HomeMy WebLinkAboutMiscellaneous - 119 MAIN STREET 4/30/2018 I
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Date....../.`j.7'`P.........
NORTI�
°!t"'°;•�"° TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
~ ,SSACMUSEt
This certifies that 7 mPr L��1�G
................................................... ................................
has permission to perform .......... r Tv/9...............................................
wiring in the building of......Spy...GO v..P6..............7- 7' .T....
1 ? p at l! ........ ....14: ,North Andover,Mass.
Fee' Lic.No. J.-IYs�? �
:. ..... .. ........
ELECTRICAL INSPEC&R
Check # _
$ 3,5: S
Commonwealth of Massachusetts Official Use Only
Permit No.
Department of Fire Services
FBOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked
[Rev. 1/071 leave blank)
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
r'
All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00
I (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date:-`
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 elect work described below.
Location(Street&Number) /� S"
Owner or Tenant LQ,I 'k P 04 1-1-y ��u
s7— Telephone No.
Owner's Address 0-5- i��.Yi
Is this permit in conjunction with a building permit? Yes No
❑ (Check Appropriate Box) /0
Purpose of Building �p L� ,,Utility Authorization No.
Existing Service 16M Amps 17.o /20T- Volts Overhead
❑ Undgrd,0 No.of Meters /0
New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: 1
t
Completion o the followin table may be waived by 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 o.of rgency ig g
rnd. rnd. ❑ Batte 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
InitiatingDevices
No.of Ranges No.of Air Cond. Tons Total No.of Alerting Devices
No.of Waste Disposers Heat Pump Number.. Tons_ _ _ No.of Self-Contained
Totals: Detection/Alerting Devices
No.of Dishwashers Space/Area Heating KW Mni
ucipal
I'OC�❑ Connection ❑ Other
No.of Dryers Heating Appliances KW Security Systems:*
No.of aterNoof No.of Devices or Equivalent
Heaters KW .of -No
Si s Ballasts Data Wiring:
No.of Devices or E uivalent
No.Hydromassage BathtubsNo.of Motors Total HP
OTHER: Telecommunications Wiring:
No.of Devices or E uivalent
'
Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: /Ltt) Gtr,�` (When required by municipal policy.)
Work to Start: g`/�-� 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 0 BOND ❑ OTHER ❑ (Specify:)-04e gel*,,!'AI- enrr, $-19-'eg'
I certify, under thegains and penalties o�erjury,that the information on this application is true and complete.
FIRM NAME: 67— .t �,e- J , LIC.NO.: / VSA
Licensee: et1,,,;0 -7;76/00�— Signature LIC.NO.:
(Ifapplicable enter" empt"in the license�number line.)
Address: /�,� s � S i r9 f �� 11 Bus.Tel.No.: 7e y //
*Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety S License: Alt 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: $ D
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www.massgov/dia
jWorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): -�—
Address:( ezzs�C-
City/State/Zip: i'9��G�9 9 Phone #:
JAre you an employer?Check the appropriate ttox: % Type of.project(required):
. 4 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. 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.] 131-1 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 are doing all work and then hire outside contractorsmust submit a new affidavit indicating such.
xContractors 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. l _
Insurance Company Name:
Policy#or Self-ins.. Lic.#: Expiration Date: .S'!� '
Job Site Address:/ ,2S /�i�j S City/State/Zip-x/l
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 advisedthat a copy of this statement may be forwarded to the Office of
Invbstigations of the DIA for insurance coverage verification.
I do hereby certi under the pa' ed alties of perjury that the information provided above is true and correct
Siature 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#•
ti
9924 Date..... -` ir.��.....
f NOR71{,
3j°.';�`` ;•�.."�o� TOWN OF NORTH ANDOVER
O 9
PERMIT FOR WIRING
F o''Y''•YY .',�'i
�,SSACMUSEt
. This certifies that .........S............v...........`....N... ........C..F....c....T {C.
has permission to perform .`...... 4:� .,,..!7.7/,q...�..............................
wiring in the building of...F��.�--.,a G..eo C.C.S........ S.....
at.... ..1.°1..I1'l/ /z........ ................................... .North Andover,Mass.
