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Miscellaneous - 133 MAIN STREET 4/30/2018 (3)
`- t�S� t� P► Z.Z-a f E E 1 '1 67 �) Date... `�.I�.(�l._/..... TOWN OF NORTH ANDOVER to PERMIT FOR PLUMBING CHU This certifies that...... ........ ......... has permission to perfonn... X plumbing the buildings of at............... ..............m.......... ........... North Andover, Mass. ........ ....... Fee................ Lic. No. ..... ................................................................................ PLUMBING INSPECTOR Check r.' R � MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY �� 3 9 -- PERMIT# ' �f2T �.�.� MA DATE _ JOBSITE ADDRESS OWNER'S NAME POWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL ET EDUCATIONAL © RESIDENTIAL 0] PRINTPLANS SUBMITTED: YES Q No CLEARLY NEW: B RENOVATION:® REPLACEMENT: FIXTURES-1 FLOOR-; BSM 1 2 3 4 5 6 7 � 8 i 9 10 C 11 ) 12 C 13 14 C BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM __-_l _ I .----! •--_-1 — --- — —!' -—! - DEDICATED GASIOILISAND SYSTEM I _ _. i • --j DEDICATED GREASE SYSTEM -----C --- ---� DEDICATED GRAY WATER SYSTEM i .-. - € -- -C ---`- DEDICATED WATER RECYCLE SYSTEM DISHWASHERt DRINKING FOUNTAIN i ._-_-___C _-----i -----._I _-_._( _..�I __.__._i _._.-___i _---_-! ----_._� [ _-_-__1 FOOD DISPOSER FLOOR!AREA DRAIN I I INTERCEPTOR(INTERIOR) ._ _--- _j i _---_.J KITCHEN SINK _I 3 � LAVATORY ROOF DRAIN __ i __! __ J _ i ___i ___1 _ _ _.1 -_-_._�i ----'\ SHOWER STALL ! I � SERVICE 1 MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPESWATER PIPING - ! --f ---- i i ......_.__� I ___J INSURANCE COVERAGE: o have a current liabilityinsurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO 0 M IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW \ LIABILITY INSURANCE POLICY[ OTHER TYPE OF INDEMNITY © BOND �I OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER E-11 AGENT I® SIGNATURE OF OWNER OR AGENT d regarding this application are true—a I hereby certify that all of the details and information I have submitted or enterend accurate the best provision of the of knowledge and that all plumbing work and installations performed under the permit issued for this application will be incompliance with all Pertinent provi Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME �I� _ L!r>ca - I LICENSE# CD S GNATURE MPH, ipQ CORPORATION .J#zn�PARTNERSHIP0#®LLC Elft COMPANY NAME �/oL�rrpo f-S •_ F ADDRESS CITY �c/t- -- _ _� STATE �ZIP O Z/ _ TEL FAX _ p CELL .... EMAIL -- ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECT O OTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES ` I The Commonwealth of Massa chusetts A Department of IndustrialAccidents y --•.d I Congress Street,Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. y Applicant Information Please Print Lesibly Name(Business/Organization/Individual): Address: City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.❑I am a employer with employees(full and/or part-time).* 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t ❑ 4.FJI am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.E]Plumbing repairs or additions 5. I am a generacontractor and I hhid thb ttlid thtthedhet have hired sub-contractors listed on e attached se . ❑ l 13.0 Roof repairs These sub-contractors have employees and have workers'comp.instuance.$ 6.F1 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have no.employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. 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 state whether or not those entities have employees. If the sub-contraciors 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: Policy#or Self-ins.Lie.#: 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 MGL c. 