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HomeMy WebLinkAboutBuilding Permit #558 - 1 HIGH STREET 2/22/2007 f BUILDING PERMIT of `'°RT/1 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received_ d 7 AVID J' s tie 4 Date Issued: *1 �Z i IMPORTANT: Applicant must complete all items on this page / ,r LOCATION � e i G� .S- e Print PROPERTY OWNS Print MAP NO: PARCEL: " fl?5 ZONING DISTRICT HISTORIC DISTRICT yes na TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑ Two or more family ❑ I90.astrial VAlteration No. of units: ommercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: 9temolition ❑ Other Se tic ❑Sewer ❑ Flood Iain . ; D Wetlands ❑. Watershed District DESCRIPTION OF WORK TO BE PREFORMED: Identification Please Type or Prin learly) OWNER: Name: re)', verse �Ur.tc« �!,c Phone: 92�360 Address: he oL l- n _ CONTRACTOR Name Vii ii � �r� � S Phone Address Supervisor's Construction License a J' � Exp. Date: ` Home Improvement License:. Exp. Date v ARCHITECT/ENGINEER VC- 'cyc� Phone: 9�P 1727,,, Address: c� -e S iee� ✓rr- Reg. No. 2919,13- FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ o�I� FEE: $ 3��, Check No.: Receipt No.:�\� 2 61' 2 NOTE: Persons contracting with unregistered,contractors do not have access re guaranty fund r ' Signature of Agent/Owner Signature of con ctor Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit Li Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products New Construction (Single and Two Family) 1 —2=�roposed it Application ❑ Plod_ Ian �P -1�=C.= icenses orkers Comp Affid vit 4 r3� ro e s of BullIn Plans (One To Be Returned) to Include Sprinkler Plan al ulations (if Applicable) opy of Con -ac ❑ ner Compliance Report 4_EPg4%e4r g Affidavits for Engineered products In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2007 Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF -U FORM DATE REJECTED DATE APPROVED I I PLANNING & DEVELOPMENT ❑ ❑ P E COMMENTS 9 DATE REJECTED DATE APPROVED 1 CONSERVATION ❑ ❑ COMMENTS i DATE REJECTED DATE APPROVED HEALTH ❑ ❑ COMMENTS TYPF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit Located at 384 Osgood Street ,FIRE DEPARTMENT Temp Dumpstern site yesno Located at 124 Main Street Fire Department signatureldate 2� d COMMENTS' Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— For department use C C, IC C2 ❑ Notified for pickup - Date ............................................................................................................-...._................................................................................................................................................................................................................................................................................................................ Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract h ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products Addition Or, Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ' o Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Flo r/ o Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan � And Hydraulic Calculations (If Applicable) o Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products 11 New Construction and Two (Single Family) Building Per it Application ❑ roposed Plot ._Ian Al"T - -!!-rte° S icenses orkers Comp Affid vit zln4 - z�-V�z .ids. e s o ul m Plans (One To Be Returned) to Include Sprinkler Plan _ al ulations (If Applicable) opy of Con rad � ❑ nergy Compliance Report i eer+niq-Affidavits for Engineered products ; In all cases if a variance or,special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2007 7 Location No. �C� Date MOR70, TOWN OF NORTH ANDOVER F 9 Certificate of Occupancy $ ;''�b'�••"'�t� Building/Frame/Frame Permit Fee $ �'� ss�CHuse 9 Foundation Permit Fee $ r Other Permit Fee $ TOTAL $ ------T— Check # <7� 1999 ' w1ding Inspector Addendum 1 ACORD CERTIFICATE OF LIABILITY INSURANCE OA-1 DATE(MMA)DNYM 27/ VANT -1 12/27/06 PRO UNDER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Capstone Insurance LLc ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Suite 230 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR Two Newton Place ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Newton tom► 02458 Phone: 617-619-3300 Fax: 617-619-3301 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: St. Paul Travelers INSURER B: AIG Insurance Companies Vantage Builders, Inc. John Connor INSURER C: 281 Winter Street - Suite 340 INSURER D: Waltham tom► 02451 ' INSURER E: COVERAGES* THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMEDABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,TME INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BV PAID CLAIMS, INSR DDT- POLICY EFFECTIVE POLICY EXPIRATION LTR NSRD TWE OF INSURANCE POLICY NUMBER DATE(MMIDONY) DATE(MM/DDIYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED A X COMMERCIAL GENERAL LIABILITY BINDER 12/01/06 12/01/07 PREMISES(E,accurence) S 300,000 CLAIMS MADE ?OCCUR, MED EXP(Anyone person) S 5,000 PERSONAL S AOV INJURY 3 1,000,000 GENERAL AGGREGATE S 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGO S 2,000,000 Poucv X �Ec Loc Emp Ben. 1,000,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 A X ANY AUTO I BINDER 12/01/06 12/01/07 (Ea accident) ALL OWNED AUTOS BODILY INJURY S SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY S NON-0WNED AUTOS (Per accident) PROPERTY DAMAGE $ (PeraceMent) GARAGE UABRJTY AUTO ONLY-EA ACCIDENT S I ANY AUTO OTHER THAN FA ACC $ AUTO ON LY: AGG $ EXCESSAIMBRELLALIABILITY EACHOCCURRENCE s $6,000,000 A X OCCUR ❑CLAIMS MADE BINDER 12/01/06 12/01/07 AGGREGATE 3 $6,000,000 S DEDUCTIBLE $ X RETENTION 310,000 $ WORNERSCOMPENSATONgND WC STATU- OTH- X TORYLRAITS ER I EMPLOYERS'UABIUTY B BINDER 12/01/06 12/01/07 E.L.EACH ACCIDENT s $500,000 ANY PROPRIETOR/PARTNERIEXECUTNE OFFX:EWMEMBER EXCLUDED? I E.L.DISEASE-EA EMPLOYEE 3 $500,000 H yea,deaedbe under SPECIAL PROVISIONS below E1.DISEASE-POLICY LIMIT s $500,000 OTHER A Domestic Package BINDER 12/01/06 12/01/07 Bus. Pers $100,000 Property DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION PROOFOF SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYSWRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO 50 SHALL Proof of Coverage IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 26 25(2001/08) 0 ACORD CORPORATION 1988 •I A IMPORTANT If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed.A statement on this certificate does'not confer rights to the certificate holder in lieu of such endorsement(s). If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s),authorized representative or producer,and the certificate holder,nor does it affirmatively or negatively amend,extend or alter the coverage afforded by the policies listed thereon. ACORD 25(2001/08) TM = ® Document A1 05 - 1993 Standard Form of Agreement Between Owner and Contractor for a Small Project where the Basis of Payment is a STIPULATED SUM This AGREEMENT is made: (Date) ADDITIONS AND DELETIONS: The author of this document has BETWEEN the Owner: added information needed for its completion.The author may also Converse Inc. have revised the text of the original One High Street AIA standard form.An Additions and North Andover,MA 01845 Deletions Reportthat notes added information as well as revisions to the standard form text is available and the Contractor from the author and should be reviewed.A vertical line in the left Vantage Builders,Inc. margin of this document indicates 281 Winter Street where the author has added Waltham,MA 02451 necessary information and where the author has added to or deleted from the original AIA text. for the following Project: This document has important legal consequences. Consultation with an Converse. attorney is encouraged with respect 1 High Street to its completion or modification. North Andover,MA The Architect is: Siemasko Verbridge 126 Dodge Street Beverly,MA 0191.5 The Owner and Contractor agree as follows. AIA Document A105rm—1993.Copyright 01993 by The American Institute of Architects. All rights reserved. WARNING:This AIA!Document Is Init. protected by U.S.Copyright Law and International Treaties.Unauthorized reproduction or distribution of this AIAe Document,or any portion of it, 1 may result in severe civil and criminal penalties,and will be prosecuted to the maximum extent possible under the law. This document was produced / by AIA software at 14:20:31 on 02/21/2007 under Order No.1000244211_1 which expires on 6/23/2007,and is not for resale. User Notes: (3713447490) I I I ARTICLE 1 THE CONTRACT DOCUMENTS The Contractor shall complete the Work described in the Contract Documents for the project. The Contract Documents consist of: .1 this Agreement signed by the Owner and Contractor; .2 AIA Document A205,General Conditions of the Contract for Construction of a Small Project,current edition; .3 the Drawings and Specifications prepared by the Architect,dated February 02,2007 ,and enumerated as follows: Drawings: Number Title Date I Al Partial Fourth Floor Plan A2 Partial Fifth Floor Plan Specifications:' Section I Title Pages .4 addenda prepared by the Architect as follows: Number Date Pages .5 written change orders or orders for minor changes in the Work issued after execution of this Agreement;and .6 other documents,if any,identified as follows: ARTICLE 2 DATE OF COMMENCEMENT AND SUBSTANTIAL COMPLETION DATE The date of commencement shall be the date of this Agreement unless otherwise indicated below. The Contractor shall substantially complete the Work not later than Thirty(30)days ,subject to adjustment by Change Order. (Insert the date or number of calendar days after the date of commencement.) ARTICLE 3 CONTRACT SUM §3.1 Subject to additions and deductions by Change Order,the Contract Sum is: Thirty two thousand three hundred fifteen dollars($32,315 ) §3.2 For purposes of payment,the Contract Sum includes the following values related to portions of the Work: Portion of Work Value($0.00) Billed in full 32,315 §3.3 The Contract Sum shall include all items and services necessary for the proper execution and completion of the Work. ARTICLE 4 PAYMENT §4.1 Based on Contractor's Applications for Payment certified by the Architect,the Owner shall pay the Contractor as follows: (Here insert payment procedures and provisions for