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Miscellaneous - 123 MAIN STREET 4/30/2018 (2)
iQ9 MAIN ST Unit C-1 BUILUIlluFILE Date..��?4r.... C�NOp7M�ti TOWN OF NORTH ANDOVER 3?:' ��• °oma n PERMIT FOR PLUMBING I u� This certifies that.... ...4"'......................`..... .......................................................... .. �► . .+ ... a�-�-.......�?.. . z has permission to perform...... plumbing in the bui dings o ... /.. ..s.. '....T.....��.....1"l ?l-.. !.'' �— at.../... : ............... .. ' !<-................................................ North Andover,Mass. Fee.-�..eo....Lic. No. 1..x...1..`1.. ................................................................................. / ^�/7 PLUMBING INSPECTOR Check# .J( i z MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ^ CITY D 2 _�),1�P4t�-P 1� MA DATE a S J�( PERMIT# �� JOBSITE ADDRESS 1 3T-4t% r- _ OWNER'S NAME - /",0MVf EL OWNER ADDRESS ( TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL 50 EDUCATIONAL © RESIDENTIAL fl PRINT CLEARLY NEW: Fil RENOVATION:® REPLACEMENT: ® PLANS SUBMITTED: YES® N001 FIXTURES 1 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM ! E i ____1 P___( _._ ._ __ _! ._ i _ 6 ___. ! 1 DEDICATED GREASE SYSTEM d 1 f I _.____i ____1 _____( _.__ __! _.......__ E _ DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER I _I _.! DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN _I __--.- ! 1 1._...._ . INTERCEPTOR(INTERIOR) KITCHEN SINK LAVATORY I _--_! � J . _ ._.____f _-__-- ROOF DRAIN ___ ( SHOWER STALL SERVICE/MOP SINK TOILET I _ _E ! _l � .___.� ! .__-- ...__._ _A= URINAL F ....._.._- __. _.-- _._. i -.-_._j ....__ € .___..._! _....._._.j ..__-. f __-1 ._..__._i r----. WASHING;MACHINE CONNECTION 4 _....__j _-___) .._.__ � ( _..__.. ____. _I _.-__i .__j --J WATER HEATER ALL TYPES WATERPIPING OTHER -_.__i=.E.7 J= INSURANCE COVERAGE: 1 have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO Q IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY PS& OTHER TYPE OF INDEMNITY Q BOND 0 OWNER'S INSURANCE WAIVER:I aaware 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 0 AGENT �Q SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in co liance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME R�a fdTT-4 iN J k Pe T�rM� LICENSE# ��� S I SIGNATURE MPO JP 0 CORPORATION 0# f PARTNERSHIP Q# LLC COMPANY NAME �T�►_y P)k,, ,o� <z?,n ; ADDRESS 3S Liu u14rt .4 4(J CITY IZZ4C r,.�I _ I STATE ®ZIP Q f�2 4 —� TEL FAX9s')�s) j CELL 9j,!tyd-7?0j EMAIL ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION ES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES The Commonwealth of Massachusetts Department of IndustrialAccidents M - X Congress Street,Suite 100 A, 3 d Boston,MA.02114-2017 H www mass.gov/dia Workers,Compensation insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Please Print Le 'bl -. A �licant Information 1 z11 n �lNJ n^ Name(Business/Orgauization/Individual): Address: 6r4 iv V" U E M� Phone#- 9V- City/State/Zip: D n n t -011Z4 Are you an employer?Check the appropriate box: Type of project(fecluired); em to ees full and/or part 7. ❑N&*'dOnstruction l.�am a employer with P y 2.Q I am a sole proprietor or partnership and have no employees Working for me in 8. Q Remodeling any capacity.[No workers'comp.insurance required] 9, ❑Demolition 3.Q I am a homeowner doing all work myself[No workers'comp.insurance required.] 10 Q Building addition 40 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 11.Q Electrical repairs or additions ensure that all contractors either have workers'compensation insurance or are sole bin repairs or additions proprietors with no employees. 12 Pium- g p S.QI am a general contractor and lb-ave hired the sub-contractors listed on the attached sheet. 13.,Q Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 14.rj Other 6.Q We are a corporation and its officers have exercised their right of exemption per MGL 0- 152,§1(4),and We have no e_mploydes.[No workers'comp.insurance required.] *Any applicant that check's box#1 const also fill out the section below showing their workers'compensation policy information. Homeowners who subQi,thi affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such tContractors that check this box must attached'n additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: rf •� • _ Expiration Date: A— Policy#or Self-ins.Lic.#: 00 ►' e- �-��� 0 Job Site Address: 1d_5 /A'JaA) S•1- City/State/Zip: /U , OU- r Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL e. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby cern der the pains and enalties of perjury that the information provided above is true and,correct. ` Date: Q�' �f-r—l s/ Signature: 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 Phone#• Contact Person: 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 hixe, express or implied,oral or written.,, An employer is defnied as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enferprlse,and including the legal representatives of a deceased employer,or the receiver'6z 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 b6 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 ofpublic 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 certificates)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"rob 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 Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel.#617-727-4900 ext.7406 or 1-877-MASS.AFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia ¢ COMMONWEALTH OF MASSACHUSETTS PLUMBERS ANDS GASF ITTERS ISSUES THE FOLLOWING LICENSE } LICENSER AS A JOURNEYMAN PLUMBER. FRANK: E POTVIN 35 LEONARD AVE' z J D12ACUT 14A 01826-2417 i 16204 05/01/16 - 214530 I Location No. 1 a i - A -,z Date s MORTIy TOWN OF NORTH ANDOVER pt 1 3? i • O ►O. a Certificate of Occupancy $ 11r-A CNUSE<�' Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 9.7 2� 5u 's Building Insfor -o�*M �. CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Permit# 104(8/7/2008) Date: October 5,2009 THIS CERTIFIES THAT THE BUILDING LOCATED ON 123 Main St - Unit C-1 — Today's Barber MAY BE OCCUPIED AS Retail Tenant Fit Up ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: San Lau Realty Trust 123 Main St North Andover Ma 1845 T� Building Inspector ORTP Town of No. o "over, Mass., cp 7 Q LAKE COCMICMEWICK 21,95°RA r e o Pi, ,CC7 BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System BUILDING INSPECTOR THIS CERTIFIES THAT. ....... .................................................... Foundation has permission to erect.:...................................... buildings on ...� ,3.......... .. . . ......... '. .. Rough to be occupied as..... /��Lt r���� Chimney provided that the person accepting this permit shall 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 Insppqion, Alteration and Construction of Buildings in the Town of North Andover. �� �S �fir UMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit.. -- /J/oi- Final PERMIT EXPIRES IN 6 MONTHS UNLESS CONSTRUCTION TARTS ELECTRICAL INSPECTO ................. ....... " ............................. Service BUILDING INSPECTOR in �L Occupancy Permit Required to Owipy 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 DEP 71PN Until Inspected and Approved by the Building Inspector. Burner Street No. SE E REVERSE SIDE Smoke Det. v D f pORT/ O tY .a`•1N Sir b•` e•OL NORTH ANDOVER BUILDING DEPARTMENT S " S yam 1600 Osgood 'SS��» St� � Street North Andover Tel: 978-688-9545 Fax: 978-688-9542 BUSINESS FORM FOR TOWN CLERK DATE:— �J --- N < C tosl ' ADORES s: ZONING DISTRICT: TYPE OF BUSINESS: j BUILDING LAYOUT PROVIDED: YES NO AVAILABLE PARKING SPACES: ZONING BY LAW USAGE: YES NO BUILDING INSPECTOR SIGNATURE r> ',, 7. 2.40 Home Occupation(1989/32) An accessory use conducted within a dwelling by a resident who resides in the dwelling as his principal address, which is clearly secondary to the use of the building for living purposes. Home occupations shall include, but not limited to the following uses; personal services such as famished by an artist or instructor, but not occupation involved with motor vehicle repairs, beauty parlors, animal kennels, or the conduct of retail business,of the manufacturing of goods,which impacts the residential nature of the neighborhood. 4. For use of a dwelling in any residential district or multi-family district for a home occupation, the following conditions shall apply: a. Not more than a total of three(3) people may be employed in the home occupation,one of whom shall be the owner of the home occupation and residing in said dwelling; b. The use is carried on strictly within the principal building, c. There shall be no exterior alterations, accessory buildings, or display which are not customary with residential buildings; d. Not more than twenty-five(25)percent of the existing gross floor area of the dwelling unit so used, not to exceed one thousand (1000) square feet, is devoted to such use. In connection with such use,there is to be kept no stock in trade, commodities or products which occupy space beyond these limits; . e. There will be no display of goods or wares visible from the street; £ The building or premises occupied shall not be rendered objectionable or detrimental to the residential character of the neighborhood due to the exterior appearance, emission of odor, gas, smoke, dust, noise, disturbance, or in any other way become objectionable or detrimental to any residential use within the neighborhood; g. Any such building shall include no features of design not customary in buildings for residential use. Zj Signature Date Capital Auto Wholesalers 32 Marblehead St. North Andover, MA 08145 September 28, 2009 I, James M Paine DBA Capital Auto Wholesalers 32 Marblehead St. N. Andover, Ma Ol 845 will be working out of the home office. The home based business in tales purchasing vehicles on the internet from out of state and local auto auctions. Any vehicles purchased for C.A.W will be bought and sold at the auction. The home location will not be used for retail, service, storage and or any automotive use. t Date James M Pai Date...9....a.:............... f ,AOR q 3r0—c :•�.4, TOWN OF NORTH ANDOVER p PERMIT FOR WIRING SACMUS� This certifies that ...... ......C .......... ................................ has permission to perform-��.. - -� �- wiring in the building of....`. .... %" �............ -�- ... - at . ... . ........ .. ,North Andover,Mass. r a d Fee..�.c........... Lic.No.'�09•�7............ . ELECTRICAL INS CTO Check # e ?-7 8371 Commonwealth of Massachusetts Official Use Only Permit No. _ Department of Fire Services Y Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.9/05] 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 INF RMATION) Date: 9 A.2- City or Town of: h� v 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) /62 / 6 G' Ld Owner or Tenant2 Telephone No. Owner's Address Is this permit in conjunction with a building permitjs Yes No ❑ (Check Appropriate Box) Purpose of Building ;k �//tQ R c�/1yQ° 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: Completion of the ollowin table may be waived by the Ins ector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans r o ota Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ n- Elo.o Emergency Lighting rnd. rnd. BatteryUnits No.of Receptacle Outlets No,of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners o.o eteng D an Initiating Devices No.of Ranges No.of Air Cond. Total Tons No.of Alerting Devices No.of Waste Disposers eat ump um er ons o.oSelf-Contained Totals: Detection/Alerting Devices Munici al Other No.of Dishwashers Space/Area Heating KW Local❑ Connection E]No.of Dryers Heating Appliances KW echo oSystems:* Devices or Equivalent No.of Water KW oof No.of Data Wiring: Heaters Signs Ballasts No.of Devices or E uivagglent No.Hydromassage Bathtubs No.of Motors Total HP elNa of Devices or Eqummunications ivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) ON Work to Start: 02748 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 1. the licensee provides proof of liability insurance including`completed operation"coverage or its substantial equivalent. The undersigned certifies that such Covera is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE [T OND ❑ OTHER ❑ (Specify:) I certify, under the pains andpenaldes ofperjury,that the information on this application is true and complete. FIRM NAME: LIC.NO.47-2 7 Licensee: / ( �',d{yG'�' Signature , ,/,����.-�� LIC.NO.: (If applicable,enter"exempt"in the license number line. p Bus:Tel.No..r�T.Y� Address: 13 x/14 �r d�4t�tidV Qa4 Alt.Tel.No.:9MfL-1V *Security System Contractor License required for this work;if applicable,enter the license number here: 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 rPERMITFEE.Signature Telephone No. � o f J 1 S ti c P August 15, 2008 Town Manager Attn: Mr. Mark Rees 120 Main Street North Andover, MA 01845 G� RE: Notification of Initial Site Investigation and Tier II Classification Messina Plaza North Andover, Massachusetts RTN# 3-0027047 Dear Mr. Rees: In accordance with 310 CMR 40.1403(3)(e), GZA GeoEnvironmental, Inc., on behalf of San Lau Realty Trust, is providing this written notice to you that an Initial Site Investigation has been completed for the above-referenced property. In the Phase 1 Initial Site Investigation and Tier Classification Report, it was concluded that additional response actions are required at this site prior to the submittal of a Response Action Outcome Statement. Additional soil contamination delineation and periodic groundwater monitoring will be required to more fully characterize the site. Based on the absence of inclusionary criteria and a Numerical Ranking System score of 281, this site is a Tier II site". A copy of the Initial Site Investigation and Tier Classification Report is available by contacting the file review office of the Northeast Regional Office of the Department of Environmental Protection at 978-694-3200, or by visiting the file review office located at 205B Lowell Street in Wilmington, Massachusetts. If you have any questions, or require additional information,please contact this office. Sincerely, GZA GeoEnvironmental, Inc. S� aL Karen D. Leavitt Project Manager cc. BWSC/NERO San Lau Realty Trust i - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - I 11'1O° P Q p0 i Q �+ e r p F 4 X31 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -- s roc H.H. Morant & Co., Inc. 3 Messina's Shopping Center O8-005 3 1013 - 123 Main Street Date �a North Andover MA ID�/21/�S 221 Washingtonton Street t -n Salem, Massachusetts 01970 1 5udding "1=" - Slab Demo X16 _ V-� 978 744-5354 �978� 740-9161 fax POLICE �iia:;:a-ui.i dal - ®� •i �• s • e •m — • E 1 l� Q E F A R T M F N T July 8, 2008 Anne M. Messina San Lau Realty Trust P.O. Box 308 North Andover, MA. 01845 REF: Messina's Shopping Centre, Main Street, North Andover Dear Ms. Messina, As we discussed yesterday, I am confirming the addressing that has been established by the Town of North Andover for the businesses located within the Messina Shopping Centre. These addresses were established back in the mid 1990's and the businesses in the shopping centre at that time were notified. Our review of the existing addressing resulted in the agreement that no new addressing was required for the existing buildings "A"through "H" as shown on your attached Exhibit A]. I have added in red on Exhibit Al the correct