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. I do hereby certify under the pains and penalties 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#: 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=contractoi(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should'enter their self-insurance license number on the appropriate line. -' City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The 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-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia Date.............. �. ................ F NORTsy o TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION ,BSACHU5E This certifies that ..............'Q... .......... ................................... has permission for gas installation . :� '�= l r{,- �` • in the buildings of........ �!!'.�'`�u .............................. .......................................................................... `--� -�' �'�^ North Andover, Mass. at................�.....2................. ............................., Fee... Lic. No. .S5..A..... Check# 19 GAS INSPECTOR MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY [icor 1��IJe��2 � MA DATE 3 / PERMIT# IO� � JOBSITE ADDRESS 3 Hix/ 5-% OWNER'S NAME . Coti f OWNER ADDRESS TE FAX[_,��� TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL RESIDENTIAL El PRINT CLEARLY NEW:IT RENOVATION:El REPLACEMENT: PLANS SUBMITTED: YES r---Jl NO[3 APPLIANCES Z FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER LZJ EQ . , . l -_ �i. _ _ BOOSTER CONVERSION BURNER _ COOK STOVE DIRECT VENT HEATER .-� DRYER - FIREPLACE 1.:._ 1 . . T - �� - it FRYOLATOR - FURNACE GENERATOR GRILLE INFRARED HEATER _ _ LABORATORY COCKS (� ( �- I ._._. - l MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT I _ I TEST UNIT HEATER I �. UNVENTED ROOM HEATER WATER.HEATER i_ .. i.-.._ J _. _ _ _ _ I . OTHER__ I III It INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES _. NO [�]! IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY e OTHER TYPE INDEMNITY EI BOND OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT 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 compliance with all Pertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. a44Z-4- . PLUMBER-GASFITTER NAME L Lc� �_ � o -Z ]LICENSE# R3 SIG ATURE MP Ln MGF[� JP [I JGF LPGI E1 CORPORATION C—.J# ld �S PARTNERSHIP©#�� { LLC D#= COMPANY NAME: .fQo�cQO _ sS r!. ADDRESS Z C' i _ _ _ —Ji CITY /� _it STATES ZIP D' S TEL FAX j CELL EMAIL — ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTILON NOTES I Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES The Commonwealth of Massachusetts r. Department of IndustrialAccidents ti d 1 Congress Street, Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Le0bly Name (Business/Organization/Individual): 114-->v/Zd �'` Address: 5 C �fd-�f t4 tel' City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(re4uired): 1.❑I am.a.employer with employees(full and/or part-time).* 7. ❑New construction 2.Q I am a sole proprietor or partnership and have no employees working for me in $. El-Re any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.Q I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 4.EJI am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 E]Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs or additions 5.FJ I am a general contractor and I have hired the sub-contractors listed on the attached sheet. These s4-contractors have employees and have workers'comp.insurance. 13. Roof repairs ub 6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. f Homeowners who submif this 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 an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-conlraciors 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: Policy#or Self-ins.Lie.#: C Y9 1n� Expiration Date: Job Site Address:l 3 3 &At W S lid k7• f A41-00 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 MGL c. 