HomeMy WebLinkAboutBuilding Permit #517 - 1600 OSGOOD STREET 2/18/2010 1
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: Date Received
Date Issued:
IMPORTANT:Applicant must complete all items on this page
LOCATION I� i�� 6 bd
Print
PROPERTY OWNER 1 Crs Q 4 C
Print
MAP NO: PARCEL:_ ZONING DISTRICT: Historic District yes no
Machine Shop Village yes
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
New Building One family
Addition Two or more family al
<91teration No. of units: ommercia
Repair, replacement Assessory Bldg Others:
Demolition Other
Septic Well Floodplain Wetlands, Watershed District
Water/Sewer
DESC P ION OF WORK TO BE PERFORMED:
�c�nc N gS'�Sr
zI
Identification Please Typer Print Clearly)
OWNER: Name: ��t s 1��..��,,.��i.- Phone:
Address: t k-QQQ� c��Sr,,Z 1.
CONTRACTOR Name: q�' !' Phone
_
Address: rjr(se'f�' I' P
Supervisor's Construction License; ✓56)- Exp. Dater
Home Improvement License: Exp Date; '
y )
ARCH ITECT/ENGINEER L 1 Q ✓ ✓Y7l� s( ��l Phone:
Address:39 C)gak. 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: $ , ���� FEE: $_ (��
Check No.: 2 Receipt No.: ,2,Zee)ro
NOTE: Persons contractin egistered contractors do not have access to the uara and
Signature of Agen NOwne µ Signature of contractor
Plans Submitted Plans Waived Certified Plot Plan Stamped Plans
TYPE OF SEWERAGE DISPOSAL
ublic 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 Signature
COMMENTS
1
b HEALTH Reviewed on Signature
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
1
PI.anning Board Decision: Comments
Conservation Decision: Comments
Water & Sewer Connection/Signature &Date Driveway Permit
DPW Town Engineer: Signature:
Locate 384 Osgood Street
FIRE DEPARTMENT -Temp Dumpster onsite yes no
Located at 124 Main Street !l/i���
Fire Department signature/date Hyl/(
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
❑ Notified for pickup -. .Date
Doc:.Building Permit Revised 2008
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
o Photo Copy Of H.I.C. And/Or C.S.L. Licenses
o 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
❑ Mass check Ener Compliance
Energy p 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
pI Doc: Doc.Building Permit Revised 2008
1
i
KENDALL, FOUNDED 1890
TAYLOR &
COMPANY, INC.
ARCHITECTS •ENVIRONMENTAL CONSULTANTS Tel: 978 667-2900
381 BOSTON ROAD•BILLERICA MA 01 821-1 803 Fax:978 667-2960
DESIGN AFFIDAVIT
REGISTERED PROFESSIONAL ARCHITECT
In accordance with Section 116.2.1 - Design, of the Massachusetts State Building Code (MSBC) Seventh
Edition, I certify that the attached Drawings A-1.0 for the alterations to 1600 Osgood Street, North
Andover, MA bearing my signature and seal, dated 07-29-09 were prepared under my direct supervision,
and; to the best of my knowledge and belief, meet the applicable provisions of the Massachusetts State
Building Code(780 CMR), acceptable engineering practices and all applicable laws or ordinances.
In accordance with Section 116.2.2 - Architect/Engineer Responsibilities During Construction, of the
MSBC Seventh Edition, I and/or my designated representative shall visit the site periodically(if engaged to
preform contract administrative services by request of the owner)at intervals appropriate to the stage of
construction to record observations and to become generally familiar with the progress and quality of the
completed work, and to determine that the work, when completed, will be in general consistent with the
documents approved for the Building Permit. Copies of Field Report Observations shall be submitted to
the Local Building Inspector.
I further certify that at the completion of construction I shall submit a final report to the Local Building
Inspector as to the satisfactory completion and readiness of the project for occilpancy.
Signature: IV
J
Name: Peter M. Blaisdell, AIA
Date: July30 2009
E9 ARCy�I
.3 LAISO Fc�
k3264
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ti�F�lT MPSSPv�
N.
Mass. Reg. #: 3964 OF
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NORTI-�
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No.��
�. == SAKE = lover, Mass., :)__ MOO
COCMICMEwICK
ADRATE D
`S BOARD OF HEALTH
Food/Kitchen
. PERMIT T D Septic System
BUILDING INSPECTOR
THIS CERTIFIES THAT... .. ALG..... !4 .�..., ... ............................................................................. Foundation
has permission to erect:....................................... buildings on .I4ba.....d (..c.T' .................:............ d
ough
to be occupied as! h.(. .....5!11r� ili#........ V1.. ........ :.... -Am*..ALA-_.
thprovided that the person accepting this permit shall in eve respect conform to the te�ins o t1' he a cation on file in
is office, and to the provisions of the odes and By-Laws relating to the Inspection, Alteration and Construction of 7ing
Buildings in the Town of North Andover. UM GINN cTpR
VIOLATION of the Zoning or Building Regulations Voids this Permit. Rou
in
trope PERMIT EXPIRES IN 6 MONTHS
UNLESS CONS IN STARTS ELECTRICA�IN®ECR
........................... Service
B ING INSPECTOR
in t9 It
Occupancy. Permit Required to Occupy Building GAS INSPECTOR
Rough
Display in a Conspicuous Place on the Premises — Do Not Remove Fina,
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 �` � +
f
CERTIFICATE OF USE & OCCUPANCY
TOWN OF NORTH ANDOVER
Building Permit Number 517 Date: 5/19/10
THIS CERTIFIES THAT DANCE WORKS
THE BUILDING LOCATED ON 1600 Osgood Street Building 20-1"Floor
MAY BE OCCUPIED AS Dance Studio IN ACCORDANCE WITH THE PROVISIONS
OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS
AS MAY APPLY.
I
Certificate Issued to: DANCE WORKS
North Andover MA 01845
_ 1
Building Inspector
i
KENDALL, FOUNDED 1890
TAYLOR &
COMPANY, INC.
ARCHITECTS•ENVIRONMENTAL CONSULTANTS TEL:978.667.2900
381 BOSTON ROAD•BILLERICA MA 01821-1803 FAX:978.667.2960
May 18, 2010
FINAL AFFIDAVIT
REGISTERED PROFESSIONAL ARCHITECT/ENGINEER
In accordance with Section 116.2.2.3 of the Massachusetts State Building Code (MSBC),
Seventh Edition, I certify that the Project known as 1600 Osgood Street North Andover,
Dance Works has been reviewed by the designer of this project, and; to the best of my
knowledge and belief, the architectural work has been satisfactorily completed in
accordance with the approved building permit documents along with egress lighting and
exit signs being in compliance with state building code and is ready for occupancy.
This final affidavit is being filed with the North Andover Building Department in anticipation
of an Occupancy Certificate for the property.
Attached is a copy of our field inspection reports.
�O.e LA Fc�
4 #3264 <f
Signature: y Boston
Massy v
Name: Peter M. Blaisdell, AIA
St.
0v tl
Mass. Reg. #: 3264
final affidavit dance works.5-17-10.wpd
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Date.... .......
NORT►,
TOWN OF NORTH ANDOVER
f p PERMIT FOR WIRING
,SgACHUSE�
This certifies that ....... J. :. :��,,r- -c: !......................................
..... ..... ....
has permission to perform ..... ........................................ . ........
wiring in the building of.......:: ? ........ ..............
at
. North Andover,
Mass.�G..�.... - . :-°:�.:...n,�
G~ ! `Fee� .......... Lic.No. ?,
Y�
ELECTRICAL INSPECTOR O
Check #
9325
I ,z
Commonwealth of Ma
s. achusetts
Official Use Only
Department Of Fire Services Permit No.
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 PRINT W INK OR TYPE ALL INFORMATIOA9 Date:
City or Town of: NORTH ANDOVER To the
— *pe
By this application the undersigned gives notice of his or her intention to perform the ele electrical work desnbed below.
Location(Street&Number) 6 00
Owner or Tenant 9U 16 C_
Owner's AddressTelephone No.
t ewks ni't
Is this permit in conjunction with a building permit? Yes
Purpose of Building 'r"R"A �
1 SO 11{ NO (Check Appropriate Box)
Utility Authorization No.
Existing Service Ams
P / Volts ea ❑ Und d
❑ No.of Meters
New Service Amps / Volts Overhd
Overhead❑ Undgrd ❑ No.of Meters
Number of Feeders and.Ampacity
Location and Nature of Proposed Electrical Work:
Com letion o the ollowin table m be waived b the gr of wires.
No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans o•of
Transformers Total .
No.of Luminaire Outlets No.of Hot Tubs KVA
Generators KVA
No.of Luminaires Swimming Pool Above ❑ o.o mergen
d cy d• Batte Units g
— , No.of Receptacle Outlets No,of Oil Burgers F1911"
LE ALARMS No.of Zones
No.of Switches �! No.of Gas Burners 0.of Detection and
No,of RangesNInitis Devices
o.of Air Cond. Total
Tons No.of Alerting Devices
ti No.of Waste Disposers eat Pump umb"�`er Tons KW o.of Se f-Contained
Totals: Detection/Alerting Devices
No.of Dishwashers Space/Area Heating KW ��❑ C unicipal ❑ ��
No.of Dryers Head A onnechon
Heating Appliances KW Security Systems:*
o.of Water KW o.of o.of No.of Devices or E uivalent
Heaters Si s Ballasts. Data Wiring:
No.of Devices or E uivalent
No.Hydromassage Bathtubs
No.of Motors Total Hp elecommunications Wiring:
f
OTHER: No.of Devices or Equivalent
Estimated Value of Electrical Work: P l t! 000 Attach additional detail if desired, or as required by the Inspector of Wires.
Work to Start --i. (When required by municipal policy.)
�!D Inspections to be requested in accordance with MEC Rule 10,andupon 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 52 BOND ❑ OTHER ❑ (Specify:) .
I certify, under the pains and penalties of perjury,that the information on this application is true and complete
FIRM NAME: �� �iSGt,►Gw
Licensee: S��Sc Si LIC.NO.: �CJbci2 Ci
(If applicable, enter `exempt"in the license number line. gnatare� LIC.NO.: �?CjCl2
Address: Bus.Tel.No.: to
*Per M.G. C. 147,s. 57-61, ecurity work r wires D Z 1 Alt Tel.No.: Z;3292
OWNER'S INSURANCE WAIVER: I am aware that th��ens a does noSaft hav1e,the liability Lrc.No.
required by law. By my signature below,I hereby waive this requirement. I am the(check one) ❑owinsurance —0 ogwneormalent.
Owner/Agent
Signature Telephone No. PERMIT FEE: $ '
i
��`
r
d
l� The Commonweatth of Massachusetts
Department of Industrial Accidents j
Office of.fnvesti ations
� g
600 Nlashin.Mn Street
�U k
Boston,, 1402111 I
www.n2msgov/dia
Workers' Compensation Insurance Affidavit. Blders/CnaCtors/ElectriA iicant InfaY-m..tion cian /Pl�mb
ers
Please Print Lem
Namie (Business/DWivation/Individual):
Address:
City/State/Zip-
Phone#: .
FlAreyouemp{oyer?C6eek.the.appropriate box:
employer with 4, Type of PrO.1ed(reifuired):❑ 1 am $general contractor end I
ees(full and/orpatt-time).* have hired the sub-Contracxors6• ❑New constructionole proprietor or partner. contractors on the attached sheet 7. ❑Remodeling
ship and have no employees
These s
ub-contractors have
8.
w Demolition
i'
ng far me an any capacity. workers' comp.insurance. ❑ rtton
[No workers'comp.insurance 5. ❑ We are a corporation and its 9., Building addition
3-❑ required_] officers have exercised their I0-❑Electrics]repairs or additions
I am a homeowner doing all work right of exemption MGL . I I
seif. . o•w 'a Pa ❑Plumbing airs or additions
�Y (N arkers comp. C. repairs
)S
P 2, §I(�j,and we have no
12.E3insurance required.]t "employees. [No workers' Roofrepairs
comp. imurancx:required.) I3-El Other
"any eownappliam stmt checks bo>:#1 must also 5Il out the section below showing their workers'nom
t homeowners who submit this affidavit indicating they are loin an Potion policy information,
— ;Contractors that check this box mustatta g wo*and��hire outside contractors must'submtt a new affidavit indicetiag such
shed an edditioaal sheet showing.the nemo o£the sub•oottt� a fs_�..� ,
i. � �"-` PDiic}'in&rrnaliorl.
P am an employer that is pr?wdwrworkers I compensation insurance or
' inforntafion. f 'employees. Below is the ofi
- P ry mid job site
Insurance Company Name:
Policy#or Self-ins.Lie.#:
Expiration Date:
Job Site Address:
City/state/Zip.
Failure to se
Failure a copy of the workers'compensation policy declaration page(showing the policy number and expiration date
cure coverage as required under.Section 25A of MGL c.152 can lead to the imposition of criminal
fine rip to $1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP penalties
nd of a
of up to WORK OR
$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Offica fine
Investigations of the DIA for insurance coverage verification. e
1
I do hereby certify under the pains and penalties nfPerjurf' Mat the in ormadon pro '
I f p vrded above is ince and corm
Si tore:
Date:
Phone#:
---------------
---------------
official use only. Do not write in this area,to he completed by city or town offtdaC
City or Town:
Per mit/License#
Issuing Authority(circle one):
L Board of Health Z Suiiding DePartment 3.C'
6.Other City/Town Glerk 4. Electrical Inspector 5. Plumbing inspector
Contact Person:
Phone#:
e10RTH
TO" Of 4Andover
0
.. �- - -
No. 1511,
i _
o may-= LAKE dover,,Mass.,- _
COCHICHEWICK
S RATE D
BOARD OF HEALTH
Food/Kitchen
PERMIT T D Septic System
BUILDING INSPECTOR
THIS CERTIFIES THAT... . 1%9CG..... 4 4....................:.
...... ......................................................: Foundation
has permission to erect........................................buildings on 1460..... ..C.. ............................. Rough
to be occupied as ��&........Aqo%......�.... �� ..... Chimney
provided that the person acceptingthisshall in eve respect conform to the tets tPhe a cafio onfile inP P P g P rY PPP 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
q000 PERMIT EXPIRES IN 6 ,MONTHS
ELECTRICAL INSPECTOR
UNLESS CONS N STARTS Rough
Service
B ING 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.
-uc
The Co on earth of Massachusetts
0
Department of Fire Services
Office of the State Fire-Marshal
P.0.Box 1025 State Road,Stow,MA 01775
PERMIT
North Andover Date:
• ]Permit No
Ci of Town Di
(
City. ) (if Applicable) g Safe Num er
In accordance with the provisions of M:G.L .4$.Chapter1(Z as provided in section
597 ('Mg 34 *
Start Date
This Permit is granted to: �,(S/�j� ��fq�Cw
i
Full name of person,Firm or Corporation
Permissicnto locate dumpster for construction/renovation/demolition of building.
I
Comments: dumpster must be . 25 ' from structure if unable e to pla
ce w '
Restrictions: i t h r e u i r e d it
clearance dumpste^r/must be covered with pl wood or tarn end of work -day
at
(Give location by street and no.,or describe in such manner as to provi adequate identification of location)
Fee Paid$ 50.00
Fire Chief
This Permit will expire- 3-3//e) (Signa o Ica g anti g pernut) Offical granting permit (Title)
r
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 LedbIlly
Name (Business/Organization/Individual): �l ���• ✓r'� 6�,sl 1L)& 6-�J
Address: sax1 m1¢•lel -TX0 V K
City/State/Zip: i V�G JV 0/� �� Phone
Are you an employer? Check the appropriate bog: Type of project(required):
1.[ P I am a employer with_ )- _ 4. ❑ I am a general contractor and I 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 in any capacity. workers' comp. insurance. 9. ❑Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs
insurance required.] t employees. No workers' 13.❑ Other
comp. insurance required.]
*:..y applicant that checks box 41 must also f;11 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 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: ,��� �/ plu In 1
Policy#or Self ins.Lic.#: I I S 3 5 (� 3 q Expiration Date:_a.
Job Site Address: �D�� S�C�D� City/State/Zip:k
-A J (I�r
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 u er alland penalties of perjury that the information provided above is true and correct.
Si ature: -
Date:
Phone#: -7L/. % ` 7 C/,15-
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as"an individual,partnership,association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership, association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary, supply sub-contractors)name(s), address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability.Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign anddate 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 question: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 permittlicense number which will be used as a reference number. In addition, an applicant
that must submit multiple perimittlicense 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 Iike 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
Dewpariment of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MBIA 0.2111
Tel. # 617-7274900 ext 406 or 1-877-MASSAFE
Revised 5-26-05
Fax# 617-727-7749
wuwv.mas .govfdia
Massachusetts- Department of Public SafetN
Board of Building- Re!-ulations and Standards j
Construction Supervisor License
License: CS 85562
Restricted to: 00
j BRYAN A BEANDO
r 19 SALMINEN DR
LEICASTER, MA 01524
Expiration: 5/17/2011
('ununissiu�i.r Tr#: 2072
PILGRIM CONSTRUCTION BRYAN BEANDO ESTIMATE
23 SALMINEN DR. CONSTRUCTION # 209
LEICESTER, MA 01524-2217 LICENSE# 0855562
PHONE# 508-892-3800 DATE 2/9/2010
FAX# 508-892-8753
GINA BUEHLER REFERENCE:
1600 OSGOOD STREET
NORTH ANDOVER, MA 01845
DESCRIPTION TOTAL
CONSTRUCT DANCE STUDIO, BUILD RAISED FLOOR COVERED BY 28,750.00
ROLL OUT FLOORING PROVIDED BY GINA, CONSTRUCT ALL WALLS
ON PLAN, SHEET ROCK, COMPOUND, AND PAINT. INSTALL ALL
DOORS AND WINDOWS, BUILD BENCHES, OFFICE AREA, BREAK
AREA, AND BATH ACCORDING TO PLAN. CHANGE CURVED
SEATING TO SQUARE TO CUT COST. INSTALL VCT TILES IN ALL
AREAS OUTSIDE STUDIO AREAS
EXTRA CHARGE FOR HANDICAPPED ACCESSIBLE BATH 800.00
SOUNDPROOFING 1,250.00
CEILING TILES MATERIALS ONLY, LABOR FREE 2,523.00
WE WILL PROVIDE ALL MATERIAL USED EXCEPT FOR ROLL OUT 0.00
FLOORING, GRAB BARS, MIRRORS ETC. , AND WINDOWS FOR
STUDIOS
r
- TOTAL $33,323.00
SH,N DATE ( C o
551�'l
vephf "-,A�� o
Location 1600 d k nay4 36 '�c- T�d o►� 16-0
No. Date — )
„OR,M TOWN OF NORTH ANDOVER
1. 9
` Certificate of Occupancy $
s' »�5,.� Building/Frame Permit Fee $ _
Foundation Permit Fee $
.-
Other Permit Fee $
TOTAL $
Check # 425�H-
22uU6 X2-,A��
V Building Inspector