K DO
Fee.. .Z r-_' Lic.No.0.2.Vx4 4............. . �....
ELEcn iC;L 22ECCTI�
t Check #
` C®!s mon wealth of-Massachusetts Official Use Only
{ '912— '71
Department�` O��!!`� �Ci"�1/l��S [Occupancy
rmit No.
BOARD OF FIRE PREVENTION REGULATIONS and Fee Checked
. 1/07] leave blank
APPLICATION FOR PERMIT TO PERF®RM ELECTRICAL WORK
All work to be performed in accordance with the Massachusetts Electrical Code(AMC),527 CMR 12.00
(PLEASE PRINTININKORTYPEALLINFO TION Date:
City or Town o£ �' To the Inspector of Wires:
By this application the undersi ed givesno ' e of his or her intention to perform the electrical work described below.
Location(Street c&Number)_,Z /
Owner or Tenant
1-' 2 r' (>e2 t t l��S ���'�1 ,�S Telephone No.
Owner's Address
Is this permit in conjunction with a building permit? Yes ❑ No LDG PERMIT#
Purpose of Building Utility Authorization No.
Existing Service Amps _ / Volts Overhead ❑ Und rd
g ❑ No.of Meters
New Service Amps /_Vohs Overhead❑ Und rd
g ❑ No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work: ,(.
Completion of the following table may be waived by the Ins ector of Wires.
No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No.of Total.
No.of Luminaire Outlets No.of Hot Tubs Transformers KVA,Generators KVA
No. of Luminaires Swimming Pool Above ❑ In_ o.o mergency Ig ting
rnd. rnd. ❑ Batte 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
No. of N
Ranges o.of Air Cond.
Rang Total Initiating Devices
Tons No.of Alerting Devices
No. of Waste Disposers Heat Pump 1�Tumber Tons" KW No.of Self-Contained
Totals• Det-ction/A
lerting Devices
No. of Dishwashers Space/Area Heating KW Local❑ Municipal
Connection ❑ Other
No. of Dryers Heating Appliances KW Security Systems:
No. of WaterNo.of No.of Devices or Equivalent
Heaters KW No.of Data Wiring:
Signs Ballasts No.of Devices or E uivalent
No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring:
OTHER: No.of Devices or Equivalent
Attach additional detail if desired, or as required by the Inspector of Wires.
Estimated Value of Electrical Work: (When required by municipal policy.)
Work to Start: 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:)
I cert, under the pains and penalties ofperjury,that the information on this application is true and complete
FIRM NAME:
LIC.NO.:
Licensee:��`Q� � � r� ��n. j�� Signature
(I
.fa
enter `exempt"in the license number line.)
Address: , c k-C C C-, c-" Bus.Tel.No.:[�3 7 3 70�f-
*Per M.G.L.0,147,s.'57-61 securi ork requires Department of Public Safety"S"Licen Alt.LIC.1v10.: y 3 �,
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. [�PEAW�TFE�,E�.-$
I
i
ELECTRICAL PERMIT NO. INSPECTION REPORT:
ELECTRICAL INSPECTOR-DOUG SMALL
1.ROUGH INSPECTION:
Passed—[ ] Failed—[ ] Re-inspection required($50.00)-[ ]
Inspectors'comments:
(Inspectors'Signature-no initials) Date
2.FINAL INSPECTION:
Passed— Failed—[ ] Re-inspection required($50.00)-[ ]
Inspectors'comments:
f
(Inspectors'Signature-no initials) Date
3.UNDER GROUND INSPECTION:
Passed—[ ] Failed—[ ] Re-inspection required($50.00)-[ ]
Inspectors' comments:
(Inspectors'Signature-no initials) Date
4.INSPECTION—SERVICE:
DATE CALLED NATIONAL GRID: NAME:
Passed—[ ) Failed—[ ] Re-inspection required($50.00)- [ ]
Inspectors' comments:
(Inspectors'Signature-no initials) Date
5.INSPECTION-OTHER:
Passed—[ ] Failed—[ ] Re-inspection required($50.00)-[ ]
Inspectors' comments:
(Inspectors'Signature-no initials) Date
DOOR TAGS ARE TO BE FILLED OUT AND LEFT ON SITE IF THE AREA TO BE INSPECTED IS NOT
ACCESSIBLE AND A RE-INSPECTION OF$50.00 IS TO BE CHARGED.