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. I do hereby certify under the pains andenaIt' s of perjury that the information provided above is true and correct. Signature- C--<– Date: l � Phone#• 7 17— Official 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#: t-� Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall. enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill-out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub=contractors)name(s),address(es)and-phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you'are required to obtain a workers' compensatiori'policy,please call the Department at the number listed below. Self-insured companies should'enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The 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-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia i • I I 1 j .. �( Ii1VIOVWEALTH piF MakAGHI�SE t CS • • . . • �:: 'i 1ttB15x ANpASFTTRS IS5US" THE F0LLCfW LICENSE., L t CE�f EI) AS A MASTERPL=t. BER � AL1 RED A Sf'OL f D0�t0 ` 23 CHAMlz P.A iL .EaICA h1A E11821. 29. 4 8326 05/01! 6 �9917� F �.w..,r i I ' 1 Date...,3,A-//5- .................... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING 12e This certifies that. //1 .,L j, /... .......................................... .. ............................................................... has permission to perform...4el�. e1i ... ...................................... plumbing in the buildings of.. ............................. .............. ... ............................................. at...... 1- 114,- /- ............................................................................................... North Andover, Mass. Fee.. CT7.-ro...Lic. No. ............;,..... ................................................................................. IPLUMBING INSPECTOR Check# Z . i MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY a C ubo v�!L � MA DATE 3 .� /S~ ( PERMIT JOBSITE ADDRESS 3 3 (v 5% ( OWNER'S NAME POWNER ADDRESS TEL FAX TYPE OR OCCUPANCY TYPE COMME CIAL EDUCATIONAL Q RESIDENTIAL Q PRINT CLEARLY NEW: Q RENOVATION: REPLACEMENT:Q PLANS SUBMITTED: YES Q NO FIXTURES Z FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OIL/SAND SYSTEM I ,_-.-__I DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM r - ... ( ( ___. DEDICATED WATER RECYCLE SYSTEM I J _....._( __. _.— 1 . I ► ! .__ 1 f _-_..._( _._..1 -I —_..1 DISHWASHER DRINKING FOUNTAIN I ( f FOOD DISPOSER 1[-_1 ._.._w_J FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) l I _.. ; 1 f _..__I � _ _i 1 f _-._.._J IF KITCHEN SINK _ ± _ _. _.1 f _.._- �( -----! .__.- LAVATORY ROOF DRAIN SHOWERSTALL SERVICE/MOP SINK I ___._l __f -_.___( ( __.__I _ [ ._.__I ► __..�I ___.I l TOILET s` ___..... ( E_ 1 I __-_I . l -_-__ f URINAL ...___ ...- _1. .------.i WASHING MACHINE CONNECTION _ ' .- _-- s ____...' _._.w. ! _. _..! I WATER HEATER ALL TYPES WATER PIPING i OTHEI'tI L-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 Q IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY 2OTHER TYPE OF INDEMNITY Q BOND QI- OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER Q AGENT Q SIGNATURE OF OWNER OR AGENT I 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 compliance with all Pertinent provision of the h4assachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME (LICENSE# 8 3-Z GNATURE MID e JP Q CORPORATION fI# . 8 S,j PARTNERSHIP Q# LLC�#! COMPANY NAME ; ADDRESSz J1 CITY /z ..__...._..._...._ STATE _ ZIP pJ Zl —� TEL — r. FAX E CELLI EMAIL ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOAS Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES The Commonwealth of Massachusetts - - Department of Industrial Accidents Office of Investigations 600 Washington Sheet Boston,MA 02111 www.mass gov1dia Workers' Compensation Insurance Affidavit:Builders/Cont°actorsfFIectricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Tindividual): iazzooxe —a° SD V 5 Address: Z �12tfeere City/State/Zip:,,/ ��` �s9 ©/ 7 f Phone#• ?7,4—�7 Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 3`�-' 4• ElI am a general contractor and I 6. [JNew 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.t '1. �g ship and'have no employees These sub-contractors have 8. E]Demolition working for mein any capacity. workers'comp.insurance. g, ❑Building addition [No workers' comp.insurance 5. El are a corporation and its 910.El Electrical repairs or additions required.] officers have exercised their 3.El am a homeowner doing all work right of exemption per MGL 11.El Plumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no 12.