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HomeMy WebLinkAboutMiscellaneous - 9 HIGH STREET 4/30/20181 0 4 11078 Date .... ...... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING --4 191 This certifies that .....................1,......... has permission to perform ...... .............................................. plumbingin the buildings of ............................................................................................. at.5 ..... H I 1�� .... !�� ......................................................../North Andover, Mass. ... Fee/ ...... Lic. No. ................................... 'P UMBING 14SPECTOR Check # U -CN— MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK UlfCITY POWNER TYPE OR PRINT CLEARLY Nor N A lki h d k(9 2 MA DATE y a 5 PERMIT # I JOBSITE ADDRESS 9 f41 (' l\ -D+- ' OWNER'S NAME Ra;- a L ADDRESS C 0" M Q 1V �{ A 64A TEL FAX OCCUPANCY TYPE COMMERCIAL [19 EDUCATIONAL ❑ RESIDENTIAL ❑ NEW: W RENOVATION: ❑ REPLACEMENT: ❑ PLANS SUBMITTED: YES ❑ NO UQ 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 DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER DRINKING FOUNTAIN FOOD DISPOSER FLOOR /AREA DRAIN / INTERCEPTOR (INTERIOR) KITCHEN SINK LAVATORY / ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET / URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES WATER PIPING OTHER INSURANCE COVERAGE: I 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 (Pr OTHER TYPE OF INDEMNITY ❑ 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 ❑ 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 v Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME T1 G 2 FT N �, LICENSE # 15 15 �). SIGNATURE MP © JP ❑ CORPORATION ❑ # PARTNERSHIP ❑ # LLC ❑ # 164614 COMPANY NAME 4- �� ADDRESS 7y eRXdij e CITY A4 STATE A-1y ZIP 0 3 0 7 / TEL FAX CELL Y7? 3-7-0 yEMAIL "JQ-a 1 r-t e 33 Cvlv r /A A) \� h The Commonwealth of Massachusetts Department of IndustrialAccidents y - . I Congress Street, Suite 100 t 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 Legibly Name (Business/Organization/Individual): ,Q M 2 SC---2 �2�/l) Address: City/State/Zip: �)/-P_ Are you an employer? Check tlie appropriate box: Phone #: 9 7 S, ya 3 •7 6 9-/ 1.4 I am a employer with (• , employees (full and/or part-time).* 2. FJ I am a sole proprietor or partnership and have no employees working for me in any capacity. [No workers' comp. insurance required.] 3.E] I am a homeowner doing all work myself. [No workers' comp. insurance required.] t 4. ❑ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.$ 6.F-1 We are a corporation and its officers have exercised their right of 'exemption per MGL c. 152, §1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 7. ❑ New construction 8. Remodeling 9. Demolition 10 Building addition 11.❑ Electrical repairs or additions 12. E] Plumbing repairs or additions 13. ❑ Roof repairs 14.0 Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. i 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 -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: /f �./�ye-- !% 4, < / Policy # or Self -ins. Lic. #: b / / UJ O 7 ¢ 7� j 5 Expiration Date: Job Site Address: 0 S / 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 of perjury that the information provided above is true and correct 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." 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' 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 P „orp F e 1p CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Permit # 070 (7/29/08) Date: October 3. 2008 THIS CERTIFIES THAT THE BUILDING LOCATED ON 21 High Street.- Stachey's II MAY BE OCCUPIED AS Restaurant ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: Stachey's II Inc 21 High St North Andover MA 01845 Building Inspector 0 Ica o Emcc mo C/) °C U) coa ►-.� �a�• nes m a C.�Z0 cm `p : .: l• �: C, a o c O ¢ 2 :`mc •o = m t O LJJ CO AD G rL.+ 'S ui .r c F=. -C-4 'a c `� c Z .m ca v .acm • W OOc �jQ H a m� o� f� _ Ml f- r $ CK m 5 MR CD 0 E C L O Z °D d O h � C I cm C C w\ O ■� W LA O O �E m m CD CL a� 0 L o a M. CM< c -a oecv •v Cc J •� EL O C Z CD LD V� O C �C C t0 y LLI Y/ W W W U) z Ike cn v �i�•�J t� W ,, a w v C (fir 2 w° U)w° U J a°': U) 1:2mi cn cn cn Ica o Emcc mo C/) °C U) coa ►-.� �a�• nes m a C.�Z0 cm `p : .: l• �: C, a o c O ¢ 2 :`mc •o = m t O LJJ CO AD G rL.+ 'S ui .r c F=. -C-4 'a c `� c Z .m ca v .acm • W OOc �jQ H a m� o� f� _ Ml f- r $ CK m 5 MR CD 0 E C L O Z °D d O h � C I cm C C w\ O ■� W LA O O �E m m CD CL a� 0 L o a M. CM< c -a oecv •v Cc J •� EL O C Z CD LD V� O C �C C t0 y LLI Y/ W W W U) KHALSA DESIGN INCORPORATED Architects & Engineers 17 Ivaloo Street, Suite 400, Somerville, MA 02143 p.617-591-8682 / f. 617-591-2086 ELECTRICAL, PLUMBING, FIRE PROTECTION, AND MECHANICAL FINAL AFFIDAVIT September 25, 2008 City of North Andover, Inspectional Services Department North Andover, Massachusetts RE: Stachey's Pizza, 21 High Street, North Andover MA 01845 Khalsa Design Inc. has visited the above referenced project during the construction period, and has provided construction related services in conformance with the Massachusetts State Building Code, Controlled Construction Section, 780 CMR §116.0. 1 verify, that to the best of my knowledge, information and belief, that the building has been constructed in substantial conformance with the construction documents for the project. The detection of, or the failure to detect, deficiencies or defects in the construction during review by this office does not relieve the contractor or its subcontractors of their responsibility to correct all deficiencies or defects, whether detected or undetected, in all parts of the work, and to otherwise comply with all requirements of the Construction Documents. • Exceptions: Cover to grease trap intercet �r missing at finish floor. Sincerely Yours, Alfred M. Marzullo PE, CPD OF ALFRED M. MARZULLO No. 40660E rl /tassgistration Seal # 40660E Then personally appeared above named Alfred M. Marzullo made oath that the statement made by him is true. Name Commission Expir4s Sara EdiX C'oft)onweolth7qPubl c9 MYCommiuion 65pd e 0dober 27, 2011 ARCHITECTURAL FINAL AFFIDAVIT To the Inspectional Services Commissioner: I certify that I, or my authorized representative, have inspected the work associated with Permit No. , dated locus —Stachey's Pizzeria 21 High Street East Mill Building_3 Suite 205 North Andover Ma Ward (on the dates used below or on at least 3 occasions during construction), And that to the best of my knowledge, information, and belief the work has been done in conformance with the permit and plans approved by the Inspectional Services Department and with the provisions of the Massachusetts State Building Code and all other pertinent laws and ordinances. �9wARoti J , a No. 30192 BOSTON MASS. Inspection Dates: 20 Paul North -029133 ARCHITECT — MASS. REG. NO. Paul North Architects PC. COMPANY 1007 East Street, Mansfield MA 02048 ADDRESS 508-339-5161 PHONE Then personally appeared the above-named jDij�!/G '=' ./VOQTf� And made oath that the above statement by him is true. _ n Before My Commission Expires: /k 1 20 ISD AF 10 PLUMBING FINAL AFFIDAVIT To the Inspectional Services Commissioner: I certify that I, or my authorized representative, have inspected the work associated with Permit No. dated locus Stachey's Pizzeria 21 High Street East Mill Building 3 Suite 205 North Andover Ma Ward (on the dates used below or, on at least 3 occasions during construction), And that to the best of my knowledge, information, and belief the work has been done in conformance with the permit and plans approved by the Inspectional Services Department and with the provisions of the Massachusetts State Building Code and all other pertinent laws and ordinances. -�H OF M,gSSgo KENNETH R. yG WAGNER MECHANICAL No. 40183 Inspection Dates: 20 Then personally appeared the above-nar And made oath that the above statement Kenneth R. Wagner - 40183 ENGINEER — MASS. REG. NO. Commercial Construction Consulting Inc. COMPANY 313 Congress Street, Boston, MA 02210 ADDRESS 617-330-9390 PHONE is true Before My C4#1mission Expires: �q ff , 20 9/12/08 h� ISD AF 10 ELECTRICAL FINAL AFFIDAVIT To the Inspectional Services Commissioner: I certify that I, or my authorized representative, have inspected the work associated with Permit No. dated locus _ Stachey's Pizzeria 21 High Street East Mill Building; 3 Suite 205 North Andover Ma Ward (on the dates used below or on at least 3 occasions during construction), And that to the best of my knowledge, information, and belief the work has been done in conformance with the permit and plans approved by the Inspectional Services Department and with the provisions of the Massachusetts State Building Code and all other pertinent laws and ordinances. of PAASg,�cy G ` � ERIA� r•H. s V�lYLL1E A` � o ELE�►Ft q� ^F��St ,SSIONN\-� Inspection Dates: 20 Brian M. Wyllie — 45219 ENGINEER — MASS. REG. NO. Commercial Construction Consulting Inc. COMPANY 313 Congress Street, Boston, MA 02210 ADDRESS 617-330-9390 PHONE Then personally appeared the above-named 4ICIA*4 And made oath that the above statement by h' tit WY L L d1' My Commission Expire /52rO