retainage, if any.) Init. AIA Document A105TM—1993.Copyright ©1993 by The American Institute of Architects. All rights reserved. WARNING:This AIA*Document is protected by U.S.Copyright Law and International Treaties.Unauthorized reproduction or distribution of this AIO Document,or any portion of it, 2 may result in severe civil and criminal penalties,and will be prosecuted to the maximum extent possible under the law. This document was produced by AIA software at 14:20:31 on 02/21/2007 under Order No.1000244211_1 which expires on 6/23/2007,and is not for resale. User Notes: (3713447490) §4.2 Payments due and unpaid under the Contract Documents shall bear interest from the date payment is due at the rate of Prime Plus ( 4% ) per annum,or in the absence thereof,at the legal rate prevailing at the place of the Project. (Usury laws and requirements under the Federal Truth in Lending Act, similar state and local consumer credit laws and other regulations at the Owner's and Contractor's principal places of business,the location of the Project and elsewhere may affect the validity of this provision.) ARTICLE 5 INSURANCE §5.1 The Contractor shall provide Contractor's Liability and other Insurance as follows: Please see attached Addendum#1 (Insert specific insurance required by the Owner.) Type of insurance Limit of liability($0.00) §5.2 The Owner shall provide Owner's Liability and Owner's Property Insurance as follows: (Insert specific insurance furnished by the Owner.) Type of insurance Limit of liability($0.00) All Risk or Builders Risk Insurance $32,315.00 §5.3 The Contractor shall obtain an endorsement to its general liability insurance policy to cover the Contractor's obligations under Section 3.12 of AIA Document A205,General Conditions of the Contract for Construction of Small Projects. §5.4 Certificates of insurance shall be provided by each party showing their respective coverages prior to commencement of the Work. ARTICLE 6 OTHER TERMS AND CONDITIONS (Insert any other terms or conditions below.) This Agreement entered into as of the day and year first written above. (If required bylaw, insert cancellation period,disclosures or other warning statements above the signatures.) OWNER(Signatu ) CONTRACTOR(Signature) (Printed name and title) (Printed name and title) LICENSE C'[ JURISDICTION: AIA Document A105TM—1993.Copyright ©1993 by The American Institute of Architects. All rights reserved. WARNING:This AIA°Document is Init. protected by U.S.Copyright Law and International Treaties.Unauthorized reproduction or distribution of this AIAe Document,or any portion of it, 3 may result in severe civil and criminal penalties,and will be prosecuted to the maximum extent possible under the law. This document was produced / by AIA software at 14:20:31 on 02/21/2007 under Order No.1000244211_1 which expires o�6/23/2007,and is not for resale. User Notes: (3713447490) Certification of Document's Authenticity AIA®Document D401 TM —2003 I,Jill Murphy,hereby certify,to the best of my knowledge,information and belief,that I created the attached final document simultaneously with its associated Additions and Deletions Report and this certification at 14:20:31 on 02/21/2007 under Order No. 100024421.1_1 from AIA Contract Documents software and that in preparing the attached final document I made no changes to the original text of AIA®Document A105Tm—1993-Standard Form of Agreement Between Owner and Contractor for a Small Project where the Basis of Payment is a STIPULATED SUM,as published by the AIA in its software,other than those additions and deletions shown in the associated Additions and Deletions Report. (Sig d) Q�MGWd-�k UJ b6A (Title) (Dated) AIA Document D401TM—2003.Copyright©1992 and 2003 by The American Institute of Architects. All rights reserved. WARNING:This AIAe Document is protected by U.S.Copyright Law and International Treaties.Unauthorized reproduction or distribution of this AIAe Document,or any portion of it, 1 may result in severe civil and criminal penalties,and will be prosecuted to the maximum extent possible under the law.This document was produced by AIA software at 14:20:31 on 02/21/2007 under Order No.1000244211_1 which expires on 6/23/2007,and is not for resale. User Notes: (3713447490) The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations kqip 600 Washington Street Boston,MA 02111 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl R � , Name(Business/Organization/Individual): biwEALi Address: W i msk Ci /State/Zi : n tY � P �� �I Phone.#: Are you an employer?Check the appropriate bo Type of project(required):. 1.0 I am a employer with 4• Y,am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. "eistruction 2.❑ I am a sole proprietor or partner- listed on the attached sheet 7. ship and have no employees These sub-contractors have g• C]Demolition working for me in any capacity. employees and have workers' [N comp.insurance comp.insurance.# 9• E]Building addition o workers' required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3.0 I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself.[No workers'comp. right of exemption per MGL insurance required.]t c. 152,§1(4),and we have no 12.0 Roof repairs employees.[No workers' 13.0 Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. =Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and 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 thepolley and job site information. Insurance Company Name: ^ 0 oaa. &MAO Policy#or Self-ins.Lic.#: x60 Expiration Date: Job Site Address: NO—Y-Or-, City/State/Zip: Attach a copy of the rkers'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 hes of a . P 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 hereb ce under the pains and penalties of perjury that the information provided above is true and correct Si afar 1i kink/ I t� Date: _ Phone#: 0 I rj L6.Other l use only. Do not write in this area,to be completed by city or town offlcial. Town: Permit/License# Authority(circle one): d of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector t Person: Phone#• Information and Instructions Massachusetts General Laws chapter 152 requires all employ6rs 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. 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 bum 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 301 39D Department of Industrial Accidents Office of Investigations 600 Washington Street y V- Boston,MA 02111 Tel. #617-727-4900 ext.406 or 1-877-MASSAFE Fax#617=727-7749-- .._ __- . . .... _...._. Revised 11-22-06 d5oe9io www.mass.gov/dia �y CONSTRUCTION CONTROL AFFIDAVIT PROJECT LOCATION: One High Street,North Andover MA 01845 PROJECT NAME: Renovation of 4th and 5th Floors NATURE OF PROJECT: 4th Floor-Adding three office(partition walls and electrical) 5th Floor-Partial demo of mailroom area and adding conference room and private office(partition walls and electrical) ARCHITECT: Siemasko+Verbridge,Inc. ADDRESS: 126 Dodge Street,Beverly,MA 01915 TELEPHONE: 978-927-3745 In accordance with Section 110 and 116.0 of the Massachusetts State Building Code, I,Thaddeus S Siemasko,Registration No. 6028,being a registered professional Architect,hereby certify that I have prepared or directly supervised the preparation of all design plans,computations and specifications concerning, ARCHITECTURAL, for the above named project and that,to the best of my knowledge,such plans,computations and specifications meet the applicable provisions of the Massachusetts State Building Code,all accepted engineering practices and applicable laws and ordinances for the proposed use and occupancy. I further certify that I shall perform the necessary professional services and be present on the construction site on a regular and periodic basis to determine that the work is proceeding in accordance with the documents approved for the building permit and shall be responsible for the following as specified in Section 116.2. 1. Review of shop drawings, samples and other submittals of the contractor as required by the construction contract documents as submitted for the building permit,and approval for conformance to the design concept. 2. Review and approval of the quality control procedures for all code required controlled materials. 3. Special architectural or engineering professional inspection of critical construction components requiring controlled materials or construction specified in the accepted engineering practice standards listed in Appendix G. Pursuant to Section 116.2.2,I shall submit periodical progress reports together with pertinent comments to the Town of North Andover Building Department. P:`,,Cotnmercial,Currej.ir,.Conv xse 2007",,.0 on tntction Control AfTidavit.doc Upon completion of the work,the Architect shall submit final affidavits as to the satisfactory completion and readiness of the project for occ panc . RED Aq OO�uS S. SC' No.6028 Sign r o 13EVERLY, o i MA ��► OF 0 Then personally appeared the above named S%(�-riCtro,p(A and made oa that the above statement by him is true. Before e, RE M.THE 1 Notary Public COMMONWEALTH OF My Commission Expires ri112,2013 P:`.Cc.?rnrx3erc iat.C urrem.*,Converse WOT,..Constmetion Control,+..flid€vit.doc r :. IiW i�ammca�uuea o�,/j/j�aaaac/uaalta BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR 4 Number: CS 055449 rim Birthdate: 03/29/1963 r Expires:03/29/2008 Tr.no: 20183 i_ Restricted: 00 ..4 -DAVID E PERRY /! 9 SAWMILL RIDGE RD, HAVERHILL,,MA 0182, Commissioner i J NORTH c Town of : s. __ ._ . Andover0 dover, Mass., T O LAKE I� COC NIC ME WICK V 7 AQRATED PPS` It5 '9S E BOARD OF HEALTH Food/Kitchen - PERMIT - -- - - - - Septic System - - - BUILDING INSPECTOR THIS CERTIFIES THAT........cmo.'V. ...�I..010Wf e................ �&/,W�.Jf*f V�'••v ••••••••• Foundation has permission to erect........................................ buildings on. ...40.41.. .. .......5. ................................ .............. Rough to be occupied as..................................�/��.............. ... .. .... . .��� Chimney provided that the person accepting this permit shall in every respect conform to the terms of the a lication on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final $079P PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTIO TARTS Rough op Service B DING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det...