Loading...
HomeMy WebLinkAboutMiscellaneous - 560 Turnpike WN Zt "jc- Y Date. .0//?/�?-- 9579 NORTh� <. •° •'�, TOWN OF NORTH ANDOVER o41 p PERMIT FOR PLUMBING �SSCHUSE� This certifies that . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . has permission to perform plumbing in the buildings of . . .Z.I^}. A. . . . . . . . . . . . . . . . . . . . . at. . . . IQ. . 'North Andover, Mass. 6. Fee'1111.0.Lic. No.�I) . . . . . . . . . . . . . . . . . . . . . . . . . . . . PLUMBING INSPECTOR Check 4{ MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK CITY ,(�o u v _ .�.,,.( MA DATE PERMIT# JOBSITE ADDRESS OWNER'S NAME 4 _ POWNER ADDRESS TELE _IFAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL ® RESIDENTIAL Ell PRINT CLEARLY NEW: 0( RENOVATION: REPLACEMENT:® PLANS SUBMITTED: YES 0 NO[JI FIXTURES 7 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM -_( _._._._f I _-._.._..� ._.._._.-f ._ ( f __.. __I DEDICATED GASIOIUSAND SYSTEM _I DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN ___..-_.I ._-_-_! —j _...._._.1 FOOD DISPOSER FLOOR/AREA DRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK _____f LAVATORY ROOF DRAIN SHOWER STALL SERVICE/MOP SINK ( _-_ ( ( ._._._I I ._.__J I } __.._! � _( TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES _s WATER PIPING I I OTHER �/3�Y S�•u ! _( I __( ...__._._-f __._._ ! _; _-_..__f _.____._f ._--__....( _( ____..___t _( yrs INSURANCE COVERAGE: I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES nANO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY 01 BOND Q 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 10 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 Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME # E3 4 SICKATURE MP 0-- JP Ej CORPORATION f## to V ;PARTNERSHIP F-1 ( COMPANY NAME 14,5p���ZjO4L b e-Se s ; ADDRESS Z C EAtP� CITY /3//l�2eGt4STATE AGR ZIP TEL ? - �GZ- 3S J;, - -- FAX € CELL EMAIL _ _ --- ...... �� ROUGH PLUMBING INSPECTIO}N NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No �a THIS APPLICATION SERVES AS THE PERMIT-' Ft❑ —� Gres¢ re.� :3 --/ Cr►^..'"�„"`- `� 3 FEE: $ PERMIT# PLAN REVIEW NOTES -A I � , a t The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): So u__9_- a�! Address: 2-3 zo City/State/Zip: (S 1 ef,�F Z� Phone#: T7;� Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with .-�y 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.E] I am a sole proprietor or partner- listed on the attached sheet.t [�}-Rtfmodeling 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.❑ 1 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.]i 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. 1 Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. rContractors 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 %reformation. [assurance Company Name: =O�G � ?olicy#or Self-ins.Lic.#: Expiration Date: rob Site Address: �(�j�5'f 'C v2r— /�i:'� ,J A/d,AA-WO-f--4City/State/Zip: attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). ailure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a Lase up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine ►f up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of nvestigations of the DIA for insurance coverage verification. 'do hereby certify under the pains and penalties of perjury that the information provided above is trite and correct. >ignature: Date �— 'hone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." q P Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel.# 617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 5-26-05 www.mass.gov/dia Date . . .f-k. ./, z TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that . . . . .0. . ��'l z�� �`T� �.F. 2 A -Qbi.6 has permission to perform . . 77(,/.I�. . . . . . . . . . . . . . . . . . . . . wiring in the building of . . .7.r 4J9 fl /�c?� ,�.. .��� W­77- - at F . . . ..G r , , . . ,North Andover, Mass. -'Fee . 32'6.Lic. No. . 7122 . rLTRICAL INSPECTOR 7 Chuck# 11076 Commonwealth of Massachusetts Official Usie Only Q 64 Department of Fire Services F11ermit No. L � 76 ' p Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/071 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: %_6- /,;Z 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) -5(oC) ' leconike. Sgee-t, Owner or Tenant fOre J V0C4A?7 Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service,2L Amps t/p/ 40 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: 00 �- om letion of the following table maybe waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of I Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA Above In- o.o Emergency Lighting No.of Luminaires Swimming Pool rnd. ❑ rnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No. of Zones No.of Switches No.of Gas Burners No.of Detection andInitiating Devices Tot No.of Ranges No.of Air Cond. Tons No.of Alerting Devices Heat Pump Number Tons KW No.of Self-Contained No.of Waste Disposers Totals: r Detection/Alerting Devices Space/Area Heating KW Local❑ Municipal [:1 Other No.of Dishwashers S P g Connection No.of Dryers Heating Appliances KW SecN.of Systems:* or Equivalent No.of WaterKW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent Bathtubs No.of Motors Total HP Telecommunications Wiring: No.Hydromassage 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: (When required by municipal policy.) Work to Start: —/0—/;— 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 cover e is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE BOND ❑ OTHER ❑ (Specify:) e ains andpenalties o er'u that the information on this application is true and complete. I cern under tlz p .fP J �J', .f .fY� P FIRM NAME: LIC.NO.: Licensee:�1 r t,,0.4 Signat LIC.NO.: (If applicable,enter "exempt"W' the license number line.) Bus.Tel.No.: F5?-Jyi—/3/S Address: Q SOUI c �s- t�e, ct� �-��4' Alt.Tel.No.: *Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent. Owner/Agent I PERMIT FEE. $ Si¢nature Telephone No. q f _ � ��r�i(t; �.�t��r► t���.'�®; .^ .+.�.`i���e����.�.��®c�'�o it CIA ;. ��sset�--,[ �+'aiieii•�r � �e-zuspeef�ou�'e�uzxecT(��O.OQ)�� � �uspectpxs'�a�nxtte�fs: av � •���•S (XnspeetaxsystnataD-.-ao�Txitfals) Pate �,'asset�•� �+`ailer�--� � � ate-�ns�eetiox�xec�uixe�(��0.00)"[ � i V)W4 k Ttts�ecto ' nmm�extfs: , (ffls)iecforsI9lgna a"xto' 'fials) Pafe 'assed--j } �'a�Tecl-•I � ate-aus�eefZo�xe4uizet�(�50.40)"[ � ttspecfoXs'coJnxuents: [�nspectoxs' zgnafuxe"�o?niffaTs) Pate t sse�--[ } �`aile�i--j � �e�xnspecffox�xequixe�{�50A0}�j � ' �,�scfbxs'eoJo�m.e�tfs: . Qksp ectors,Niguature-io Wiials) Rafe - BCfO?59 EDLT1-me.'ats: ' S ' �1nspecioxs'Minatuze-)aoftdals) date ' .�._ �_- ._.... .._._._�_��.U.^.n...w.-.... ..-.�__. •r..i. ����......._i....._.�....-.w....u.—.-r.� f w-.h-1 t M�•i.Yl Ywk'fYri4'f IYTT'.'+MM.nMr..+r r! J The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual):. 1(�IAC�, Address: City/State/Zip: 11 , bC&& , MP', 01960 Phone#: E57-a 4�- 13T Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ 1 am a general contractor and I 6. ❑New construction ' employees(full and/or part-time).* have hired the sub-contractors 2.�1 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.❑ 1 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.] 13F]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 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. a Insurance Company Name: Policyu#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine Df 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. f do hereby certify un ie pains enalties of perjury that the information provided above is true and correct. 5i r Date: /'G' lol, 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#: y. Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance " requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. e City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom v of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax# 617-727-7749 www.mass.2ov/dia Date TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that,� . . . . . . . . . . . . . . . �• has permission to perform . 2fPe' . . . . . . . . . . . . wiring in the building of v ^-�?L . . . . . . . . . . . . at . . . . . . . . . . . . . . . . . . . . . . . rth Andover, M S. Fee s . . Lic. No./y 3 . . '`��-. . . . . . . . . . . . . ELECTRICAL INSPECTOR 11173 sumo, mo s PetmitNo. BOARD OF FIRE 9 PREVEN-n0N REGULA77t?iVS =q and Fee Chmked APPLICATION FOR PERMIT TO PERFORM ELECTRICAL. n7 CMR l2�WORK Au�awsk to 5c pulhm�d�a�or�ae w�@� code (?MAMPRIN3`IN.ffiW Olt TYPE AIS I1ttFO"AMA9 Date:_ City or Tovm of �l_&Lws �,�-,rTo the Frwa. By this MAcaucatee m�sigwd gtvs notma of ms or hrr intention to perfann the betow. Location(fes&N�) Owner-err Tenant �.E».•t5 n�4-LL1 Tel) hone No. t3wne:'sAddress �r1 Is this Permit is comm w th 8 iubftg Pte' Yes No ❑ (Che&4 ) of Bwubg L UMy Authors Edw No�aw &%g2n /�C Bxfstiag Service Amp . A /Zb Yokt 0wrhead❑ Undgrtl❑ No_of Meters New Service /2zi I Vo#s Overhead Q Undgril❑ He.of Meters _L Number of Feeders mW A�apacity Location and Nature of Proposed Metrical Work: table&Wbe avrrf the a w War ofJust. No.of Reeessed L uminatm Not ofCaSusp.(PaMe)Fags - fin.of TOW TrauffJCVA 7 No.of Lame Dutra o.of IwTubs orm= KYA o. 3whma-mg Pow Ela. am Batter Units �Io.ofReoep�de afORls Aim Lworzones No.efswfthn NL of G=Bmmm of _ an Na.ofRauges ofAfr Cid. otai Tow ofAt i No,of Waste Disposers Totals; 'rem- Devic s; Na of Drs skiers Area EWxft RW ❑ ❑Other I No.of Dryers HesfmgA"fiances Noe of Vva-twor EquivWcat HeatersICW NIX of Ballasts Naevi or Equivaknt No.BY&'o a Bombs No.of Motors Total" unions Pim of Devices or OTSSR: . Attach deo rj I Es �arregr�iredby t&e Inapea_of jrr=_ ta�ted Yahie of :curl Wor#� mqu'sed h3' Pte:} Work to Start: bRuxtions to ba mgmested in sono yiM tM Ruts 10.and neon dation. DMIRANCKCOVMAG&Undstvaivedbydt owm,no pematfmSc ofetect&d MO&my issue wdem the rm=wwoyid=pwofofriah�� ° age or its al equivalent. me cavanV is is foax,ad haste Isaafafsamato dmpemut i�g oto _ CHEC'C 0W INSf MMCE 5h BOND ❑ UrMR 0 (SPeorr) I certsfy,mmder Ikepdw affdpwaWw Of s fFietibe�art t/l, mm mum— VAii t t? i=i,c'i�-f2e�}tL CtxiT ��.r. , istree mrd oom�sl L3C.NOS Licensee: .Vt9 LIG NO.: H15&-i 3 (�f bleeeter d FltJeel�awisesesrb�TTmej — Addrew. _ Nr�.ik ft#-`rE�" flr� tib 1SIhm Tel.Nmt c 7:=*'jSqL-62,&2- *PerhCG.L m 147,s.57-6I,sNO&YWO&mqifnm Depaitnent ofPUWC Art:TeL -j-13 7 OWNER'S INSURANCE WAHM* I am aware dmt die I.ir.No. by dow iW mve slur iiabt7t'ty c:ovsragc gy Byinyd aknbdow.Ilanebywaive this Tube Owner/Agent (ick nae ❑ownw owmes t. Scgnature Telephone Na i s .•'��} i f'� �� `�, _._._.�, _. < <, , . „ , ., ,, a The Com mnweadth of Massachusetts Print Form Dgmyfmw t of InduS&WAccidenis Ofice efinve%*a9ions I Congress Street;.Suite IOU Bastow,MA 02114-2017 www nwmgov1dw' Workers' Compensation Insurance Affidavit:BuRdaWContractors/Eleddeian /Plumbers Annficant Information Please Print Legibly Name(Boskmdorganjzatim nnffiividnal): DAVID ELECTRICAL CONTRACTING LLC Address: 87 BELMONT ST CilylState/Zip: NORTH ANDOVER,MA.01845 phoIle#.- 978-682-6252 Are you an emploW.Check the appropriate]ba= Type of project(required 1-0 I am a employer WM 7 4. ❑I an a general counactor and I Cu3Pt0yCCS(faIl andlor e)*. have hired the yrs 6. ❑New construction . 2❑ I amasolepwprietororpartw listed on the anached sheet T- ❑Remodelmg ship and have no employees Thi have 8. Demolition woddng for me in any rapacity. employees and have workers' [No� ,camp romp_ 9 Burldirig addition j 5- We are a c orpmation and its 1.0.0 Electrical repaim or additions; 3- I am a homeowner doing all work of rims have exercised their I L[]Plumbing repass or additions myself-[No wudw&coniP rigbt of exemption per MGL 12Q Roofrepairs msuranoe requirefl t c.152,§1(4),and we have no employees[No wwkers' 13.[]Otber comp_insurance required.] 'Any applicant that checks box i€I must also fill out the section below showing their workers'compensation policy informa¢or Homemvners who submit this affidavit indicating they are doing an work and then hue outside conhactars must submit a new affidavit indicating sum. 'Conhactors drat check this box must attached an additional sheet showing the name of the sub-contractors and state vAmew or not chow enuties have employees.If the s<rb-oormadors have employees tray must provide their workers'comp_policy number. I am an employer that is provijaW workers'compe»sadon hnwmzee for my employees Below is thepolrcy and job site information. lusurance Company Name. THE HARTFORD Policy#or Self-ins.Lie.#: 08 WEC C18293 Expiration Date: MARCH 1,2013 Job Site Address: ,_� _ ��WCity/Stat,&ip 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 e.152 can lead to the imposition of cHminal 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. B advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for' cx eo a verification. Imeder - ----___-- of tla�tLre. provided abere is tame and carreaL Slenarty Phone#: s7s-ssz offish l rise a,* Do nwwaite is th area m beat by cLfy arfovea o� City or Town: Permi mucense# hsumg Authority(care one)-- 1- nes1-Board of Health Z Bunding Department 3.Cityf own Clerk 4.Electrical Inspector S.Phrmbing Inspector 6.Other ContactPerson• Phone#: Location S V J C/�N .�/ 2tina- Non U -201-3 Date e - TOWN OF NORTH ANDOVER • �, � Certificate of Occupancy $ Building/Frame Permit Fee $ t. : a Foundation Permit Fee $ z Other Permit Fee �,y $ TOTAL $ Check# hwl 25817 Building Inspector f SIGN PERMIT APPLICATION 1600 Osgood Street Building 20, Suite 2-36 TOWN OF NORTH ANDOVER Site Owner 2 'j"1 Ct _ Applicant 'E:>eLL— � �t� Tel �� ?J7G � Site Address �bD -fp`f,C' �z0« r'� �� Size of Proposed Sign May Parcel Illumination: a)Not illuminated How attached: a} gainst the wall MOON l 1✓� b) Internally illuminated Roof ©Externally illuminated C— ground Y17Jther t t u=i►� Materials: k CC,r V-1 Proposed Colors: Background Lettering f-,S f�lC3 Tk:5-T_'*, Border Cost of Sian e-2- Requiredj�t�Required Attachments: Note: No permanent/temporary 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 C�{lC1q SlC-� U lKA_ T C*4Uy applicable provisions of the By-Law. Will sign overhang any public road or walkway Yes ( ) No(N If Yes, Name of Agency who will provide liability insurance: ti AN INCOMPLETE APPLICATION WILL NOT BE ACCEPTED DATE FILED: f 0 k-2 .2sQ1'Z Receipt# Check# •� Revised 10.31.2006Form Sign Permit Application tAA , tPPLICANT APPROVED BY _ FORTH IE f6+a�0 ='ti• ;ll TOWN OF NORTH ANDOVER SIGN PERMIT DATE: October 12, 2012 PERMIT: S003-2013 THIS CERTIFIES THAT Zinga Frozen Yogurt has permission to erect. on 560 Turnpike Street two signs — one 40"x 170" Zinga Frozen Yogurt and one Vinyl Sign 1" sintra letters on pylon 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 Inspe for of Buildings .Amount Paid:$60.00 Check : 11807 Receipt: 25817 c &(13 5 65 KQ)kD 5 AT NORTH ANDOVER V7� § t - - t HAMBURG RS o r W ONE& Ho 0MCAL 1 c�� zinga.YOGURT ,: SIM ElBucczz o r C�C�G=p R m CUSTOM FRAMING kk � III i •• r r . 3 t� 4 4' g s- 6 s l'—n. Nk R" k uo ?411t s •t; t g A i lI ' 173.5 100.001, 70.3" 12.2" 40.5" 0 OGUFcI) V