1
The Commonwealth of Massachusetts
r Department of Industrial Accidents
= �, Office o Investigations
1 r Yi'! r• � g '
600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers
Applicant Information f l Please Prinf Le ibl
Name (Business/Organization/Individual): E4-- 6 20 t3 t� l l
Address: aG
City/State/Zip: Phone#: CC�3 <,' 7 ,5 7 V l
e--,l o
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I ama' employer with 4. ❑ I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
Z 2. I aia sole proprietor or partner- listed on the attached sheet. # ❑Remodeling
ry
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
officers have exercised their 10.❑ Electrical repairs or additions
required.] o
3.❑ I ain 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.] employees.[No workers' 1311 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 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 acid 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. Lie.#: Expiration Date:
r
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 and penalties of perjury that the information provided above is true and correct.'
Sienature• 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#:
r
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 numbers)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 confinnation 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' _
y m the event the Office of Investigations has to contact you regarding the applicant. i.
Please be sure to fill in the pen-nit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple•,pennit/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 pen-nits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or pennit not related to any business or commercial venture
(i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
Tel.#617-727-4900 ext 406 or 1-877 NUSSAFB
Revised 5-26-05
Fax#617-727-7749-
www.mass.gov/dia
Location
No. Date /01;;2(,1,-1410
TOWN OF Nb TH ANDOVER
' Certificate of Occupancy $
9
Buildin /Frame Permit Fee $
s,kNust
Foundation Permit Fee $
ther Permit Fee $ 3D. yd
TOTAL $
Check # 7-3
23606
Building Inspector
NORTH w"
O�,10LE0 16, YO
o TOWN OF NORTH ANDOVER
IL
h
SIGN PERMIT
��SSgcHus���y
DATE: October 26, 2010
PERMIT: S017-2011
THIS CERTIFIES THAT Frederick's Pastry Susan Roberts
has permission to erect. Wall sign 8' x 22"
on 119 Main Street North Andover MA 01845
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
,A& (�t6,,
•
Inspector of Buildings
Receipt: 23606
Paid: waived
f 1
Ax
Location th/m4�1 ,�Nc?/.,--
No. Date 10
7Z�64--6
�oRTM TOWN OF NORTH ANDOVER
�? •.. • 0
9
i Certificate of Occupancy $
Building/Frame Permit Fee $
It MU IL
Foundation Permit Fee $
6he Permit Fee $ .340. -00,
TOTAL $
Check # A 7-3
23606
Building Inspector
I
I
I
I
I
I
I
i
I
SIGN PERMIT APPLICATION
1600 Osgood Street—Building 20, Suite 2-36
TOWN OF NORTH ANDOVER
Map Parcel
DATE SUBMITTED
Site Owner _ac5stKo-- AQ2101 Applicant_f/e& )iJ 5 Vd5fy4S Tel coo 305 '1123
Site AddressI 1 q M ,✓1 !;� N a off Size of Proposed Sign oZ
INTERNALLY ILLUMINATED SIGN PROHIBITED
How attached: a) Against the wall � ��tz CK�''-S
b) Roof Illumination: a Not illuminated
c) Ground 6b Externally illuminated
d) Other
Materials:_ StG �
Proposed Colors: Background b�CIG�
Lettering qol
Border q'o — ivt lxvt�,
Required Attachments:
Photographs of building Note: No permanent/temporary sign shall be erected, or enlarged until an
_Material sample application on the appropriate form furnished by the Sign Office has been
Color sample filed with the Sign Officer containing such information including
Site or Plot Plan (Required for all free-standing signs) photographs,plans and scale drawings, as he may require, and a permit
drawings of proposed sign for such erection, alteration, or enlargement has been issued by him.
Other, specify Such permit shall be issued only of the Sign Officer determines that the
sign complies or will comply with all applicable provisions of the By-
Law.
Will sign overhang any public road or walkway Yes ( ) No
If Yes, Name of Agency who will provide liability insurance:
AN INCOMPLETE APPLICATION WILL NOT BE ACCEPTED
DATE FILED:
SIGN RE OF AP ICANT
A Tradition of excellence
9728 Date.../
ORTN
TOWN OF NORTH ANDOVER
0
PERMIT FOR WIRING
�,SSAckuSEt
This certifies that ................Pie-A......U.4t�--; ZAz....... ......
has permission to perform .......... 7- C�-A
..............................................................
wiring in the building of.........r ev)k �........................
at..... :;� .. ........................... North Andover,Mass.
... WMI....!
Fee./.?-. Lic.No. .......
24�
Check # f-/ !; ELECTRICAL-74/
i -------- Permit No. / 7 ,?-8
Department of Pane Services
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS [Rev. l/07j (leaveblank
APPLICATIONN
All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00
(PLEASE PRINT RV)NK OR TYPEALL INFORMATION Date: \d - r) ` �6
City or Town of: NORTH ANDOVER To the Inspector of Tires:
By this application the undersigned gives notice of his or her intention to perform the electrical work described below.
Location(Street&Number) \\,CA
Owner or Tenant Telephone No.
Owner's Address v k v-j'- r. S,.,
Is this permit in conju tion 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 � c>� Amps \A) VoIts Overhead Undgrd ❑ No.of Meters
Number of Feeders and Ampacity
Location and Nature of Proposed Electrical Work:'
Completion ofthe following table may be waived by the Inspector of Wires
No.of Recessed Luminaires No.of Cell.-Sus Fans No.of Total
P•(Paddle) Transformers KVA
No.of Luminaire Outlets () No.of Hot Tubs Generators KVA
No. of Luminaires Swimming Pool Above ❑ In- ❑ o.o Emergency Lighting
rnd. rnd. Battery Units
No.of Receptacle Outlets 'D() No.of Oil Burners FRE ALARMS No.of Zones
No.of Switches No.of Gas Burners No.of Detection and
Initiating Devices
Tot
No.of Ranges No.of Air Corid. Tons No.of AIerting Devices
No.of Waste Disposers Heat Pum Numbex Tons KW No.of Self-Contained
P Totals: ..... . .-........................ ..................... iDetection/Alertina Devices
No. of Dishwashers \ S ace/Area Heating KW Local❑ Municipal El Other
P g Connection
No. of Dryers Dr Heating Appliances KW Security Systems:
Y No.of Devices or Equivalent
No.of Water No.of No.of Data Wiring:
Heaters KW Signs Ballasts No.of Devices or Equivalent
No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications
No.of Devices or E uivalent
OTHER:
-Attach additional detail if desired,or as required by the Inspector of Wires.
Estimated Value of Electrical Work: C)(, J (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 .A BOND ❑ OTHER ❑ (Specify:)
I certify,under the pains andpenalties ofperjury,that the information on this application is true and conzplete.
FIRM NAME: C LTC.NO.:0,,_�t7�
Licensee: (, .l� ���Lr` Signature .
(If applicable,enter `exempt"in the license number line.) ( Bus.Tel.No -
Address: �50',\ G;�`J r�--h.c,� 6 r LN e ��e tT:.+—mac.cob- � � Alt.Tel.No.:i '3"-,: %
*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
Owner/Agent PERMIT FEE: $
Signature Telephone No.
4(�
Y
6 ,
The Commonwealth of Massachusetts
Department of Industrial,Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
a4 sY• www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): C,✓a` �� %� ��` C `nL
Address:
City/State/Zip: �1,e CC _"CAC' •- Phone
Are you an employer?Check the appropriate box: Type of project(required):
1.,92 I am a employer with 1-4 4. ❑ I am a general contractor and 1 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.# ❑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' 13.0 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 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:_ C�n� S
Policy#or Self-ins.Lie.#: Expiration Date:
Job Site Address:�� �^1 �t'- 5".z. City/State/Zip: \-J A cc
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.
I do liereb t fy and r t s and penalties of perjury that the information provided above is true 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#:
Date.