addresses for the buildings. Some of the buildings have more than one business and suite numbers do exist for each of those businesses. Our current information on suites for businesses within the shopping centre is as shown on our attachment to this letter. You have inquired about addressing for a new structure to house a bank ATM in the corner of the parking lot near the Main Street and First Street corner. Once you have received the appropriate permits, approvals and the structure is built, it would be assigned an address of 107 Main Street. I appreciate your concern to insure proper addressing for the businesses within the Messina Shopping Centre and if I can be of further assistance please do not hesitate to contact me. I can be reached at my office 978-683-3168. Sind ely, N2 'Richard C. Boettcher Director Administrative Services Division Cc: Mark Rees —Town Manager Richard M. Stanley— Chief of Police 566 MAIN STREET, NORTH ANDOVER, 16 SSACHL'SETTS 01845-4099, TeleDhone: 972-683-3158 Fax: 972-681-1172 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. C 11 Exhibit " Al " SCHOOL STREET MEM M -IRMO TT ' C • B C D �� voro—AnJ =—Iil Q]�) F ❑a❑❑ v I : d d G I z 4 4 I ❑�� rn m RT&U l t � H ATM Ki q NMI ' O CA FIRST STREET . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Date.... �+ �..n .... pORTI� TOWN OF NORTH ANDOVER p PERMIT FOR WIRING SS US �� �. This certifies that ............................ ............................... ................................ has permission to perform ......,. -�L: . ... -- U .�........ .................................z wiring in the building of.N.`.d� ^. �-�' �� �'- �' �✓� �*�-�j` at n ..... .. mac-- j '.... North Andover Mass. .................... , Fee...�............. Lic.No?q ZZ?.......... . .::.... ELECTRICAL INSPE ro ' Check N `� 7668 Commonwealth of Massachusetts Official Use Only - Department of Fire Services Permit No. G S, BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked Rev.9/05 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: 9/24/2007 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) 109 Main Street Owner or Tenant San Lau Realty Trust Telephone No. Owner's Address 109 Main Street North Andover,MA 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 200 Amps 110 / 220 Volts Overhead ® Undgrd. No.of Meters 1 Number of Feeders and Ampacity Location and Nature of Proposed Work Temporary Service for Construction Trailer Completion of the ol ving table may be waived by the Inspector of Wires. No.of Recessed Fixtures No.of Ceil:Susp.(Paddle)Fans No.of Total KVA No of Lighting Outlets No.of Hot Tubs Generators KVA No.of Lighting Fixtures Swimming Pool Above ❑ In- ❑ No.of Emergency Lighting Grnd. Grnd. 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 Ranges No.of Air Cond. Total Tons No of Alerting Devices Ido of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained hYo.cM Dishwashers Space/Area Heating KW Loca u ctX Other Connection ❑ No.of Dryers Heating Appliances KW Security Systems No.of Devices NA or Ennevalent No.of Water KW No.of Signs No.of Data Wiring No.of Devices or NA No.Hydromassage No.of Motors Total HP Telecommunications Wiring No. NA Rnthtnh,Other ttac t additional etai i desired,or as required by the Inspector of Vir-es Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start 9/25/2007 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 permit issuing office. CHECK ONE: INSURANCE ❑X BOND ❑ OTHER ❑ (Specify:) July 2008 (Expiration ate I certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: Crocker Electrical Company Inc. LIC.NO.: A 7197 Licensee: Edward Crocker Signature LIC.NO.: A 7197 (If applicable, enter "exempt"in the license number line) Bus.Tel.No.: 617-773-1030 Address: 115 Sagamore Street,Quincy,MA 02171 Alt.Tel.No.: *Security System Contractor License required for this work;if applicable,enter the licence number here: 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 0 , Mowner agent Owner/Agent , GC2 Telephone No. Cirmofixn PERMIT FE The Commonwealth of Massachusetts Lh 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/Organization/Individual): j� Address: City/State/Zip: 49//.7 C y _ 0,,pLi7/ Phone #: a l,;l'—.72 3 Are you an employer? Check the appropriate box: Type of project(required): 1.a I am a employer with as_ 4. ❑ I am a general contractor and I 6. [J eew 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. 0 emolition 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 10.0 Electrical repairs or additions required.] 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.E] Roof repairs insurance required.] t 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 are doing all work and then hire outside contractors must submit a new aliidavit 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. ,2 Insurance Company Name: �-i� ,SdS Policy#or Self-ins. Lic. #: 14.1r- F5/677 41 2 3 Z Expiration Date: de Job Site Address: //5) �Qi�! ��7� 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 nalties of perjury that the information provided above is true and correct. Si nature: Date: f3 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#: