency ig mg No.of Luminaires s Swimming Pool rnd. rnd. ElBatteryUnits No.of Receptacle Outlets c�5 No.of Oil Burners FIRE ALARMS No.of Zones No.of Detection and No.of Switches No.of Gas Burners TotInitiating Devices No. of Ranges No.of Air Cond. Tons No.of Alerting Devices 3 HeFP No.of Waste Disposers aTotals Number Tons KW• No.ofSelf-Contained Detectio n/Alerting Devices * l Other No.of Dishwashers Space/Area Heating KW Local[ n ❑ r Heating Appliances gay Securit No.of Dryers No. E uivalent No.of Water No.of No.of Data Wiring: Heaters KW Signs Ballasts No.of Devices or Equivalent Telecommunications Wiring: No.Hydromassage Bathtubs No.of Motors Total HP No.of Devices or E uivalent OTHER: •.4ttach additional detail if desired, or as regtdred by the Inspector of Wires. Estimated Value of Electrical Work: 6 ai,Gt no (When required by municipal policy.) Work to Start: CA �-ap 10 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 N] BOND ❑ OTHER ❑ (Specify:) v X certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: C', :C. LIC.NO.: Cry I '(Y Q ' Licensee: (l,,n�a� L.�1p (1�_rj Signature LIC.NO.: (If applicable, enter "exempt"in the Incense number line.) Bus.Tel.No. �� Address: IDlr-,e S�c P—ACt 0 S L _�1ca�Sh�xa.� t'p A. O,3 106n Alt.Tel.No.: � *Per M.G.L c. 147,s.57-61,security work requires Department of Public 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 Owner/Agent PERMIT FEE:'$ Z/(J• 7 Signature Telephone No. t �, r� R 1 F ' The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): lz—ke- C;y,- 0 P_Ck :C Address: ,:::; City/State/Zip: Vis-,,, Phone Are you an employer?Check the appropriate box: Type of project(required): 1.R I am a employer witht,— 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.1 7• ❑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. [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. lContractors 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: Policy#or Self-ins.Lic.#: Expiration Date: 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. I do hereby certify under the pains andpenalties ofperjury that the information provided above is true and correct. Signature: 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#: Date....l. .-(�.`.. Q... NORTH 3?;•_ �`' ;•;,"�o� TOWN OF NORTH ANDOVER o : p PERMIT FOR WIRING CHUSEt This certifies that f ............................................................................................. has permission to perform ��i �j �i2F — }'S wiring in the building of �`f Z.. . � �� S�' 14•Z. ...... ......... .................................. at......./..l..... ......................... .... .North Andover. Mass. Fee....7..� v- Lic.No.y�..�,Y ............... ..... . 1� . ELECTRICAL INSPECTOR Check # Cotnmotuueattlz o//y�a66achu4ett� Official Use Only Q c� Permit No. L� _ IV 211P.artment ap,e services Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULK-FIONS . [Rev. 1/07] (leave blank) J 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 IN INK OR TYPE ALL INFORMATION) Date: City or Town of: A-)Ur fi A4- Q. To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform I trica work described below. Location(Street&Number) �U /^ /o� 3 !/(�S7' e 6o Owner or Tenant 0 h (JG/3e Telephone No. - Owner's Address Is this permit in conjunction with a building permit? Yes ❑ No.. (Check Appropriate Box) Purpose of Building Utility-Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: �S 1 lJ)') Ol= Sk.e.L¢,t-c./ e r —t re S,�S j G77 • Completion o the ollowin table may be waived by the Inspector ofIVires. o.o Total No.of Recessed Luminaires NQ.of Ceil:Susp.(Paddle)Fans Transformers KVA No.of Luminaire Outlets No..of Hot Tubs Generators KVA Above Ei In- o.01 mergency,Lighting No.of Luminaires Swimming Pool rnd. grnd. ❑ 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 andInitiating Devices Tota No.of Ranges No.of Air Cond. Tonsl No.of Alerting Devices No.of Waste Disposers Heat Pum Number Tons_ W _ o.of Self-Contained P Totals: --- — Detection/Alerting Devices ' No.of Dishwashers Space/Area Heating KW Local❑ Municipal El Other Connection ecur' stems: r No.of Dryers Heating Appliances KW r E uivalent J` No.of Water KW No.of No.of Data Wiring: s Heaters i Signs Ballasts No.of Devices or Equivalent No. Hydromassage Bathtubs No.of Motors Total HP Tel No of Deviations�Yiring: No.of Devices or E uivalent OTHER: Auach additional detail if desired, or as required by the Inspector of hires. 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. 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:) I certify, under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: t � LIC. NO.: Licensee: Mof lL.-t'c)tr hu Signature LIC.NO.: (If applicable, enter "exempt"in the hcen 10 umber line.) • Bus.Tel.No.: 0.3 SYlak Address: 1 'i� C L l n—k em \)r.- 0 4Alt.Tel.No.: "Per M.G.L.c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.No. ONNINER'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. 1 am the(check one)❑ owner ❑ owner's agent. Owner/Agent FER111IT FEE: S Signature _ _Te :u N'o:` , • r � � �� -2� �1C9 Y Z t NORTH ANDOVER HEALTH DEPARTMENT 27 Charles Street • North Andover, MA 01845 Tel. 978 688-9540 • Fax: 978 688-9542 email: healthdept@townofnorthandover.com Complaint Investigation/Inspection Report OWP [2-t,.1 gc--A-"— ��jncSi5;:Le'4 ADDRESS ` DATE v fid Com-"'�' �t� Z.✓ G'L ,j� � � � ��.i c�c,. �i L7 ��rri 2. +�'C�Z� LST v -tom 5 Rev.6/04 W PECTOR z r1 tFhF3MK tl"�;�3°v'v�'I a � ry,. 4 i k s It 41, 1�C _+ 4 '; "ilklr ,rr n s i z ktfi €. a� eN �a 1 rz : .. l 4 fr ORM 41 � N e a a 4 e . x