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HomeMy WebLinkAboutBuilding Permit #054-13 - 124 MAIN STREET 7/24/2002 BUILDING PERMIT OORTH ,,I,-r.D J6 TOWN OF NORTH ANDOVER 0 0 APPLICATION FOR PLAN EXAMINATION If Date Received Permit NO: ArEt, CHUS Date Issued: 7 I PO ANT:Applicant must complete all items on this page Fr x ,riot PRO 'ERT #VOY V N 7 R'm Al i, " i mAp,.)N(V.- 'ZONIN - -Hyes OtRICT n 0 .nqo' , Machine qge. Yes ,�,, ,no, - TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Addition Two or more family Industrial Alteration No. of units: Commercial Repair, replacement Assessory Bldg Y Others: Demolition Other -KU'.j%C1?rC- '15in- Me e oodp atef/SiDw6r- DESCRIPTION OF WORK TO BE PREFORMED: 4ec1DL 'EXL%T t,$ I-P Li E L W e 'q- S Identification Please Type or Print Clearly) OWNER: Name:- -T 1�-"-),.j-T11 Phone: fit- GSk- 73J6 Address: 12Q MA%,J tsJ OJ:e 2 11!�c1t CONTRACTOR' arp — bow Superviso Licen- ' x _Expo a HbMPiIMpMMRMPtYiq0QPs LxP ARCHITECT/ENGINEER --\b. 2 A sso WSsoc Phone: q'-4 Address: (Dws Ek-&A �0, A u-eq- YV) Reg. No. FEE SCHEDULE.BOLDING PERMIT.,$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ S:00 FEE: $ 4�J Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to anty and ---------- Ofk- Wd - Signature Ob ner 8ibfibtbhj of contract ti:' Plans Submitted Plans Waived Certified Plot Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/Massage/Body Art Swimming Pools Well Tobacco Sales Food Packaging/Sales Private(septic tank,etc. Permanent Dumpster on Site THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS CONSERVATION Reviewed on Siqnature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments i Conservation Decision: Comments Water & Sewer Connection/Signature &Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT 'Temp Dumpster on site yes° 3 .♦ v-^,- -M •K-. �`C-.:.. ,.dam Located,at�124,Mam•Street� :. - - ` �'?" "" � _ `F�re'Department signatureltlate;. 1. CQMMENTS, 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 2008 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 ❑ Building Permit Application o Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract o Floor Plan Or Proposed Interior Work o 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 o Certified Surveyed Plot Plan o Workers Comp Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract o 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) o Building Permit Application o Certified Proposed Plot Plan L3 Photo of H.I.C. And C.S.L. Licenses o Workers ComP Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o Copy of Contract ❑ 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 must be submitted with the building application Doc:INSPECTIONAL SERVICES DEPARTYIENTMFORM07 i Revised 2.2008 r ,_ NORTFj W. 1 _ 6 L ic . . ve,. . I No. 09+ 1 t - h ver, Mass, `7 Y// 2COC NIG Nl WICK y1. %d,a 0,4 S U L D BOARD OF HEALTH Food/Kitchen PER T Septic System 1 BUILDING INSPECTOR THIS CERTIFIES THAT ............ .in 02....... .... ....... . . .. .44 .... ........................ has permission to erect .. ................ buildings on . .L .. � l/. .. ............... Foundation � .. �l Rough U/ �Xf" ato be occupied as ....... �1'7r i !.!.. ..� Chimney provided that the person accepting this permit shall in every respect conform to th terms of the application Final on file in 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 PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION TS Rough Service ......................... .. .. ........... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building 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. Smoke Det. SEE REVERSE SIDE d • S��TL �16gs Town of North AndoverW. - Office of the ' Town Manager ; North Andover Town Hall � 120 Main Street r North Andover, MA 01845 amaylor(a-,),townofnorthandover.com Andrew W. Maylor Telephone (978)688-9510 Town Manager Fax (978)688-9556 MEMORANDUM TO: Gerald Brown, Inspector of Buildings, Town of North Andover, MA FROM: Andrew W. Maylor, Town Manager "t DATE: July 17, 2012 RE: Fire Station #1, 2nd Floor Bathroom Remodel, 120 Main Street, North Andover, MA The proposed 2nd floor bathroom at Fire Station #1 is intended for the private use of North Andover Fire Department personnel and is not to be used as a public toilet facility. /kar cc: Andrew Melnikas, Fire Chief Stephen Foster, Facilities Management Director Architects JDLaGrasse & Associates, Inc. Joseph D.LaGrasse,AIA Architects, Engineers &Land Planners Thomas R Galvin,AIA Julianna E.Hoch,RA July 17, 2012 Gerald Brown, Inspector of Buildings Town Hall North Andover, MA 01845 Re: North Andover Fire Dept. 2°a Floor Toilet Dear Gerry, The second floor toilet room remodeling is a private toilet room and is not for public access. Sincerely, Joseph D. rasse,AIA One Elm Square T 978.470.3675 1420 Celebration Blvd. Andover,MA 01810 F 978.470.3670 Celebration,FL 34747 AA26001333 www.lagrassearchitects.com i NOTE THIS 2ND FLOOR TOILET ROOM IS INTENDED FOR PRIVATE USE ONLY AND SHALL NOT BE ACCESSIBLE FOR USE BY THE GENERAL PUBLIC. EXISTING EXTERIOR WINDOW TO REMAIN RELOCATE EXISTING RADIATOR BELOW WINDOW DOUBLE ROLL TOILET RAl PAPER DISPENSER INSTALL NEW TOILET M D D NEW S'-0"x1'-10"SOLID ►E ON C BATHROOM SURFACE COUNTER WITH j NEEDED in ING AS SOLID SURFACE SINK c BASIN.PROVIDE AND — INSTALL NEW SUPPLY NEW PARTITION:2x4 TOWEL BAR NEW PHENOLIC LINES AND SANITARY WOOD STUD,%"M.R. TOILET PARTITION LNE.PROVIDE AND p GM,TAPE AND FINISH INSTALL VANITY BASES 0 p NEW FLOOR DRAM FOR STORAGE. w O NEW 3'x3'2 PIECE L SHOWER Uk3'NIT ar REFINISH EXISTING NEW 5WALL MIRROR _ - DOOR INTERIOR MOUNTED ABOVE ONLY, C SHELVES FD —a, PAPER TOWEL w DISPENSER V-S"z 1, 4'-4"1 OFFICE FIELD DIMENSIONS (VIF) (VIF) PRIOR TO EXECUSION COMMON WALL SIGN PLAQUE PRIVATE USE ONLY NO PUBLIC ACCESS COMMON WALL rMMOVISE-0 FLOOR PLAN SCALE:ALAA3/8"■I'-0" A-2 AA REVISED 1/11/2012 N-In7tWerfio.rs.- p' ` ` Nord Andoiiii iie Depaftent ¢f .� 2 February 2012 4 AS NOTED �rREVISED 2322 Amchi�-E.� Land PlanningOne Elm Square,Andover, A 01810ihast MP T.978-470-3675 F.978-470-3670 FLOOR P LAN -71,7 tZ_ A Z www.Iogrossearchitects.com — E—mail: JDLAIOA0L.00M r 1 i l i t / Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Super-isor License: CS-068083 -rg= ALLEN S CAPON 11 PEVWELL DIX ^'� r SAUGUS MA O1S06 (�+ Expiration Commissioner 04/16/2014 • North Andover Fire Department Bathroom Renovation ...g � �.�µf ewe.YP "a- U���•Yd'Ks+,"�'7�r 10, � ,c--r�- �� > ��• �s� _ Bks„� � ti ) 1 IVV. res: All ' -z 'j 1 • 1 � co � e ` North Andover Fire Department Bathroom Renovation Project Narrative The project is for the renovation of the existing second floor bathroom of the central fire station. The project shall include the demolition of the existing space removing all materials to expose the framing members (studs and joists). A new subfloor shall be installed level, by shimming or strapping the existing framing members. New mechanical fixtures s a e installed in the bathroom including but not limited to light fixtures, electrical outlets, exhaust fan, radiator(installed in new location), revise plumbing to accommodate new layout include floor drain in shower area (all plumbing shall be worked from above unless patching repairing ceiling below is include in contractors work. Frame new wall along shower to install water supply lines. The finish of the project will be homogeneous vinyl or rubber flooring with welded seams and flash coved base, Symmetrix fiber reinforced panels by Marlite installed as a wainscot in the sink area and full walf panel in shower area, acoustic ceiling with fluorescent fixtures. Install new phenolic toilet partition and stainless steel hardware, solid surface counter with integral sink, 5'-0"x3'-0"mirror over sink.Toilet accessories shall include towel bars, soap dispensers, 18"x6"stainless steel shelf over each sink, paper towel dispenser, toilet tissue dispenser and coat hooks. Lighting shall include 5'-0"valance fixture over mirror, 2x2 fluorescent fixtures in ceiling, exhaust fan, new speaker for existing intercom system, new GFCI duplex outlet.at each end of sink counter. Contractor shall coordinate colors with owner(NAFD). Page 2 l t _ z 7 A- e - f • • •._ are - t ­77— wo 3 5 r c ..� -i.. 9 A i, ' r sr .:x •r North Andover Fire Department Bathroom Renovation 1.0 General conditions 1.1 Contractor and subcontractors shall provide and pay for all labor, material, equipment and tools necessary execute the work described in this document. 1.2 The Contractor, sub contractor and their employees shall conduct the work in a legal and safe manner to assure the safety of the workers and the public. The Contractor shall supply all temporary shoring, bracing and enclosures.as needed to complete the work. 1.3 The contractor shall conform to the current Massachusetts Building Codes.All sub- trades shall conform to the rules and regulations pertaining to their discipline. 1.4 The Contractor shall coordinate with the North Andover Building Department for required inspections and sign-offs. 1.5 The Contractor shall remove debris from demolition and waste materials at the close of each workday. Debris shall be disposed of in an appropriate and legal manner. 1.6 The Fire Department will remain.in operation durin construction 9 . The Contractor shall coordinate work so as to minimize disruption to the operations of the fire department. 2.0 Demolition 2.1 Contractor shall coordinate dumpster location with the authority having jurisdiction. 2.2 The contractor shall test for lead in the area of work and carry an allowance of$2,500 for the abatement and removal of any materials testing positive for lead or other components known to be hazardous material. 2.3 Contractor shall dispose of all removed material in a legal manner. Debris shall be removed daily from the work area.and disposed of in work dumpster. 2.4 Terminate electricity,water and gas (if applicable) in work area prior to any demolition work. 2.5 Remove existing wainscoting, door and window trim and deliver to owner for possible reuse or repair. 2.6 Remove existing entry door to bathroom and store for refinishing and reinstallation. .2.7 Remove all plumbing fixtures, radiator and ceiling grid. 2.8 Remove acoustic ceiling tiles and grid, all plaster(walls and ceiling) and subflooring to expose framing members 3.0 Rough Carpentry 3.1 Install 2 layers of/" subfloor over existing floor joists, shim or strap existing joists as needed to provide same thickness as original subfloor and finish. If joist spacing exceeds 16" O.C. notify architect to review framing and substrate before installation. Page 4 North Andover Fire Department Bathroom Renovation 3.2 Provide headers as needed to install plumbing fixtures in new locations. Coordinate with plumber for fixture locations and pipe size: 3.3 Provide blocking as need to support plumbing fixtures and accessories. Provide 2x8 wood members between studs at counter and toilet partition locations. 3.4 Frame new 2x4 stud wall to enclose shower area. Construct wall from floor deck to ceiling joist. 3.5 Frame soffit around window well at exterior wall.Approximately 8"deep by width of window. Soffit shall hang 1" below acoustic ceiling. 3.6 Install 1x3 wood strapping at over vapor barrier along ceiling joist. 4.0 Mechanical Components 4.1 Revised hot water loop to new radiator location below window. Provide and install sloped top enclosure over copper pipe and aluminum fin assembly. Cover shall have factory baked enamel finish. Length shall be sufficient to provide adequate heat for the space. 4.2 Provide new plumbingsupply lines pp y and sanitary Imes to toilet, shower, floor drain and sink locations. Plumbing shall include but not be limited to hot and cold water supply lines to shower and each sink in counter area, and a cold water supply line to the toilet. Provide and install material for the installation of new sanitary lines from the sink area, shower floor drain and toilet. Piping shall be sized appropriately for the fixtures of this area. These installations shall be worked from inside the demolished space while faming is exposed. 4.3 Provide new wiring to electric panel board for power and lighting requirements of this space. Lighting shall include 2 new 2x2 fluorescent fixtures in bathroom ceiling and one valance fixture over sink counter. Power requirements shall be 2 new GFCI receptacle at the sink area (one at each end)and a common outlet @18"AFF at the outside wall, 1'00 CFM exhaust fan located in ceiling. 4.4 Alternate#1 power requirements will be for 2 new 2x2 fluorescent fixtures in the common hallway new ceiling. 5.0 Insulation 5.1 Provide and install thermal insulation along exterior wall. Insulation shall fill cavity from floor to ceiling joist of roof deck. Thermal value shall be R-15 for 3.5"cavity and R-19 for 5.5"cavity. 5.2 Provide and install R-30 insulation in floor over unconditioned space (Garage Space). 5:3 Provide and install R-38 insulation in ceiling cavity at roof joist or maximum R value allowed by ceiling joist cavity.. 5.4 Provide and install 6 mil vapor barrier over insulation between studs and wall board. Lap seams in corners minimum 2" and tape with seam tape. 6.0 Gypsum Wall board 6.1 Provide and install 5/8-gypsum wall board base for veneer plaster finish. Install as per manufacturers requirements. Provide all accessories necessary for a complete job. Page 15 North Andover Fire Department Bathroom Renovation 5.4 Provide and install 6 mil vapor barrier over insulation between studs and wall board. Lap seams in corners minimum 2"and tape with seam tape. 6.0 Gypsum Wall board 6.1 Provide and install 5/8"gypsum wall board base for veneer plaster finish. Install as per manufacturers requirements. Provide all accessories necessary for a complete job. 6.2 Install wall board in window well and wrap wall and soffit to finish well on window side. Wall board shall extend.6" above acoustic ceiling on room side. 7.0 Interior finishes 7.1 Fiber reinforced wall panels shall be provided and installed for shower area and as a wainscoting in the sink area. a. Shower panels are to be Symmetrix FRP by Marlite and shall be installed 4" off finish floor and extend 8'-0" up wall. Install as per manufacturer requirements for installation over gypsum wall board. Seams shall be silicone joint. b. Sink area shall be Symmetrix FRP by Marlite and shall be installed 4" off finish floor and extend 48" up wall. Install as per manufacturer requirements for installation over gypsum wall board. Seams shall be silicone joint. Cap FRP panel with refinished chair rail removed during demolition. 7.2 Unfinished gypsum wall board shall be primed prior to installation of FRP. Primed wall over chair rail shall receive 2 coats finish paint with semi gloss finish (color by owner). 7.3 Ceiling shall be 2x2 grid with acoustic tiles appropriate for wet locations. Tiles shall be Armstrong 'Dune'tile with beveled edge. Ceiling shall be installed at 8'-4"above finish floor. 7.4 Flooring shall be rubber sheet good with welded seams and cover flashed base edge to 4" up wall. Install as per manufacturers requirement. Flooring shall be flashed into floor drain. 7.5 Toilet partition shall be phenolic type solid panel (refer to plan for dimensions), floor mounted overhead braced, all hardware/"shall be stainless steel. Coordinate blocking in wall during framing. 7.6 Provide and install (2) 30"sink base vanity cabinets. Coordinate with owner for style. 8.0 Fixtures 8.1 Bathroom fixtures shall include 36"x36" gelcoat 2 piece shower stall, toilet fixture(floor mounted, tank operation)with toilet seat, floor drain in shower area, sink basins shall be integral with solid surface counter, faucet for each sink(coordinate style with owner). 8.2 Light fixtures Lighting and electrical equipment shall include 5'-0"valance fixture over mirror, 2x2 fluorescent fixtures in ceiling, exhaust fan, provide and install motion sensor switch at room entry[switch shall control ceiling, valance and exhaust fan and stay on for 15-20 minutes after activation], new speaker for existing intercom system, (2) new GFCI duplex(one at each end of vanity, one duplex receptacle 8.3 Toilet accessories shall include towel bars, soap dispensers, 18"x6" stainless steel shelf over each sink, paper towel dispenser, toilet tissue dispenser and coat hooks. Page 6 I I I O I EXISTING IUNDm To. DC l AND I STORE FOR RE-4J3TALLATkx L EXISTW,RADIATOR To BE REMOVED.RM-IFE Li TO NEW LOCATION, INSTALL NEW RADIATOR EXISTING SMCS TO BE REMOVED REVISED J'UMWI AS NEEDED REMOVE E�XIS cwAbt PAAm WAMSCOT.CNAIR RAIL TO IQMJSED FOR NEW FINIM EXISTI 6 FLOOR PLA i SCALE yr repar or.: North Andover Fire Department te: 2 February 2012 ` �: 's.- ... b,........ EXISTING AS NOTED ob Architects-Engineers-Interiors-Land Planning 2322 ane Elm Square,Andover,MA 01810 neet: r.978470-3675 F.978-470-3670 FLOOR PLAN ttyp.1agroweorchltects.com— E—man:JDLJOAOLCOM A Ex►STING perEWJpR "'0M TO FOaIN DIATOR�O . 1'J71_1" WINpOW DOUBLE RLXL �.�e�ru DI„Y,_� ILLI di NEW LLOOGq�O►LET►N o RAc�►ar �j) hEEM =r SANRoo" E U NEW I*AR rla&Z14 �5�" �-b"SOLID I GM 87E D NNI TOUEL Batt G �SDE aN[� 6 APE AND FINISH NEW pHE►tOLIG INSTALL NEW �p AND FROVb�Yij� NEW 3k3'Y ftca TOILET PARTITIONa Q4OUER WIT L� tY NEW FLOOR DR41N WTaLL v*tly BASES ONLY. OR 55(3'WALL ® o sNMVES ABOVE ft a FD PAPER T J pe OUtL 'VE FY F ELD D ONS _ .q'_ " C MMON HALL FPJOR To�CUSICN �v tv OFFICE Ca"MON 14ALL FYI S�D� �L`OOf� PL,4 , epa( or. NolthAndhe,'FmeDepa/ln7ent i 3 's- t� 2 February 2012 Engineers -Land Planning REVISED cap:n Square,Andover,MA 01810 ob AS NOTED !70-3675 F.978-470-3670 ^ w 2322 eorchltec(".com— E—mail:JDLAIOAOLCOI) heeC FLOORPN /1 n DUCT EXWAUST FAN ABOVE CEILING,DRILL 4'HOLE THROUGH UIOOD FRAME OVER EXISTMG WMDOW,INSTALL YENt WOOD COYER WITW BAFFLE,SEAL TO BE WEATWER TIGWT. F- ' NEW GM SOFFIT AND EkN4l15T F _ — I WMXW AREMAY TO —'! ( TOP OF W►NDOUL SCFF►T 2x2 LksFrf I SHALL BE P BELOW CEILW.LNE. M RE ASNEEDED NEW Lk,NTOLIER THIMONt 6'CLOUD' 48'LONG MOIMED ABOVE MIRROR 2x2 LIC*M TILES LL B D COATED FOR WET L_ LO, _4ICN 2x2 FLUORESCENT AXTU6ZE LIGHfOL1ER UES'SERAIES FOR LET LOCATICN. ALTERNATE Mr T'ROYIDE AND INSTALL NEW 2x2 CEILWs GRID IN COMMON WALL WITH 2 NEW FLUORESCENT FIXTURE(LIGHTOLIER 'CV5'SERIES) 2x1 LkaHT 2x2 Lk,HT REPLffGTEI;� GE I L I O PLS i SCALE.3/8'=I'-O' A-3 M"' repar, Noah.4/ldoverFire Department `� qa212 REFELCTED ob 'chit"-Engineers-Interiors-Land Planning .. )ne Elm Square,Andover,MA 01810 Heel 978 470-3675 F.978 470-3670 CEILING PLAN ip.logrosseorchkects.eom—E—MOU:JDWOAOL.COM PERGO-3 OP ID: KS1 CERTIFICATE OF LIABILITY INSURANCE r DAT07/10D/YYYY) 07/10/12 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. 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). PRODUCER CONTACT 781-914-1000 TGA Cross Insurance,Inc. NAME:ONE Kelly Sturtevant FAx 401 Edgewater Place,Suite 220 A/C.No.Ex .781-914-1000 vc No: 781-224-9490 Wakefield,MA 01880 E-MAIL ksturtevant t across.com Chris Hawthorne ADDRESS: g INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Arbella Protection Ins.Co. 41360 INSURED Pergola Construction Co.,Inc. INSURER B:Associated Inds of Mass. 175 Essex Street Swampscott,MA 01907 INSURER C: INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE 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, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IPOLICY EFF POLICY EXP NR TYPE OF INSURANCE ADDL SUB POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 AMAGE TO RENTED A X COMMERCIAL GENERAL LIABILITY 8500051851 06/28/12 06/28/13 PREMISES Ea occurrence) $ 300,000 CLAIMS-MADE Fx] OCCUR MED EXP(Any one person) $ 15,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 X POLICY PRO CT LOC $ AUTOMOBILE LIABILITY Ee aBINED SINGLE LIMIT $ 1,000,000 A ANY AUTO 65028400004 06/28/12 06/28/13 BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS X AUTOS BODILY INJURY(Per accident) $ X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident X UMBRELLA UAB X OCCUR EACH OCCURRENCE $ 5,000,000 A EXCESS LIAB CLAIMS-MADE 4600051852 06/28/12 06/28/13 AGGREGATE $ 5,000,000 DED I X I RETENTION$ 10,000 $ WORKERS COMPENSATIONWC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N X T RY LIMITS ER B ANY PROPRIETOR/PARTNER/EXECUTIVEWMZ 8006084012012 06/28/12 06/28/13 E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? F_N� N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ 1,000,000 If es,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1 $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) RE: second floor bathroom at Fire Station 1. The Town of North Andover is additional insured as required by the written contract, only to the extent required. CERTIFICATE HOLDER CANCELLATION TOWNNO2 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of North Andover Fax: 978-688-9556 AUTHORIZED REPRESENTATIVE 120 Main Streeta �/ North Andover,MA 01845 ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): e.2 Go C ON S l rLJ C C Address: I S L`SSC, e0 '(— City/State/Zip: Sv 1 t-�! S C gjt-1 VNA Phone#: _410- S-99- LIM Are you an employer?Check the appropriate box: Type of project(required): 1. I am a employer with 20 4. ❑ I am a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. : Remodeling ship and have no employees These sub-contractors have 8. Demolition workingfor me in an capacity. workers'comp.insurance. 9 y p 13'• ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions I q ] . . 11. Plumbing repairs or additions 3.❑ I am a homeowner doingall work right of exemption per MGL ❑ g p myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑Roof repairs insurance required.]t employees. [No workers' comp.insurance required.] 13T] 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. 11 # Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. _ Insurance Company Name: AS 0 C i 1 L _ I W A's 0 � S Policy#or Self-ins.Lic.#: W M Z 9 OCD b 02"0 ) 2_ 0 11 Expiration Date: 1p _2 Snr- 3 Job Site Address: � Z L4 W\A i vJ ST City/State/Zi�tJjqvjaov i 22 Mn d l ?y Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine 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 hereby certify t ai dp al s of perjury that the information provided above is true and correct. Signature: Date: — I o - Phone Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: lfomrnonwea&of///aieac"Ib Official Use Only c� Permit No. � a1JePartmeret o� ire�erviced BOARD OF FIRE PREVENTION REGULATIONS [Rev:Occupancy and Fee Checked 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 PRINT IN INK OR TYPE LL IN ORMATION) Date: City or Town of: �, (�mY� To the Ins ector of Wires: By this application the undersigned ives notice of bis or he 'n ention to perform the electrical work described below. Location(Street&Number) Owner or Tenant Telephone No. Owner's Address Is this permit in conjunction with a building p. es ❑ No ❑ (Check Appropriate Box) g Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd❑ No.of Meters 11 New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion of the followingtable may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans o.of Total Transformers KVA \r No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above In- o.o mergency Lighting rnd. rnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detection and' Initiating Devices Total No.of Ranges No.of Air Cond. Tons No.of Alerting Devices No.of Waste Disposers Heat Pump Number Tons W o.o Self-Contained ,� \ ............................... ........................ `Y Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ElMunicipalConnection El Other No.of Dryers Heating Appliances KW Security ystems:* y No.of Devices or Equivalent i No.of Water No.of No.of Data Wiring: Heaters KW Signs Ballasts No.of Devices or Equivalent _ Ne.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring. 1 No.of Devrces or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of El" 'cal Work: (When required by municipal policy.) Work to Start: 1,10 Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE C VE GE: 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: Q -� LIC.NO.: Licensee: f, �� t Signature C.NO.: 7� (If applicable, enter "exempt"in the lice e n mbe I' e. Bus.Tel.No.. Address-r y Alt.Tel.No. *Per M.G.L. e. 147,s. 57-61,security work requires Depardhent of 15ublic Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one)❑owner ❑owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE: $ � �► `� YZe�.I � v�cc.�L �