HomeMy WebLinkAboutBuilding Permit #023 - 100 ANDOVER BY-PASS 11/24/2008 MAY-04-2010 TUE 05:41 PM MES I T I DEVELYMENT f RA NU. I LAtd bbl d i bU r u�
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BUILDING PERMIT c��``°
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
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Permit NO:— Date Received 4� +a�o.•+��
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Date Issued-
IMPORTANT;Applicant must cow Tete all items on this page
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TYPE OF IMPROVEMENT PROPOSED USE
Residential Non-Residential i
Now Building One family
AdditionTwo or more family Industrial
Atteraton~ -- ``- No. of units: Commercial
Repair, replacement Assessary Bldg Others:
Demolition f� Other
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Mdr .plaif 'Wetiarids: hla
WaterfSewer,
DESCRIPTION OF WORK TO BE PREFORMED:
Identification Please Type or Print Clearly)
OWNER: Name: Phone:
..Address
tame , flh ne �O C
Address. JO - f _
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Sit' er�rlsar;:s-Gan�ruction.�l�*rtse ' ;e�l'�>��t� � � -.,,,,�� :..►5� .,,:
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::}�g0ae InllproveTi�ent�cetise; '' �ate •
ARCHITECT/ENGINEER FZ p1,Qj...I_-- . �/a..l�.s,L..- Phone: cock Address: o 3 iz�b$ -.;z 1 14-Reg. No. O b�
FEE SCHEDULE:BULDINC?PERMIT.Tr12.00 PER 11000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Coat: $ �? FEE: $ o'
Check No.: Receipt No.:
NOTE: Persons contracring with unregistered contractors do not have access to the guaranty fund
oto
ignture'of AgentoOwner Sigria�ture of:confrs "'
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
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❑ 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
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
❑ Building Permit Application
❑ Certified Surveyed Plot Plan
❑ Workers Comp Affidavit
❑ 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
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
New Construction (Single and Two Family)
❑ Building Permit Application ;
❑ Certified Proposed Plot Plan
❑ Photo of H.I.C. And C.S.L. Licenses
❑ Workers Comp Affidavit
❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Copy of Contract
o Mass check Energy Compliance Report
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
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 i
must be submitted with the building application
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Doc:Building Permit Revised 2008
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SSACMU`+
CERTIFICATE OF USE & OCCUPANCY
TOWN OF NORTH ANDOVER
Building Permit Number 023 (,7/14/08) Date: November 24, 2008
THIS CERTIFIES THAT
THE BUILDING LOCATED ON 100 Andover by Pass
MAY BE OCCUPIED AS Medical Facility—Merrimac Valley Health IN
ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE
BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY.
Certificate Issued to: Merrimac Valley Health
100 Andover By Pass
North Andover MA 01845
Building In pector
i
MAY-04-2010 TUE 0540 PM MESITI DEVELOPMENT FAX NO, 1 978 557 8160 P. 01 h
MESI it
DEVELOPMENT CORPORATION
FAX COVER SHEET
NO. OF PAGES INCLUDING COVER SHEE : 2
I
DATE: May 4, "010
FAX TO: Gerald Brown
Building Inspector
Town of North Andover
FAX NO. 978-588-9542
FROM: Tony Mesiti
SUBJECT: MESH DEVELOPMENT BUILDING PERMIT f
Gerry,
Attached per your request.
Thanks.
Zony7'.Zesiti
A
Attachments
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DCVELOP.BUILD.MANAGE
97"87.5300.17ax:978:557-11 U0.email:muMmesitigroup.com.wwatmeshirkvelopmem com a 1100 Andover By-Pass.Suite 300 . North Andover,1AA 01845
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
❑ Notified for pickup - Date
Doc.Building Permit Revised 2010
s
�onrh TOWN OF NORTH ANDOVER
°t 4```° '•�ti OFFICE OF
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u; 'A BUILDING DEPARTMENT
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� ,� 400 Osgood Street
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ef'a Tie iAf North Andover,Massachusetts 01845 j
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D.Robert Nicetta, Telephone(978)688-95454
Building Commissioner Fax (978)688-9542
CONTROL CONSTRUCTION- SECTION 116.0 M.S.B.C.
CERTIFICATE OF ENGINEERING/ARCHITECTURE
BULDING INSPECTOR
TOWN OF NORTH ANDOVER
400 OSGOOD STREET
NORTH ANDOVER MA 01845
I, CERTIFY THAT
THE BUILDING CONSTRUCTED AT
DOES CONFORM IN ALL RESPECTS TO THE MASSACHUSETTS STATE BUILDING
CODE AND APPLICABLE FEDERAL REGULATIONS FOR THE FOLLOWING:
AUTHORIZED SIGNATURE:
DATE:
REGISTRATION:
NOTE: ENGINEER"WET STAMP"MUST BE AFFIXED TO THIS FO
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Control Construction Form revised 11.15.2004 NO.'I
✓_
N GREENFIELD 2
an MASS.
V�
�oy�F��>•N OF u�5�'`�
' Date,!f � ...... ........
NORTH
4.
° '•'"° TOWN OF NORTH ANDOVER
• 's
p PERMIT FOR WIRING
,SgACMUSE�
Thiscertifies that ..... .....................................................................
has permission to perform ....
wiring in the building of'? ................. .Rt.................
at........................................................ ........... .. North Andover,Mass.
j Feek ...J.... Lic.Noy'?0. .�....... . � ��
V ELECTRICAL INSPE R .
} Check # _
856
r N Commonwealth of Massachusetts Official Use Only
Department of Fire Services Permit N°. �SC�
BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked
[Rev. 1/07] (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 PRINTININK OR TYPE ALL INFORMATION) Date:
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)
3�
Owner or Tenant /LJ 0,# p l C T Telephone No. I
Owner's Address _ /00 AP
Is this permit in con,unction with a building permit? /Yes ❑ No
(Check Appropriate Box)
Purpose of BuildingPE /C 7- Utility Authorization No.
Existing Service Amps / volts Overhead ❑ Undgrd❑ No.of Meters
New Service ,.200 Amps (k, /-36Y volts Overhead❑ Undgrd
No.of Meters
Number of Feeders and.Ampacity
Location and Nature of Proposed Electrical Work:
3
Corn letion of the folio win tab l ay be waived by the Ins ector of Wires.
No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No.of Total
Transformers KVA
No.of Luminaire Outlets No.of Hot Tubs Generators KVA
No.of Luminaires SwimmingPool Above In- o.o Emergency Lighting
d. rnd. Batte Units
— No.of Receptacle Outlets
of No.of Oil Burners FIRE ALARMS No.of?ones
I
No.of Switches No.of Gas Burners No.of Detection and
Initia ng Devices
No.of Ranges No.of Air Cond. Tons No.of Alerting Devices
No.of Waste Disposers Heat Pump A M!!b r .Tons No.of Self-Contained
Totals: - Detection/Alertin Devices
No.of Dishwashers Space/Area Heating KW Local[I Municipal
Connection [] Other
No.of Dryers Heating Appliances KW Security Systems:*
No.of water No.of No.of No.of Devices or Equivalent
Heaters KW Data Wiring:
5i s Ballasts . No.of Devices or E uivalent
No.Hydromassage Bathtubs No.of Motors Total Hp Telecommunications Wiring:
OTHER: No.of Devices or E uivalent
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: Inspections to be requested in accordance with MEC Rule 10,and upon completion.
INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless
the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The
undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office.
CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:)
I certify,under the pains and penalties of perjury, that the information on this application is true and complete.
FIRM NAME: F027-in1 6Re+T1lERS z7e.,r--cTit c. j_4_r_ LIC.NO.: /1130 4
Licensee: 96BetiT & Fox-rlN /L, Signature G
I a ltcableenter"ewmP, t"in the license number line.) LIC.NO.: fs13 G /�
(IPP
Address: _//2 A10 1-"./•ro.SA( AD hq1VVAL N e{ G 3.r/0 Bus.Tel.No.:Ldg 879 6.579
*Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Alt.Tel.No.: G63 a3S-.5 S- //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
Signature Telephone No. PERMIT FEE:$ �"a'
I
The Commonwealth of Massachusetts
I Department of Industrial Accidents
Ogee of Investigations
DO 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/Individasl}; /O/L r t N 154 d T!-IfIL sf L7�C-7'/l, G L L C-
Address: //-I- /7'/c.7'1v7-o5 K W o
City/.State/Zig: dal'U Z IV hf 03.5;14f Phone #: .
Are you an employer?1Cheek.the appropriate box:
D'1
1•I� l aro a employer with d 4. ❑ I am a general contractor and I Type of project(required):
employees(full and/or part-time),* have hired the sub-contractors b• ❑New construction
2.2'I am a.sole proprietor or partner_ listed ori the attached sheet x 7• ❑Remodeling
ship and have no employees These sub-contractors have 8. Q Demolition
working for me in any capacity, workers' comp.insurance. q Building addition
[No workers'comp, insurance S. ❑ We are a corporation and its
required.] officers have exercised their 10.[-flectrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL I l.❑Plumbing repairs or additions
myself.[No-workers'comp, c. 1.52, §1(4),and we have no 12.❑Roof repairs
insurance required.]t employees. [No workers'
comp. insurance required] 13.❑Other
*Any applicant that checks bo)'#I must also fill out the section below showing their workers'bompenmtion policy information
r Homeowners who submit this affidavit indicating they are doing all work and then hire outside conttactots must submit a new affidavit indicating such.
4cownwtors that check this box must attached an additional sh-t cho-fi .the name of the sul`cortraci s and thair workers'comp,policy irfortnadon.
1 ant an employer that is providin workers'
$ compensation insurance for m1'employees:
nfarmatiorc Below is the policy and job site
Insurance Company Name:
Policy#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 $4500.00 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 violamr. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains andpenakku ofperjury that the information provided above is true and correct
S._ianature: Date /A ° a
e Phone#:
Elcialuse only. Do not write in this area,to be completed by city or town officiaL
Town: Permit/LicenseAuthority(circle one):of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
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,nottthe 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 nr—nb.;, listed below. Self-insured companies should entaur 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 Iicenses. 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 4
Department of lndtast Hal Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel.#617-7274900 ext 406 or 1-8.77-MASSAFE
Revised 5-26-05 Fax 4 617-727-7741
wwwMass.gov/dia
STEVE DRAKULICH
& ASSOCIATES
August 29,2008
Project Number: 0808aim Date: 8-29-08
Project Title: Community Center
Project Loca 6. Y 100 Andover By-pass,N rth Andover, MA
Name of Buil ' �ss Building
Scope of Project: Interior renovations for a medical imaging suite.
RE: CONSTR UCTION CONTROL CERTIFICATION
FRAMING INSPECTION
Dear Sir:
In accordance with the Massachusetts State Building Code, 780 CMR, Chapter 1, Section
116; 1, Steve Drakulich,Mass. Reg.No. 6565, being a Registered Professional
Architect,have reviewed the light-gauge metal wall framing on 8/29/08 and certify that
the material, spacing, and anchorage installed is in accordance with the documents and
meets, to my best ability to determine,the Massachusetts State Building Code.
The Contractor,therefore,has my approval to close-up the walls, pending Building
Inspector approval.
If you have any questions,please give me a call. 1-413-531-6475.
Respectfully,
Steve Drakulich,Architect
CC: Houle Construction
Alliance Imaging
27 James Street Greenfield Massachusetts 01301
Phone: 413-531-6475 Fax: 413-773-1670 Email:steve@stevedrakulich.com