87 -53
�d�aa/l
40 TOWN OF NORTH ANDOVER
PERMIT FOR PLUMBING
• � a
,SSACHUS(c� ,e....��
This certifies that . . ._. . . . . . . .
k ci. . . .
has permission to perform . . .,pQ!Y��.✓. . . . . �. ov.... . . . . . . .`. . .
plumbing in the buildings of . . . . .. . . . . . ,�� �` !1.� P
at . . . . .�I.l.''ll. . �'l�. . . �� . . . . . . . . . . . . . North Andover,Mass.
Fee./0-?,)t./Lic. No.f 3*/*-t .-7 . . .
c PLUMBING INSPECTOR
Check 4 ����a
A CSU TT Ul 'OAl�JC AppLIC�-TIOj7 'Op,�FRMIT TO DO PLUMBING
-lV�AS
(Type or print) 5 `L1( 2 Z `!G
NORTH ANDOVER,MASS.A-CHUSETTS nom,LJ �- Date
)K//o ,g% Owners
Building Locatidn Amount
'I' e of occupancy
r;y ]T --
_ - TIev1 0 Renovation j�v Replacement Plans Submitted Yes No
FIXTU"S
Lyn)w
a Lo o
o rr !�.
w
H W C A A,
P, Q` s-a Ri H C�
� a
spa-Bsmc
Mff-OM a
mom
Check one: / certificate
(Print or type) j4 �j 20 . L=i off-
Installing CompanyName
� ��, ,/�,) N �.JG',/�' .C.t1-�• �G� L--1 Tanner. - -
Address ► "'
FirnalCo, -
Business Telephone
Name ofl icensed plumber: / ��'� ill, _
Insurance Coverage: Indicate the e of insurance coverage by checking the appropriate box:Bond
Liability insurance policy Other type of indemnity jj'_�1.�
Insurance Waiver: I,the undersigned,have been made aware thatthe licensee of this application does not hays any one o£the above
. three insurance _
. Owner � Agent
ignature
I hereby certify that all ofthe details and informs ionna have ns pp£oor �e��in above
bo T-tissued forthis applicac
plicationare.traeafxonwimll be ince
best of myknowledge and that all plumbing work
compliance with allpertineniprovisionsoftheMassachusetts teFluinbin ode dCha t 42oftheGeneralLaws.
By: igna o kens um er
Type ofPlumbingLicense
Title LJourneyman
icenr/ 'er
icity]TO-iNm e ~ Master
APPROVED(OFFICE USE ONLY - _
The Commonwealth of MJzNVachusetts
Department.af£radustsial�ccident�
office ref�Iivemt-,doors
' 60.0 Washington Street
$o,stan, AL4 02_1,7.1
- �t'►�'y►'-�iczs�go�/dia
Workers' Compensaizon Iusuraaxce Afficla-it:Builders/Contracfors[Electricxans/Pi-ambers
A.npiicaut Information '
Please Print Le6xbi�
Maine(Business/Ora nization/rndividual):
.A.ddxcLs:
City/State/Zip: Phone#:
-.A-re you an employer?Check_the appropriate box:
• 1.Q I am a employer with _ 4. ElI am a geheml contractor and I Type of project(required):
employees(full and/orpart time)*, have hired the sub-contractors 6. ❑Nein constauction
2.❑•I am a sole proprietor orpartner- listed on ALe3 attached sheet.1 7• ❑Remodeling
ship and have no employees These sub-contractors have 8. [l Demolition
working for me in any capacity, workers' comp,insurance,
o workers'com ins aranee �. 9. ❑Building addition
[No p. I] We are a corporation and its
required.] ofncers have,exercised their10•❑Blectrical'repairs or additions
3,❑.I am a homeowner doing all work right of er-cmptiou per MGL 11.0 Plumbing regain or additions
myself:[No workers'comp, c. 152,6-1(4),and we have no12, Roof repairs
insurance required.] t employees. [No workers' �
�.dmp,MmAranc�regnired.] 13-El Other
i��r tr? .,5_ironf til°.t C��Yn SJpv 4T M.--,alS(I Pu!Cat iL=EcctiL1n Cal^w.^.a ..0 V• ' _v
-==sTL'p Y..::j.•'...�^i—..,:-_-m.
IEomeownets wixo suamift tiC affidavit indicating Wig, $emg all-j-,ro c anti;:nen hire•ouYside con pct_ L–
��aS&rt 9-dErU t anew afndavit indicafing such.
+Contractors that cheCk thi-box mu—st a�..^he as addWonal sheet showing the
aame'of the sub-contractors and theirwerim,comp.poesy infomngon-
lam an employer that isproviding yunrkers'cora-pensaiian i
an_formmlan. nsurance for my employees BeXox;is the paficl)rind jab site.
Insurance Compiny Name.-
Policy#or Self-ins.Lic.A F-cpiration Date:
Job Site Address: City/State/Zip:
Attach a copy-of the workers'compensation poficy declarati..,on,page(slovdng the policy number•and expiration date).
Failure to secure coverage as required under Section 25A ofMGL c. 152 can lead to the imposition of criminal penalties of a
nue up to S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a nue
of up to 5250:00 a day against the violator, Be-advised that a copy ofthis statement may be forwarded fp the Office of
Investigations of the DIA for insurance coverage verification. _
I do hereby ceriiifp under the pins¢nd peitnities ofperjur��thre inormaiion proYided above is true¢nrl cors act
Siadatur•e:
- ___ Date• .._.
Phone#:
Official use only. .JVD nat writo in this irmz� to be c0mpletad,by CA',or toH n OfJICZCL�
City or Tovm: 1 ermitucense#
Issuing A.uthorRy(circle one}:
I-Board of Health 2,SuiIaim,Department 3. CiVTgwn Clerk 4.Electrical Inspector 5.Plumbing I=nspector
6,Other
Coxrtact Pet-son. - Plane'#
Location /''A/ � Ae�tlloll�-14/1
No. Date
,: NORTM TOWN OF NORTH ANDOVER
f �,r
~ L
Certificate of Occupancy $
MUs t� Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #
3 7 �3
Building Inspector
o,NO DT
0
r -r
e M�49
y�S`TAC NU`+f1
CERTIFICATE OF USE & OCCUPANCY
TOWN OF NORTH ANDOVER
Building Permit Number 338-2011 Date:November 19, 2010
THIS CERTIFIES THAT
THE BUILDING LOCATED ON 119 Main Street, Frederick's Pastries—
Susan Roberts
MAY BE OCCUPIED AS pastry shop IN ACCORDANCE WITH THE PROVISIONS OF
THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS
MAY APPLY.
Certificate Issued to: San Lau Realty Trust a/k/a First and Main Marketplace
109-123 Main Street
North Andover,MA 01845
Building Inspector
Fee: 100.00
Receipt: 23723
ORTH
Tovm of And
No. ti ... . ....
(1O LAKE `O dover, Mass.,
COC H I C ME
f?4TEO
J BOARD
PERMIT T DFood/Kitc n
Septic System
THIS CERTIFIES THAT C- J.AA4M) . ... ...! .. }. 'r /� BUILDING INSPECTOR
....... ... �..J.................... .C��.�+� ✓........ ....... ... Foundation
4l-1
has permission to erect. ................................... buildings on ... .......... (.&...s� ...... ................................... ough
to be occupied as.......... . ..... ......�. ........... ...ps,. e..1cit14..... .... . ey
provided that the person accepting this permit shall in every respect coform to the terms of the application on file in ina
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 INS�ECTrOR
( iz5 .�
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough
PERMIT EXPIRES IN 6 MONTHS Q Fi
ELECTRICAL INSPECTO
UNLESS CONSTRU - N ARTS <eq d �
Service
.........�................................................BUILDING INSPECTOR ,+ j-
Fina
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 FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner
d
Street No. S7
®.lam F
SEE REVERSE SIDE Smoke Det. (� l
THE COMMONWEALTH OF MASSACHUSETTS
STATE BUILDING CODE
CONSTRUCTION CONTROL AFFIDAVIT
On this 15th day of November, 2010 A.D. before me, for the State of New Hampshire, personally
appeared Richard E. Landry who, being duly sworn, deposed and says that he is registered to practice
Architecture in the Commonwealth of Massachusetts and that he has supervised the preparation of all
design plans and construction documents for the Renovations for"Frederick's Pastries" located at First
and Main Marketplace 109-123 Main Street, North Andover, MA and that such plans conform to the
applicable provisions of the Massachusetts State Building Code (7,nedition), the National Fire Protection
Association and that the materials specified for use in the construction conform with the Controlled
Construction Procedure therein defined (Section 116); and that a professionally qualified representative of
his office will administer the Construction Contract, and that he will make regular and periodic visits to the
construction site and prepare written progress reports of said visits to be sent to the permit granting authority
to determine that the construction is proceeding in accordance with the approved plans, and that he will
inform the Owner and the permit granting authority of any observed deviations from the approved plans or
applicable codes.
�\S-,FRED AR�y/
lz�)ERNESO,31/ 0
No.4496
(Signature) _ WINDHAM,
SO
(Registration o.)449 o N.H.
�J
V
9�Ty OF MP�c'P
SUBSCRIBED AND SWORN TO BEFORE ME THIS 15th DAY OF NOVEMBER, 2010 A.D.
My Commission Expires Z3
hl
(Notary ublic
THE COMMONWEALTH OF MASSACHUSETTS
STATE BUILDING CODE
CONSTRUCTION CONTROL AFFIDAVIT
On this 18th day of October. 2010 A.D. before me, for the State of New Hampshire, personally
appeared Richard E. Landry who, being duly sworn, deposed and says that he is registered to practice
Architecture in the Commonwealth of Massachusetts and that he has supervised the preparation of all
design plans and construction documents for the Renovations to The first floor space (E-1) located at
107-127 Main Street North Andover MA for Frederick's Pastries and that such plans conform to the
applicable provisions of the Massachusetts State Building Code (7 nedition), the National Fire Protection
Association and that the materials specified for use in the construction conform with the Controlled
Construction Procedure therein defined (Section 116); and that a professionally qualified representative of
his office will administer the Construction Contract, and that he will make regular and periodic visits to the
construction site and prepare written progress reports of said visits to be sent to the permit granting authority
to determine that the construction is proceeding in accordance with the approved plans, and that he will
inform the Owner and the permit granting authority of any observed deviations from the approved plans or
applicable codes. --�
1 \S,ERED AR
ERNEST� TFc
i rP 9� �
' _--.---- No.4496
(Si atute) ' 3
WINDHAM,
"(Ftegistratio o.)4496 o N.H.
�J
O
grTy OF MPSSP
SUBSCRIBED AND SWORN TO BEFORE ME THIS October 18th, 2010 A.D.
My Commission Expires 23 I
(No{ar�ublic)
1
IR SAN LAU REALTYTRUST
P.O. Box 308 Phone:978-686-8683
North Andover, MA Fax:978-681-8498
October 21, 2010
Brain Leathe
Inspector of Building
Building Department
Town of North Andover
1600 Osgood Street
North Andover, MA 01845
Re: First & Main Market Place
Unit E1, Frederick's Pastries
Dear Mr. Leathe,
San Lau Realty Trust and Frederick's Pastries agree to use the bathrooms located
at 119 Main Street, Unit E1, for employees only. The public will not be allowed to
use or have access to these bathrooms.
Signed and Agreed to:
SAN LAU REALTY TRUST FREDERICK'S PASTRIES
Anne M. Messina, Trustee S s -Lozier Robert,
M,afiager
COMMONWEALTH OF MASSACHUSETTS
On this thea\day of October, 2010, before me, the undersigned notary
public, personally appeared Anne M. Messina of San Lau Realty Trust and
Susan Lozier Robert of Frederick's Pastries, proved to me through
satisfactory evidence of identification, which was a copy of his/her
license, to be the person whose name is signed on the preceding or attached
document, and acknowledged to me that he/she signed it voluntarily for its
stated purpose.
Notary Public
Name-�
My Commission expires:
(VETTE JORGE
Notary Public
WCommonwealth of Massachusetts
My Commission Expires
May 13, 2016