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HomeMy WebLinkAboutBuilding Permit #553 - 1211 OSGOOD STREET 2/27/2006 o' �o . . ° ° TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received' Date Issued:-2 IMPORTANT: Applicant must complete all items on this pauc ___ l 1 LOCATION _ _ ��ccPrint PROPERTY OWNER �"� ul ��w00y-0 6r, -it U���de•� -� Print MAP NO.: PARCEL_=F ZONING DISTRICT: TYPE AND USE OF BUILDING HISTORIC DISTRICT YES 0 TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential _ New Building One family Addition Two or more family I Industrial Alteration No. of units: _ Repair, replacement Assessory Bldg — — ;_- Commercial Demolition Moving(relocation) Other = thers: ! Foundation only c DESCRIPTION OF `YORK TO BE PREFORMED Identification Please Type or Print Clearly) OWNER: Name: c)a Phone:P� sq nature :address: D-11 Oct q C& l , CONTRACTOR Name: IJC�U 1 �����(�li l�► Phone: V� �� Address: � � � 119 Supervisor's Construction License: �a u i G�Ic�L� o _Exp. Date: 10 0 D '7 Hume Impruycmcnt Liccnse: ��t �In(a� Exp. Date: i � /�l 0 7�� �RCI IITECT, FN(11N-El' Nae: Phone: _ Address: L a F VVAi Y, 01 l- Reg. No. 6 FEE.SCHEDULE:Bt LDIAG PIT PER 51000.00 OF THE TOTA ESTI){A� T�ED COST BASED O,y 5125.00 PER S.F. o (yjL ��� +41q l ?�/. 00 Total Project Cost : - x10.00 FEE:$ Chcck No.: 12'1YYk Rcceipt No.: 0. r— TYPE OF SE\NARGE DISPOSAL Tanningilvlassage Body ,art Swinulling Pools j Public Sewer Well — i Tobacco Sales -- I Food Packaging.Sales Private(septic tank,etc. Permanent Dunlpster on Site , L I i 'MOTE: Persons c•ontrac•1111), with unregistered c•ontruetors lignatUre riot ltave�ru•ress to thei;unrun nd end Signature of ;l ent Owner 5`eeak a oivn (eof Contractor Plans Submitted U�i Plans Waived D Certified Plot Plan i. Stamped Plans THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF- U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT D D Water Shed Special Permit Site Plan Special Permit ❑ Other COMMENTS DATE REJECTED DATE APPROVED CONSERVATION D D COMMENTS f,12 DATE REJECTED DATE APPROVED HEALTH r' COMM&NTS /_onin�, Board ofAppeals: Variance. Petition No: Zoning Decision,receipt submitted yes Plannim-,, Board Decision: C011lmelltti Conservation Decision:_ conlnlcllls %X-ater& Sewer connection si,nature&(late Tenl Dunl stc:ronsite '� p p. yes___noFire Department signature date BUildinp Permit ,approved and Issued by: i j Building Setback (ft.) Front Yard j Side Yard T Rear Yard Required Provided Rcc uircd Provides Required Tj Provided i DIMENSION Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area,sq. ft.: NO ]ES and DATA— For department use) r i i 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 j Building Permit Application u Debris Removal Form f j Workers Comp Affidavit j Photo Copy Of H.I.C. And/Or C.S.L. Licenses Copy of Contract Floor Plan Or Proposed Interior Work Addition Or Decks j Building Permit Application Li Form U u Surveyed Plot Plan Debris Removal Form o Workers Comp Affidavit u Photo Copy of H.I.C. And C.S.L. Licenses a Copy Of Contract u Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) u Mass check Energy Compliance Report (If Applicable) New Construction (Single and Two Family) u Building Permit Application u Form U Certified Proposed Plot Plan • Photo of H.I.C. And C.S.L. Licenses u Workers Comp Affidavit • Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydrauli, Calculations (If Applicable) • Copy of Contract u Mass check Energy Compliance Report I all cases if a ,,ariance or special permit was required the TONn Clerks office must stamp the decision from the Hoard of Appeals that the appeal period is over. The applicant must then het this recorded at the Registry of keds. One copy and proof of recording must be submitted with the building application Ooc:i\SPECTIONAL SER%KCS t1EP.kRrVt:1'r:SrFoa\Io5 Location/14'//'4'// Of�,- S� No. Date A } NpRTq TOWN OF NORTH ANDOVER N: • ` 09 ` Certificate of Occupancy S r cMus S Building/Frame Permit Fee $ 261 s� Foundation Permit Fee $ Other Permit Fee $ TOTAL $ �^ Check # 7(' i 9r) Up Building Inspector NORTH Town of t 4Andover No. dover, Mass., -0 27" T Q t- LAKE COCHICHEWICK V ADRATED `S BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System BUILDING INSPECTOR THIS CERTIFIES THAT....F.M.4 'e► .. Q ................................................ Foundation • has permission to�ereel.t~titS .N�. ............... buildings on....I.I.J.)......0.s. r.....s ..�!�! ............ Rough � 1 to be occupied as t-t4-1+0if46. 4.tl S f"Aaf...... Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application on file in Final this office, and to the provisions of the Codes and y-Laws relating to the Inspection- Alteration and Construction of Buildings in the Town of North Andover. 3 S Q PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR � UNLESS CONSTRUC STWS;(BU1WLWDWDG Rough i Service INSPECTOR Final 1 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. �`/ FSEE REVERSE SIDE Smoke Det. ! I� r Q D.O. CONg'RACTINO, INC. Commercial and Residential Kitchens,Baths,Additions,Home repairs,Finished basements,Decks,Excavation work David Gulezian President 428 Pleasant Street, North Andover, Ma. 01 845 OFFICE: 978 689-4797 HOME: 978 683-0397 FAX: 978 686-6337 MA Lic. # 001821 INSURED Home Imp. # 120199 Installer of Sportcourts February 8, 2006 Frank Terrannova Bakery 1211 Osgood St. No. Andover Estimate per GSD plan dated 1/23/06 revised I am forwarding this estimate to you. As you know your architect (Greg) has given you a proposal for other engineers to do the final plans. You indicated you do not want to hire them as the price of $ 12,000.00 +- seemed like wasted money. I think there is a good chance we can do the job without you spending that amount of money on those plans. As long as you are aware there could be some change orders during the job. H.V,A.C. (off the existing roof top unit) Price to run duct work in the entire space feed and return. This price includes a manual damper to shut the back area off. $ 6,200.00 Same installation with controls, separate zone , with bi-pass damper. $ 8,300.00 Plumbing Jack hammer up the floor to install 2 floor drains. (The distance of these floor drains from the existing pipe depends on the height of the existing drain pipe). Install trap primers on the 2 drains. Repair the concrete floor. Supply water to mixer, supply water and drain to grease trap/triple bowl sink (equipment supplied by others). Supply gas and water to hot water tank (tank supplied by others). Supply gas and water to boiler/steam unit (unit supplied by others). Supply gas to convection oven (oven supplied by others). Supply gas to oven (oven by others). All basic venting is included. However, price could change when a vent design is drawn up. Supply and install 2 i i s hand sinks on the front of the bathrooms. Also supply water to this area for coffee maker. $ 16,450.00 Electrical Do the electrical work per GSD plans. Any work not listed on the plan is not included. There are a few power requirements not listed (they are listed as verify with new tenant). We are assuming these items run on a 20 amp circuit with 2 receptacles to the circuit. The price also includes adding 2 emergency light/exit packs and one fire alarm horn strobe. $ 22,567.00 Cost for 8-5" recessed wall wash fixtures which is included in the electrical price is $ 1,300.00 with wall switch, labor and materials. Cost for 9-abolite pendant fixtures with wall switch is $ 2,370.00 labor and materials which is included in the electrical price. Fire Sprinkler Frank got a price of 90 cents per sq. ft. Tenant space fit up Build a wall to divide the space (front and back). There will be a pass thru hole in the wall (wire racks not included and accent the not included). Build a 50 + - sofit 2' wide thru the space. Do normal tile installation in the customer area (tile supplied by you). Install VCT in the office. Install FRP fiberglass board to a height of 8' off the floor in the work areas in the back part if store. Build a office/and alcove for the sink. Build a receiving area. Build a wall to create a storage area. Install the ceiling grid and tile. Install vinyl baseboard through out. Tenant fit up section Price $ 20,550.00 Add for washable ceiling in baking area $ 700.00 These prices do not include any cabinets, or counters, or work associated with cabinets or counters, showcases or end cap walls. Or showcases, installation of bakery equipment, bakery equipment, i q painting, grease trap, triple sink, hot water heater, tables, pallets, ice bin, showcases, flooring in the back half, engineers or architects, or changes required by the town. This price does not include bringing a new gas service into the building if needed. Thank you, David a TOWN OF NORTH ANDOVER Office of COMMUNITY DEVELOPMENT AND SERVICES A ., %97 HEALTH DEPARTMENT 400 OSGOOD STREET NORTH ANDOVER, MASSACHUSETTS 01845 Susan Y.Sawyer,REHS/RS 978.688.9540—Phone Public Health Director 978.688.9542—FAX healthdept 9mnofnorthandover,com www.townofnorthandover.com Albert and Joan DeFusco DeFusco and Son Italian Bakery 1211 Osgood Street North Andover,MA 01845 February 22,2006 Re:Plan review Dear Mr. And Mrs.DeFusco, This correspondence is to inform you that the North Andover Health Department has received all the information requested in regard to your plan for a new food establishment. The plan has been approved with the comments in blue and red noted below. A copy of this approval will be forwarded to the Building Department. Be advised,if any substantial changes in the plans occur during constriction you are expected to advise the Health Department. 1)The hand sink in the front coffee area cannot be used to dump coffee or rinse items. It is necessary to locate an additional sink in this area. Add sink Food Code 5-205.11 OK 2)The Bakery Work area—The closest hand sink in 18 feet away. This distance is excessive and not adequate for the main work area.Place a hand sink in"bakery work area". Food code 5-203.11 OK 3)Please not that any freestanding equipment,that is not on rollers,such as the mixer, shall be sealed to the floor with caulking or other material to assist in cleaning. 4)The application,page 3,was not completed with signatures,Fed. Id numbers,etc. Complete page 3 of the application for a food establishment OK 5)Equipment specification sheets. Applicant submitted some of the information,but there are many pieces not identified; such as a soup warmer.Please review equipment list and identify and supply as many items as possible.Also,please note on the list items that you do not have specification sheets for. OK 6)Plan does not show a walk in refrigerator. Only a freezer.Where will items such as cooling of soups be done? OK 7)There is no menu provided,however discussion and review have found that you will be doing items such as soups and pizza. There must be a mechanism to keep the pizza hot or it will be stored in the refrigerator case. Pizza slices may not be left at room temperature.A warmer may need to be purchased.Also,please submit a menu. OK 8)On Page E-11 of application-Cooling—No mention of pizza soup etc.is made here.How will you cool hot foods?Please check appropriate boxes. OK 8)Storage pallets are noted for storage. Note that these shall be on rollers and constructed from a non-porous material,not from wood.OK 9)Page E-12 r ' 9)Page E-12 (5)The bleach concentration must be 100-200 ppm and there must be a test kit on the premises. There must also be directions posted in the ware wash area,on the proper way to make sanitizer.OK 10)Page E-17 Drain Boards—It is noted that the applicant is choosing to use a 3-bay with only 1 drain board. There are no other tables shown around for housing dirty or clean dishes.Please describe how the ware washing will occur and how there will be no stock piling of dirty dishes on the floor or no towel drying of the food contact surfaces with only one drain board. OK Once basic construction is complete and the equipment is in place,please contact the health office for a construction inspection to verify that you have built it to plan.At that time we will sign off the building permit. The final health inspection should be requested approximately 24-48 hours prior to opening the establishment. At the final inspection,it is expected that the premises will be ready for business.Also,please make sure that all Health permit fees are paid as well as the Common Victualer's permit at the Town Clerk's office. Some items needed to receive the permit to operate are: 1) The establishment will be clean of all construction materials 2) The handsink and bathroom will be stocked with a wall mounted paper towel and soap dispensers 3) The ladies room will have a covered trash can for feminine item disposal 4) Bathroom must have"employee must wash hands before returning to work' signage 5) Handsinks should be labeled"hand wash only" 6) There must be test strips for the Chlorine sanitizer on site 7) There must be on site.Directions on mixing the sanitizer should be posted. 8) The three-bay should be labeled"wash,rinse, sanitize" 9) Gloves must be on site. Please note that the state does not recommend the use of latex gloves due to some person's sensitivity to latex that may cause them illness. 10) You must obtain copies of the state and federal food codes and keep them on premises 11) At minimum,employees should be trained on the sick policy and sanitation basics. Sincerely, "Su Sawyer,REHS/RS �. Public Health Director Cc: Building Dept. file 1 ;� J1ie �nnanrareu�czlf� e�. ��rssccc�rese<C�it Board of Building.Regulations and Standards r= HOME IMPROVEMENT CONTRACTOR ° Registration: 120199 i Expiration: 11/1/2007 j Type: Individual i DAVID GULEZIAN { DAVID GULEZIAN) ` 428 PLEASANT ST �,r„ ,��,,✓ � NORTH ANDOVER,MA 01845 Administrator �V- J ,. Xl.ytr.,pRl/fc n ! BOARD OF °�' 11:t.:rycn/trs,:r'lla y F License; BUILDING REGULATIONS �. CONSTRUCTIO N SUPERVISOR Number: CS 001821 Or Birthdate: 1R/0211959 Expires: 10/02/2007 Restricted: O0 Tr.no; 5396.0 428 PLEA DAVID P GULEZIAN E N ANDOVSANTST ER, MA 01845 G' CorrimFssioner TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR,RENOVATE,CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING7. iTi OTHER THAN A ONE OR TWO FAWLY DWELLING RIDING _ __ Tltis erection for Official Use BUDaly ;� s :tea - ILDING PERItiIIT NUMBER: MATE ISSUED: A SIGNATURE: Buildin Commissioner/I or of Buildin Date SEC nort L-Saw 1.I Pmperty Address: 1.2 Assessors Map and Parcel Number: 05 od�.�� Map Number Parcel Number -3710 1.3 Zoning Uilotnuttion: 1.4 Property Dimensions: y+�e Zonin .Distrid Proposed Use — -- Lot area s -- - Fronts R 1.6 BUILDING SETBACKS(ft) m Front Yard Side Yard — Rear Yard Required Provide Required Provided Required Provided 1.7 Water Supply M.G.L.CA 54) I.S. Flood Tone Tntornation: 1.8 Sewerage Disposal System: Public 0 Private U Zone Outside Flood Zona 0 Municipal On Site Disposal System 0 PltlEJPERTY 2.1 Owner of Record d Name(Print) + Address for Service: ---- -- --- -- do Signature Telephone Authorized Agent S-C a Name Print Address for Service: - — Signature - Telephone — --- ---— aZ 3.1 Licensed Construction Supervisor Not Applicable ❑ Addressjj License Number Licensed Construe' Su tsor: q�F- Expiration Date ----------------- �_ Signature Telephone ------ —--- r 3.2 Re istered liome mp ovt, tontcontractorNot Applicable C1 --- — "1< Company Name Registration Number W.- /911 r�(n2fG n r Address Expiration Da --- -- Z Sro ignatu ----- ---- -- � -- — — G) Telephone SECTION 4,-WORKERS COMPENSATION(M.G.L C 10 j 'iwo Workers Compensation Insurance affidavit must be,:omplcted and submitted with this application. Failure to provide this a83davit will result ri the denial of the issuance of the building permit. Signed affidavit Attached Yea.......i1 No.......L] SECTION 5-PROFESSIONAL.DESIG14 AND CONSTRUCTION SERVICES ICOR BUHMkNGS AND STRUCTURES SUBJECT TO CONSTRUCTION CONTROL PURSUANT TO''M CMR 116(CONTAINING MORE THAND 3.5,000 C.F.OF.ENCLOSED SPACE) 5.1 Registered Architect: Name: Address Q78 W9Vl '�9. Signature Telephone 5.2 Registered Professional Lnglncer(s): ' Area of Responsibility Name: Registration Number Address: Expiration Date Signature Total Not applicable 0 Nance: Registration Number Address Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date I Name area of Responsibility Address Registration Number Signature Telephone Expiration Date S 3 (;eaeral Contrut" Not Applicable ❑ Company Name:�� Responsible in Charge of Constniction iBCI'It?l<IS')IrSGRIPI'[OHI E 1PRUPOSED WORK (check all appliutblc) -- - New Construction ❑ Existing Building ❑ Repair(s) J Alterations(s) \ddition � \ccessory Bldg. Demolition E Other Sp'2city — Brief Description of Proposed Work: S)�CPION'7-USk GRiUQP AND CONSTRUCTION TYPE. USE GROUP(Check as applicable) CONSTRUCTION TYPE A Assembly ❑ A-1 a A-2 ❑ A-3 IA A4 ❑ A-5 ❑ 1 B B Business ❑ 2A C Educational ❑ 2B F Factory ❑ F-I ❑ F-2 ❑ 2C ❑ H High Hazard ❑ _ 3A IInstitutional ❑ I-1 ❑ 1-2 ❑ 1-3 ❑ 3B M Mercantile FJ 4 _ R residential ❑ R-1 ❑ R-2 u R-3 ❑ 5A ❑ S Storage ❑ S-1 ❑ S-2 ❑ 5B ❑ TJ Utility ❑ Specify: M Mixed Use ❑ Specify: S Special Use ❑ Specify: COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS,ADDITIONS AND OR CHANGE IN USE Existing Use Group: Proposed Use Group: Existing Hazard Index 780 CMR 34: — Proposed Hazard Index 780 CMR 34: SEGTION�B10lI:pll ;BES ARS BUILDING AREA EXISTING(if ap (p iGMe _ PROPOSED — -- Number of Floors or Stories Include --- Basement levels ,Floor Area per Floors _-- Total Area(f) —-- —---- - -------- Total Height(ft) 71 HALL— I ndependent_Structural Engineering Structural Peer Review Required _ Yes a No 0 SECTION 10a Owner Authorization- TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT ✓ � iA i� 1-c ---,its Owner of the subject property dl ,c Hereby authorize act on Nf behalf, in all matters relative two work authorized this building — � Y by g perznit application Signature of Owner Date — — ---- I � * 4 y � t` i+E'>Z 1 • 9 Q4. ) Owner/Authori;_ed Agent Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury N -A 6j10y/an Print Name l a 6 Signature of Owner/Agent Date SECTI01�11-E3T[MATED CONS' IRUCnON.Coft ]tem Estimated Cost(Dollars)to be Oi+p'I IAL.Ust ONLY Completed by permit applicant 1. Building % /% 5-5-05-5-0 , od (a) Building Permit Fee 10 Multiplier 2 F-.lectrical - 7_�� (b) Estimated Total Cost of V` ( Construction from(6) 3 Plumbing (( 006. 6 a Building Permit fee (a)x(b) 4 Mechanical(HVAC) l 0 . 00 5 Fire Protection' 6 Total (1+2+3+4+5) z)`7�j 60 Check Number t r NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1ST 2 ND 3RD SPAN DEMFNSIONS OF SILLS DEMENSIONS OF POSTS DIMENSIONS OF GIRDERS HFIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATLRIAL OF CHIM1,TEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE W c� 1 ' . Tip \ The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 t www.mass.g ov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly 4 Name (Business/Organization/In(iividual): Address: lN-f a ��!�7 � Phone #: IK ? I� T? �r City/State/Zip: m�1 q Are you an employer?Check the appropriate box: Type of project(required): LB I am a employer with_ 3 4. ❑ I am a general contractor and 1 6. ❑ New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. * 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. q. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its officers have exercised their 10.❑ Electrical repairs or additions required.] 3.❑ I am a homeowner doing all work right of exemption per MGL 1 I.❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof rep//airs insurance required.] t employees. [No workers' 13.0 Other (O rC F� U� comp. insurance required.] *Any applicant that checks box#I must also till out the section below showing their workers compensation policy information. t Flomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box most 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. Q r,, Insurance Company Name: I 1 ' v Policy#or Self-ins. Lic. #: UJ �� Expiration () /p Zf _ �7v Date: 3 Job Site Address: I'M I( N City/State/Zip: Attach a copy of the workers' Vompensation 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 tine 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 i surance coverage verification. I do hereby certify un a pains and penalties of perjury that the information provided above is true and correct. Si nature: _ h �1Q p L Date: Phone#: U V J QfJieial use Dirty. Do not write in this area,to he completed by city or town offrcial. City or Town: Permit/License# Issuing Authority(circle one): I. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: 1 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 numbers)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 till out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to full 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 fulled 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.gov/dia •~"`� 2oe5 06:25 19763276517 WILLOWS PAGE Iii �+ DATE(MM+bDnTYY) OofrA��iE 04/27/2005 uRaDucex 878 975 434► QNLYC�PIQ OTIFERS NO£RIGH S EAUPQNRTHE i C RR fiACATE WILLOWS 11NTERNET iNSURA1dCE�AG.1NC HpLDER. THIS CERTIFtGATEc DOES NOT AMENp, EXTEND OR 522 CNlCKERING RaAD ATTER Tt'tE COVERAGE AFFQRtEfD E3Y ?H1r pQIICf>rg £El-OW. NORTH ANDOVER;TAA 01845 INSURERS AFFOR©ING COYERAQET NAIG# Q.G.CONTRACTING.INC. } NSUt?5R& DAVID GULEZIAN I i^L9LtftEtiC: . - 428 PLI�ASR►JT STREET INSURER D: AIG INSEJhANCE _---- - - - -- _ NORTH ANDOVER,MA 01345 INSUREKf-: — -- COVERAGES ANY LISTED Ota PF APIY CONTRACT OR ©ER.DOCUMEN ABOVEVE BEEN 13SUED TO THE INSURED EWITR SPEC;70 W►atCH THRtS CERTDtF LATE(n�B�tENG nSSUEotClR MAY PERTAIN.THE INSURANCE Af�ORDE 3 BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCtuSiflN$AND COn�1T10NS OE SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, Y ExPIRA�TDN, -- _. --- -- INSR'AtJls1 — _.. V—OLF UMITS POLtCY NUMBER � TR I I EACH OCCURRENCE �, GENERALUABRtTY ? I DAVA-GE'"URTECl_.—. AI I {PRfiMlSE${E8oGSyrnna�_ _--S _ _ _{G_OMRIcRGiALGENEftAtLLRN(LtTY iMEDEXP(AI:YOLOPI 7011'1_ ! CLAIMS MADE !OCCUR _ _1 1 PERSONAL a ADV.NJiJRY 8 its_ GENERAL AGGREGATE 3 i •-- GENT AGGREGATE PRG APPLIES PER: { POi.ICY i G, LOC AUTOMO81lE1-to@TETT i COMBINED SINGLE LIMI $ I i !(ESwzdwl) + ` a { i ANY AU'fC --.- I t +ALL OWNEDAUTDS 4 I 20DiLYINJURY S SCHEDULEDAUTUS -- r 600ILY INJURY S � H!R'EOAUTO.S ;Fsacd09:t!; .._.;M'ONVOWNEDAUT OS PROPERTY DAMAGE (PPsoccidant) AUTO ONLY,EA ACG+DENT $ GARAGELIABRJ'TY 1 ! I OTHERTHAN ACC i ANY AUTO AUTOONLY'. AOC, S i I I E=ESWUMGRELLA LtAWITY €EACH OGCURR€NCE— f -- -- 1 = AGGREGATE OCCUR C2AtA/5s1ADE f z I.__ RETETaTtOtd E ` TtAtCY STATU. -4 WORAERS COE%SATION AND Ub1T_ tiW -S, D EMPLOYERS'LIAMTY #WC333-27-74 03/31t2004 i 03/31/2005 E.L.EACHACCIDENT S 100,Q00 c„kwFF�FFICIR ErvtunAR;riExrE ctrnve RENEWAL 3/31t2005 3/3112006 -- — ! i ER+MEr�sErtExCLVOEm 'E.L:DISEASE,EA EMPIOYEE_5— 100,000 H yvtgp�avu O¢sa+beuifUef J E.L.DISEASE,POLICY L MIT i 5 500,000 SPEG`IAl.PROVIStQN&bei"__._ OTTER F i 1 1 i OE—TION Of OPERATIONS,L.00ATLONS I VEM MLES I EXCLUSIONSADU ED BY ENDORSEMENT I SPECIAL PROVISIONS f i CEcRTWICATE HOLDER CANCELLATION SHOW.0 ANY OF THE A@OVE DESCRIBED POLICIES BE CANCELLED BEF4oRE THE EXPIRATION DATE THEREOF,THE 195UFNG WISURER IMiLJ_ENDEAVOR TO MAIL 10_ DAYS u/Rt1TEN NOTICE TO THE CERTIFICATE"OLRER NAMED TO TRE LEFT,BUT FAILURE TO DO SO SHALT. IMPOSE NO OBUGA nON OR LIABILITY OF ANY KINO UPON THE INSURER, ITS AGENTS OR TE*N-f AUTNORQED ACQRD 28(24Ettf481 'ACORD CORPORATION 19$11 NORTH ANDOVER BUILDING DEPARTMENT Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of Building Permit at: is that the debris resulting from this work shall be disposed of in a property licensed solid waste disposal facility as defined by NIGL 11, S 150 A. Also, note Permits are required under Fire Prevention laws Chapter 148 Section I OA. The debris will be disposed of in: Lc6-,c2 e�ajVm (Location of Facility) Signature of Permit Applicant Fire Department Sign off: Dumpster Permit Date TOWN OF NORTH ANDOVER Construction Control Affidavit Project Number: 0511114 Project Title: DeFusco &Son Bakery Project Location: 1211 Osgood Street—Tenant Space #1 Name of Building: Osgood St Retail Center Nature of Project: Tenant Fit-up for Bakery in existing shell space. In accordance with Section 116.0 Registered Architectural and Professional Engineering Services-Construction Control of the Massachusetts State Building Code, I, Gregory P. Smith,AIA Registration No. 8688 being a Registered PFOfessi. nal E ffgi. eer/Architect, HEREBY CERTIFY that I have prepared or directly supervised the preparation of all design plans, computations and specifications concerning: Entire Project Architectural _X)000_Structural Mechanical Fire Protection Electrical Other(specify) FOR THE ABOVE-NAMED PROJECT AND THAT SUCH PLANS, COMPUTATIONS AND SPECIFICATIONS MEET THE APPLICABLE PROVISIONS OF THE 780 CMR MASSACHUSETTS STATE BUILDING CODE. ALL ACCEPTABLE 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 116.2.2 1. Review, for conformance to the design concept, shop drawings, samples and other submittals which are submitted by the contractor in accordance with the requirements of the construction documents. 2. Review and approval of the quality control procedures for all code-required controlled materials. 3. Be present at intervals appropriate to the state of construction to become, generally familiar with the progress and quality of the work and to determine, in general, if the work is being performed in a manner consistent with the construction documents. UNDER SECTION 116.4, I SHALL PERIODICALLY SUBMIT A PROGRESS REPORT, TOGETHER WITH PERTINENT COMMENTS, TO THE BUILDING INSPECTOR UPON COMPLETION OF THE WORK, I SHALL SUBMIT A FINAL REPORT AS TO THE SATISFACTORY COMP ND READINESS OF THE PROJECT FOR OCCUPANCY. ( D ARC Signature and Stamp(no facsimile) Q����GaRv P.s�yFo� No.8688 1�•Z2' 2O0Io. q NORTH ANDOVER, 0 PG � q�TN OF 1, S SUBSCR ED ASV S BEFORE ME THIS DAY OF 2006 MY COMMISSION EXPIRES bd/p// NOTAR L C