❑Roofrepairs insurancere iced. i 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. tContractors that cheektbis box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. r am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. lr� Insurance Company Name% lee Z&Zl / Policy#or Self-ins.Lie.#: ExpirationDate: Job Site Address:./3-7/lAf ! .�D�f�t �I� 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 requiredunder Section 25A ofMGL o. 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. X do hereby cert&under the pains andpenalties of perjury that the information provided above is true and correct. - Siafore• 3 . Date: �/ef' 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.EIectrical Inspector 5.Plumbing Inspector 6.Other - Contact Person: Phone#: t ' . 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 ofhire,- 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 employes." 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 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 thatthis affidavit maybe 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 whichwill 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(ifnecessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. Anew affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank:you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: T`he Cemmouwalthof�►"assarhvsPtts Department ojfhtdustriial Accidents Office ofInves6gatiious 600 WasW.Vm Street Boston,MA.0.21 If `Q1.#6X7-721.7 49QQ ext 406 Or-Z-877�YJASSAFF, Revised 5-26-05 Fax#617-727-7749 _wWwauass,govfdia o <: OMMONWEALTH OF MQ. . AHUSETT : :'< BQA ?'Q ;>PLUMBE S':A:ND GAS:FITT: ERS < i S SUEST..HE FOLLOWIAIG` 'l GEHSE <; ;. LICENSER A'S A JOURNEYMAN PLI�MBE w ALFRED ASPOLIDOO 23 CHAMP..A` RD `•,`t���.a,:;�� I J % , :<.;::., MA 01821-2g E E I CA o'"/Q 1./�=:6; »< 19917 0 16lort.-<, : . E OMMONW"LTH OF MA SACHIJSEl'TS.. PLl1MBEf�S"�'ND GASF ITTERS ISSUES THE FOLLOWING :LiirENSE CEISEi1 AS A MASTER PLUMB'E�R A SPOL I DMI6 ! o 5\ 23CHAM:PA #�D W F I CLLEf ICA MA 01821- AX.2914 832 ogyol/16 199171 3i�e�••f e��OVL ANCY,SS�CH��E4 CERTIFICATE OF USE & .00CU TOWN OF NORTH ANDOVER Building Permit Number__Date: May 10, 2012 THIS CERTIFIES THAT THE BUILDING LOCATED ON 133 Main Street—House Of MAX BE OCCUPIED AS Restaurant IN ACCORDANCE WITH T . Pizza— HE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. 16 se's i Certificate Issued to: Nick Papaioannou 350 Kenoza Avenue Haverhill,MA 01830 Building Inspector Fee: 100.00 Receipt: 25289 Check :119 ,I Location /33 /v 7 f N Sk- No. S Date /2-- z • • TOWN OF NORTH ANDOVER 5,A,fir.ru r���, • • Certificate of Occupancy $ Building/Frame Permit Fee $ t ' Foundation Permit Fee $ xOther Permit Fee -� ^�s $ — TOTAL Check# Q 25233 Building Inspector QF NORTH qw. �S1„ED 16Y 'YO o TOWN OF NORTH ANDOVER h '�I���� � ���w�•,��� * SIGN PERMIT A�R'ITED �SSACHt15�� DATE: April 25, 2012 PERMIT: S026-2012 THIS CERTIFIES THAT Nick Papaioanou — House of Pizza r has permission to erect. Wall sign 12"x5" on 133 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. II INTERNALLY ILLUMINATED SIGNS ARE PROHIBITED Inspector of Buildings Receipt: 25233 Paid 30.00 nY ., NORTH Ot.S L•E� 16 TOWN OF NORTH ANDOVER SIGN PERMIT � .7 'o:i�i'uk:OM1• 0'4Ari ED SACHU DATE: April 25, 2012 PERMIT: S027-2012 THIS CERTIFIES THAT Nick Papaioanou — House of Pizza has permission to erect. 2 piece 4"x4" and 1 pc 1"x5" on 133 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 .J . Inspect r of Buildings Receipt: 25233 Paid 30.00 - I SltGN PERMIT APPILIECATRON 1600®890®ell Street Building 20,Suite 2-36 TOWN 07 NORTH ANDOVER Date: S 2_ _Name of appiIca nt who is purchasing the sign Site Owner -sin, LaPl Phone#of applicant who is purchasing the sign 17——714— Site Address 1 Name of sign company, u)r�' I Z he Phone# Man _Parcel I Size of Proposed Sign Z c ' Illumination: a) ot-illuminated Plow attached: a)Against the wall_12. , x S ternally illuminated b)Roof c)Ground c)Externally illuminated d)Other e-x i 5 •m e A liter*ials: Gt 1 L ir» i n um Ce moi{ Proposed Colors: Background Y Lettering Border Cost of Simon n G n�Va l� Reanui red Afteh n ennts: 2121e: No permanenthemporary sign shall be erected,or enlarged until an Photographs of building ✓ application on the appropriate form furnished by the Sign Office has been filed Material sample✓ with the Sign Officer containing such information including photographs,plans Color sample✓ and scale drawings,as he may require,and a permit for such erection,alteration, Site or Plot Plan(Required for.all free-standing signs) or enlargement has been issued by him. Such permit shall be issued only of the Drawings of proposed sign✓ Sign Officer determines that the sign complies or will comply with all Other,specify applicable provisions of the Ey-Law. Will sign overhang any public road or walkway Yes( ) No(� If Yes,Name of Agency who will provide liability insurance: AN INCONNDLETE APPLICATION WILL NOT BE ACCEPTED DATE PIED: Receipt# Check# Revised 10.31.2006Form Sign Permit Application SIGNAT OF APPLICANT APPROVED BY a (2x)48"x with 3 blank spaces ,+ . oche � for other businesses � X _ 4"'! ,'l .rs A'y�.c 7�TM �,'iud7p i �u�3� F P+. ) 7 �✓ID 91Y +��'.v (Dj I Z7�,y 2 01, f P 1 a0l, Of P JLed � � Y S u i' � 3 t�+++t♦1 1 (1x)12"x48"sign for above door j 9 + ,•y...,_.. .,:'li.,.`}��:� ��! mss.. ".'"'t� r J � r...r....- ..-........- .. _ .... _ _ NING ..& Take Out 106 CASUAL i � < W P17Z S 3ESIGN IS AN OR'G4JAL.r'dl.=,Trli�T?.F CQ-=` ,:!T=R=D i-if 7Rr.VSFFf:aFD F'�ANY 1:=TH;:� J�l p f,\( BOX Bridge S! 301i,r, NH 020?611-AG0-527-7g4F. fax - E-!,9ail ir�fo�lh�a�nmac�ndsc�ns corzi �wkrvr.l'3rrirriar�ndst}�1s.r•�ri - � ININ�� cc ExistingSign: Paint existing wooden sign white and. apply (2) 4'H x 47"L 04 ed Aluminum Panels !with Hih ! 23 Gold iexistingsigndecorated as shown on. - .sa y , c [� GNadh Andover MA.�01845 8�n 6 7 Gnd �. S; -olhan, NH 73;7!6 1-RGO-bel i49Sn ;;all ica>It rnrna^ana ons cora www.f'amrnerartdsGais.cczra 01 53 Date....................... TOWN OF NORTH ANDOVER PERMIT FOR WIRING ��SS�cmuh e This certifies that ....... ...... x ............./.................................. has permission to perform ...... ............... wiring in the building of.......... ............................................. at..../-La .......... ........... ............North And ver, s ..... Lic.Nol&72..4'.-.... .. .. ........!: ...... CAL fN!iPECrOR Check # 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the provisions of M.G.L.c.143,§3L,the permit application form to provide notice ofi-istalla'a"51, of wiring shall be uniform throughout the Commoifwealtl;and applications shall be filed on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166,§32,an d electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L.c.143,§3L. Permits shall-be limited as to the time ofongoing construction activity,and may be.deemed.by-the.Inspector_of_Wires abandoned.and.invalid_ifhe—_. or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this puipose by establishing an automatic four-year extension to certain permits and licenses concerting the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence"during the qualifying period beginning on August 15,2008 and extending-through August 15,2012. ule 8—Permit/Date Closed: L ***Note:Reapply for new permit 0 Permit Extension Act—Permit/Date Closed: 4otJuihvis7ioaWr o� ixiiaclairda�i of/ficial Use Only aLla arEnwnEoa�irnJnruicai PermitNo. .! 61 ��D P I BOARD OF FIRE PREVENTION REGULATIONS oev.1/1171 (l Fee Checked eah►e bihhnt:) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All wort`to be performed in accordance with the Massachusetts Electrical Code C),.537 r 12.00 Pl£,tSEPRf1tJ M.N.2L'OR72PEMVO-RAMMOA9 ate: 1p oil City or Town of: N, -ill, To the Inspector of Ttrires 3y this,application the undersigned gives notice of his or bar intention to form the eleetrirat work described below. Location(Street&Number) _ H A t bi' , "i )honer or TennntA 01 Telephone No_ hvner's Address n► 'f�f 's this permit in conjunction ivith a building permit? Yes K No ❑ (ChecItApproprinte Box) 'arpose of Building V Utility Authorization No. :xisting Service Amps / Volts Overhead ❑ Undgrd❑ No.of Meters law Service Amps ! Volts Overhead❑ Undgrd❑ No.of Meters lumber of Feeders and Ampacity ,ocation and Nature of Proposed Electrical'York: EL,8 a lt,� Q @ I t77-s (J ,,�A cow&fw affhe fallarvi fable may be 1vaived 63i dheoro K�res Vo.of Recessed Luminaires No,of Coil,-Snsp.(Paddle)Fans No. a�osmers ISA Jo.of Luminaire Outlets No.of Hot Tubs Generators ICVA- lo.ofLnminalres SwimminglPooi Above ❑ in- EJ No.o Emergency z mg grad. grad. Battery Units lo.of Receptacle Outlets No.of Oil Burners i FIRE ALARMS No.of Zones io,of Switches No,of Gas Burners o.IniDtfabnb DehricPS to.of Ranges No-of Air Coad. Tons No ofAlerting Devices to.of Waste Disposers HenTPnmt p umber JTous IC Delection/Alerting Devices Municipal to.of Dishwashers SpacelAren Heating ICW Loral❑�Connection to. io.ofDryers HcatiagApgliances ICZV Security ot N f Devices orEquivalenk !o.of Water ICIY No.of No.of Data Wring: Heaters Signs BalLasts No.of Devices or E nivnient H dro assn a Bathtubs No.of Motors Total 1HP Te[ecorrzmnnientions tiringg o. .- Y g No.of Devices or Equivalent iTHER: 00 Affadi additional detail iifdarhz4 or as required by the Inspector of 11 errs. timated Value oflcctrical Worts Q.lp (When required by municipal policy) art: ark to St �j �o�o`I if inspections to be requested in accordance with MEC Rule 10,and upon completion_ S11RANCC,-COYIZRAGE:=Unless,waived-by-tbe-owner;no=per Mt-fortile=pei#'otinnf-etddKc—l= un unless - Iicensee provides proof of liability insurnace including."completed operation"coverage or its substantial equivalent_ The dersigned certifies that such crBOND is in force,and has exhibited proof ofsanie to the permit issuing office_ IECK ONE: INSURANCE ❑ OTRER ❑ (Specify:) eriif}y,under t/tepafiis mrdp nfperjtrrp,lltat the it fornrativn on tIris upplicutlon is late and conrpleic. RM NAME: -r-\1 k' h t ycl P, U /._ +L C! At LIC.NO.: censee: ?1%i�"i7 -=7pw�,l,y `.Di. Signature J"'r'"- LIC.NO.: 4 t/ t' applicable,enter' 1"i t fi ninnberlme.) M��A f1 Bus.Tel.No.., L " (dress: I `6"- - `M471,*- j ,v` /r Alt.Tel.No.: er M.Q.L.c.147,s.57-61,security work requires Department of Public Safety"S"I icenie: Lie.No_ VNER'S INSURANCE WAIVER: I am nivare that the Licensee does not have the liability Insurance coverage normally luired by law. By my signature belmv,I hereby waive this requirement. I am the(creel[one)❑owner ❑owner's a eat veer/Agent PEffA47TFHE.S ,nature Telephone Pio_ ,.__ The Commonwealth of Massachusetts Department of Industrial Accidents It 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): GITX-rt J.;a t LL ECrr.1-L/AL. =We, Address: 0 T'Ack Sooy S'T " ReA %, City/State/Zip: Kr*1U GAJ9 MA 018VI Phone #: q78 - 68Z•,.5 3 Q. Are you an employer? Check the appropriate box: Type of project(required): L❑ I am a employer with 5 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. ElWe are a corporation and its required.] officers have exercised their 10. lectrical 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.❑ 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: A AVT rV R—O =NS U N ASC E a Policy#or Self-ins. Lic. #: 08 -AJ E C. ` Cr 4 3 C11 Expiration Date: C)(0/01 /12, �1 s Job Site Address: I�7 N' I t` JV0� � r "JJ�� City/State/Zip: [4A 4R 1 0 / SIVf 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 hereNeifj er the pains andpenalties of perjury that the information providffed above is true and correct. Si atureDate: OPhone#: �� J 3 Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: