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HomeMy WebLinkAboutBuilding Permit #142-14 - 1600 OSGOOD STREET 8/14/2013 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit N0: / // Date Received Date Issued: M ORTANT:Applicant must complete all items on this page LOCATION O Mint PROPERTY OWNER ®` pr 100 Year Old Structure ' yes o MAP NO: PARCEL ZONING DISTRICT: Historic District yes no Machine Shop Village yes no i TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial L7.Pclteration No. of units: ❑ Commercial El Repair, replacement ❑Assessory Bldg [I Others: { ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain ❑.Wetlands ❑ Watershed District ❑Water/Sewer DESCRIPTI9N F WORK O BE PERFORMED: f I Z.2 e� d 7a2(14-a ✓ p .0 SJ�C_ i Identification PI ase Type or Print Clearly) OWNER: Name: D Z.L Phone: ' F.5, Address: a CONTRACTOR Name: Phone: CK Ad dress: Supervisor's Construction License: Exp. Date: _0_ '�. Home Improvement License: Exp. Date: .. ARCHITECT/ENGINEER Phone: i Address: Reg. No. FEE SCHEDULE:BULDING PERM :$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. j Total Project Cost: $ D FEE: $ Check No.: I Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund ;Signature of Agent/Ow Slgpature of contractor Plans Submitted ❑ PI aived ❑ Certified Plot Plan ❑ Stamped Plans ❑ J Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGEDiSP.OSAL Public Sewer ❑ Swimming Pools ❑ Tanning/MassageBody Art ❑... g Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ i I THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS i CONSERVATION Reviewed on Signature 1 COMMENTS i HEALTH Reviewed on Signature P COMMENTS I Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments . Conservation Decision: Comments Water& Sewer Connection/Signature& Date Driveway Permit DPW Tow;! Engineer: Signature: SIRE DEPARTM(_iVT Temp Dump'ster on site es_. Located 384 Osgood Street Located at 124 Mair Street no Fire Departmert,signature/date ' r COMMENTS_ �� O� 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 req Electrical Inspector Yes No uires approval of DANGER Z®NE LITERATURE: Yes MGL Chapter 166 section 21A-F and G min.$100-$1000 fine No i NOTES and DATA— For department use ® Notified for pickup - Date 1 Doe.Building Permit Revised 2010 r Building Department The fol-awing is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofii-ig, Siding, Interior Rehabilitation Permits D Building Permit Application u Workers Comp Affidavit u Photo Copy Of H.I.C. And/Or C.S.L. Licenses L3 Copy of Contract a 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 LD Building Permit Application u Certified Surveyed Plot Plan u Workers Comp Affidavit u Photo Copy of H.I.C. And C.S.L. Licenses u Copy Of Contract o Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o Mass check Energy Compliance Report (If Applicable) Li 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 a Certified Proposed Plot Plan L3 Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit u Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) L, Copy of Contract o Mass check Energy Compliance Report o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cas<s if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the apt)•�al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be subm.tted with the building application i Doc: Doc.Building Permit Revised 2012 %io gr ' 37.4 4r..nrES19 Sh 5 C H1 CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Permit Number 142-14 on 8/14/13 Date: September 25, 2013 THIS CERTIFIES THAT THE BUILDING LOCATED ON 1600 Osgood Street, Bldg. 20, 3 d Floor MAY BE OCCUPIED AS Tenant fit up — ME Technologies IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: Ozzy Property Management 1600 Osgood Street North Andover,MA 01845 Build ng Inspector Fee: PrePaid Receipt: 26727 Check : 9313 September 24, 2013 Mr. Gerald Brown Inspector of Buildings Town of North Andover 1600 Osgood Street North Andover, Massachusetts 01845 Re: ME Technologies space interior office fit-up, floor 3, Building 20, Ozzy Properties 1600 Osgood Street,North Andover, MA Dear Mr. Brown: Based on site visits through09/24/13, the ME Technologies space interior office fit-up, floor 3, Building 20, Ozzy Properties, 1600 Osgood Street,North Andover,MA has been reviewed by us, and to the best of our knowledge and ability, this project has proceeded according to the drawings dated 07/29/13,with minor revisions,prepared by this firm: R. Rumpf&Associates, Inc. Furthermore,this project is substantially complete and ready for occupancy. If you have any questions regarding this project,please call my office. Sincerely yours, recive ore itect SWL/ thrI R. Rumpf& Associastes, Inc. Engineering, &Architecture 75 North Street Box 4483 Salem, Massachusetts 01970-6483 978.740.5025 978.740.5026 fax Final Construction Control Document u W To be submitted at completion of construction by a W d Registered Design Professional F for work per the 8th edition of the y�e Massachusetts State Building Code, 780 CMR, Section 107 Project Title: Date: Col it No. Property Address: ew . Project: Check one or both as applicable: 0 New construction Existing Construction Project description: 14" AACIze iq I � �MA Registration Number: Expiration date: , am a registere design professional, and I have prepared or directly supervised th preparation of all design plans, computations and specifications concerning: % Architectural [ ] Structural [ ] Mechanical 3 Fire Protection [ ] Electrical [ ] Other: for the above named project. I,or my designee,have performed the necessary professional services and was present at the construction site on a regular and periodic basis. To the best of my knowledge, information, and belief the work proceeded in accordance with the requirements of 780 CMR and the design documents approved as part of the building permit and that I or my designee: 1. Have reviewed, for conformance to this code and the design concept, shop drawings, samples and other submittals by the contractor in accordance with the requirements of the construction documents. 2. Have performed the duties for registered design professionals in 780 CMR Chapter 17, as applicable. 3. Have been present at intervals appropriate to the stage of construction to become generally familiar with the progress and quality of the work and to determine if the work was performed in a manner consistent with the construction documents and this code. Z-o ' , Wit; - Nothing in this document relieves the contractor of its responsibility regarding the provisions of 780MR' Enter in the space to the right a"wet''or ~ l`M` Y i electronic signature and seal: Phone number: ��%� D C�" Email: ✓� . Building Official Use Only Building Official Name: Permit No.: Date: Version 06 11 2013 September 24, 2013 Mr. Gerald Brown Inspector of Buildings Town of North Andover 1600 Osgood Street North Andover, Massachusetts 01845 Re: ME Technologies space interior office fit-up, floor 3, Building 20, Ozzy Properties 1600 Osgood Street,North Andover, MA Dear Mr. Brown: Based on site visits through 09/24/13, the ME Technologies space interior office fit-up, floor 3, Building 20, Ozzy Properties, 1600 Osgood Street,North Andover, MA has been reviewed byus, and to the best of our knowledge and ability,this project has proceeded according to the drawings dated 07/29/13,with minor revisions,prepared by this firm: R. Rumpf&Associates, Inc. Furthermore, this project is substantially complete and ready for occupancy. If you have any questions regarding this project,please call my office. Sincerely yours, repcd ive ore 'tect SWL/ R. Rumpf& Associastes, Inc. Engineering, &Architecture 75 North Street Box 4483 Salem, Massachusetts 01970-6483 978.740.5025 978.740.5026 fax Final Construction Control Document W To be submitted at completion of construction by a ' A H W a d Registered Design Professional W for work per the 8th edition of the Q+n� SYe Massachusetts State Building Code, 780 CMR; Section 107 Project Title: 44Date: /er+A-*rmit No. Property Address: 4 " -I Project: Check one or both as applicable: ❑ New construction xisting Construction Project description: I go,IIEREV —��4� MA Registration Number.: Expiration date: , am a "k r_egistere design professiona, a�ave prepared or directly supervised th preparation of all design plans, computations and specifications concerning: Architectural [ ] Structural [ ] Mechanical ] Fire Protection [ ] Electrical [ ] Other: for the above named project. 1, or my designee,have performed the necessary professional services and was present at the construction site on a regular and periodic basis. To the best of my knowledge, information, and belief the work proceeded in accordance with the requirements of 780 CMR and the design documents approved as part of the building permit and that I or my designee: 1. Have reviewed, for conformance to this code and the design concept, shop drawings, samples and other submittals by the contractor in accordance with the requirements of the construction documents. 2. Have performed the duties for registered design professionals in 780 CMR Chapter 17, as applicable. 3. Have been present at intervals appropriate to the stage of construction to become generally familiar with the progress and quality of the work and to determine if the work was performed in a manner consistent with the construction documents and this code. Nothing in this document relieves the contractor of its responsibility regarding the provisions of 780,CMR`10 7 Enter in the space to the right a"wet"or n,ld " electronic signature and seal: Phone number: © Email: VI Building Official Use Only Building Official Name: Permit No.: Date: Version 06 11 2013 Town of t E n over No. C% i. ver, Mass, �,• ' COC"Kht WKM ��AERATED P'P�,`�5 S U BOARD OF HEALTH Food/Kitchen LDPERMIT T Septic System _; , .. BUILDING INSPECTOR THIS CERTIFIES THAT .......::..::.:.`. : :::....:.::.: . Foundation has permission to erect .. buildings on iT : : ....:. ...... ��''"' ........................ .......... .. ......er..e..::. .................:.r.' ..::.......... tr( �``�� dough ' to be occupied as ............. ...:�: .... .:..�..:.....:.:................;. ' ........ . .. .. ... . .::............................... y `':. provided that the person accepting this permit shall in every respect conform to the 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 STARTS Roug.h ��- Service '�" .... ..it..Yr.....i..i............................................. i ............ ina s f. BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Reguired 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. Ber Street No. Smoke Det. =SEE REVERSE SIDE 51- �,_ Town of 2 s n over h ver, Mass, coc"Ic Hlwm" A0R~7ED 5 S V BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT .......:...::` : ....................................` �' ............... BUILDING INSPECTOR has permission to erect .......................... buildings on .......^...........:... : ' 'V—, � _ Fou7aYion � a' �� :, �. Rough � ° to be occupied as r a �� E°�: .,, -s c v .................................................................,:................................................................. Chimne provided that the person accepting this permit shall in every respect conform to the 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 STARTS Rough = _ ✓+L� Service /� y� Z �y ........................:..<„a.................................................. /, /e BUILDING INSPECTOR ma ' S- �` 2f�'l� 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. Ber Street No. Smoke Det. SEE REVERSE SIDE �;_ NORTH Town of 2Andover No. h ver, Mass r� 5 � ✓ � coc"Ic"twic« �d AORg7E0 P4�`t�� L U BOARD OF HEALTH 7. Food/Kitchen PERMIT T D Septic System THIS CERTIFIES THAT .......:...::f ......:.......................... ..� .........J ..':....... .....:: ..::.:y' ,. , :..... BUILDING INSPECTOR .r.: .�.... ... :.•r".:...d.. . t.. t.:.........f.......:. ..:....:...:/'X. , Foundaiio�nf r .� has permission to erect .......................... buildings on ...... :.:.. . = �' - : � �' h tobe occupied as .................................................................;:......:..............-......:.. ............................... Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Final l �� 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 , ...�^e ��f r : UNLESS CONSTRUCTION STARTS Rqugh ry- - r Pr ..� Service r� 9r Js ' �� y" �a ................. ................................................... ina /7— ,2 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. Ber Street No. Smoke Det. SEE REVERSE SIDE 2- �,_ NORT1y Town of t� Andover o - to No. h ver, Mass 5 T O LAN! ,/- COC NICNlwtCN y1' 5 U BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT ........... . ::=a.........................' ......:.' .......:...� ........ :...:.: �:.:::..�'..y::...... :..... BUILDING INSPECTOR .,9. .. ` �.;�� Foundation has permission to erect .......................... buildings on .... . .. ...:................... - .. .......... .... ... ........ ...:......::...' �` Resugh Z � to be occupied as �' .........:...............:...:............................`....:..;:......:.s"�..:......r..::`:: Chimney ..... ................................... provided that the person accepting this permit shall in every respect conform to the 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_ STARTS Rough i Service 7 j ..........::........:..:........... ............................................. ina ✓ /� t`Pf'_ �' 2f'�!j 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. B er Street No. Smoke Det. SEE REVERSE SIDE �? �;_ Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ 50000.00 m $ - $ 600.00 Plumbing Fee $ 75.00 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 75.00 Total fees collected $ 850.00 1600 Osgood Street Building 20 third Floor 142-14 on 8/14/2013 Tenant Fit Up for ME Technology � NORT1-/ Town of ? : Andover No. ��_ * ver, Mass COCMICH.wICK �,p A�R�TED r'V C, 7s U BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THATaxeOwAla . j',J.., BUILDING INSPECTOR OSFoundation has permission to erect .......................... buildings on ..1.6.00 ...��.....�4?'/�..2.P........� _ . Rough 709 to be occupied as `.`.�'�'�"�� U�.. .�. .. �E: Chimney provided that the person accepting this permit shall in every respect conform to the 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 STARTS 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 04/18/2013 12:44 9786833147 PAGE 01/01 OA1 E IMM0I)1YYYYI ACORD CERTIFICATE OF LIABILITY INSURANCE 4/18/20 .3 THIS CERTIFICATE IS 1.1SUED AS A MATTERFO INFORMATION ONLY AND CONFERS NA RIGHTS UPON THE CERTIFICATE MOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMFND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURERS), AUTHORIZED REPRESENTATIVE OR ISRODUCER, AND THE CERTIFICATE HOLDER, oil les endorsed. If SUBROGATION IS WAIVED,Subject to IMPORTANT! If the C9rIlflCete holder is an ADDITIONAL INSURED,the p cy{ }IttUst be } the terms and COMIti0ntt of the pollt]y,Certain policies may reciulre an endorsement, A Statement On this certificate dm W Confer rights to the certificate holder In lieu of such endorsewnt(s). WNTAVI ORODUCER M P ROBERTS INS AGCY INC PHONE C� ,jj, t;9?$) 6$3-SO 3 AIC No:{978?683-31.47 1060 Osgood Street ADDRESS:EMIlIlprobertainsurance.com North Andover, MA 01$45 INaURERIsI AFFOROtNa CCYERAaE IiA1Ct7 INSURER A;MERCHANTS INSC7RMCE INSURED DOWQXERT CONSTRUCTION COMPANY INC. INSURER B!GUARD I13SURhNCE 175 BRADY AVE INSURER C: SALEM, NH 03079 INSURER 0; INSURER E: a INSURER F COVERAGES CERTIFICATE NUMBER; RFVISiON 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. NOTWITH:37ANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY IS ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES-LIMI'T'S SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, MTq TYPE OF Ir13URANC6 INg POLICY NUMBER 1DDIYY"FF D/YY LIMITS GENERAL LIAfllt,n'Y EACH OCCURRENCE s 1,000,000 X COMMERCIAL GEPIERAL LIABILITY P I:MISO(Sa aeeurrence $, 100,000 CLAIMS-MAPH CI OCCUR MED EXP(Al W*Person) 9 5 000 CUP9151606 03/23/13 03/23/14 PERSONAL&ADVIN,IURY � a 1,000,000 GENERAL AGGREGATE $ 2,000,000 OEN'L AGGREGATE;LIMIT APPLIES PER; PRODUCTS-COMPIOP AGG s 2,000,000 POLICY PACT RU- LOC $ AUTOMOBILE LIABILITY Era accident 4 1,000,000 ANYAVTO CAPI054884 03j31/13 03/31/!4 BODILY INJURY(Per pervan) 5 ALL OWNED SCHEDULED BODILY INJURY(Per accident) s A AUTOS X AS ROPERTY 5x=E­_' HIRED AUTOS X ANUTOUTOSwNED Per e00"t 9; s X UMBRELLA UAB X OCCUR EACH OCCURRENCE S 1,000,000 A EXCESS 41AS CUP9142034 03/23/13 03/23/14 CLAIMS-MADE AGGREGATE S RETENTIONS 3 RKERG CO PENSATION rYTATU OTH- AND EMPLOYERS`LIABILITY ANY PRCPRIETOR/PARtN_RIEXF=TIVL� YIN DOWC338140 O/28/1B 10/26/13 E.L.EACH ACCIDENT s 1,000,000 OFFICERIMEMBER 0CLUDW7 NIA IMAnaMaa Ie NN) E,L,DISEASE•EA EMPLOYE $ 11000,000 If vas,describe under DF CRIPTIQN OF OPERATIONS Mew E.L.DISEASE-POLICY Limrr s 1,000,000 DESCRIPTION OF 4PFRATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,AddittanEt Remarks Sottsdule,V mom spoor is roqulred) THE CERTIFICATE HOLDER IS NAMED AS ADDITIONAL INSURW AS PER THE TERMS OF TEE WRITTEN CONTRACT AND AS PER THEIR, TNMEST IN THE INSURED IS OPERATIONS ON A PRIMARY AND NON—CONTRIBUTORY BASIS CERTIFICATE HOLDER CANCELLATION OZZY PROPERTIES INC 1500 OSGOOD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE ST LLC DUNDEE OFFICE PARR LLC THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN DUNDEI STATIO14 LLC DUND+�, ACCORDANCE WITH THE POLICY PROVISIONS. REDSPIRING LLC" HERITAOS PLACE LLC AUTHORIZED REPRESENTATIVE 21 H014S ST LP ZORCON LP C/O 022Y PROPERTIES 1600 OSGOOD ST NO.ANDO i 01985.2010 ACORD CORPORATION, All right4 reserved, ACORD25(2010!05) The ACORD name and logo are registered marks of ACORD I The Commonwealth of Massachusetts Department of Industrial Accidents off". Office of Investigations 600 Washington Street tier Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): 0v a , 2� _6 Address: � ��T e City/State/Zip: Phone #: Are you an employer?Check the appropriate box: Type of project(required): I.M-I"am a employer with ?' 4. [JI am a general contractor and I employees(full and/or p .* have hired the sub-contractors 6. New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g, ❑ Demolition working for me in any capacity. employees and have workers' 9 ❑ Building addition [No workers' comp.insurance comp.insurance.t required.] 5. ❑ We are a corporation and its 10.E] Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.]t c. 152, §1(4), and we have no employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. *Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: �J 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 under the pains and penalties of perjury that the information provided above is true and correct. Si nature: Date: 'k —&Z 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 r. Contact Person:so Phone#• . i 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 number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for fixture 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 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-NIASSAFE Fax# 617-727-7749 Revised 4-24-07 www.mass.gov/dia 1 I Massachusetts- Department of Puhiie Safety Board of BuildingReg lations and Standards Construction Supervisor License License: CS 48040 sr TAbEUSZ DOWGIERT 17A BRADY AVE x, SALEM,NH 03079 Expiration: 10/2DI201 3 y t'ommicsioner 7r#: 5561 I - N Jul, 30. 2013 3: 12PM Town of North Andover No- 0171 P. 1 Ulfhitial Construction Control Document To be submitted with the building permit application by a Registered Design professional. for work per the 8t'edition of the Massachusetts State Building Code, 780 CMR,,Section 107 Project Title: �t Date: Property Address: . ...............il��A 4il Project: Check one or both as applicable: ❑/New ,construction Coustructxon Project description I Registration Number: Expiration date: am a. regVendAWWprofessfoizal,and I have prepared or directly supervised the preparation of all design P computations and specifications concerning: Architectural ' [ ] Structural [ ] Mechanical ] Fite Protection [ ] Electrical [ ] Other . for the above named project and that to the best of my knowledge,information,and belief such plans,computations and specifications meet the applicable provisions of the Massachusetts State Building Code,(780 CMR),and accepted engineering practices for the proposed project. I understand and agree that I(or my designee)shall perform the necessary professional services and be present on the construction site on a regular and periodic basis to: 1. Review,for conformance to this eokand the design concept,shop drawings,samples and other subup ttals by the contractor in accordance with the requirements of the construction documents. 2, lPerfonn the duties for registered design professionals onals sn 7$0 C1vIR Chapter 17,as applicable. 3. Be present at iatcrvals appropriate to the stage of construction to become generally familfiar with the progress and quality of the work and to determine if the work is being performed in a manner consistent with the approved construction documents and this code. Nothing in this document relieves the contractor of its responsibility regarding the provisions of 780 CUR 107. When required by the building official,I shall submit field/progress reports(see item 3.)together with pertinent �, comments,in a form acceptable to the building official. �'/� l Upon completion of the work,I shall submit to the building official a`Final Consttuction Control Document'. ;,, Enter in the space to the right a wet : or .•,,�. ;, electronic signature and seal: Phone number: Ph i4vo ' 1: ej j Building OMcW Use only Building Of Wal Namo: Permit No.; Datc: Version 06 11 201.3 Location /G00- No. / —/y Date • - TOWN OF NORTH ANDOVER • �, Certificate of Occupancy $ U� Building/Frame Permit Fee $4 Foundation Permit Fee $ ATE, Other Permit Fee t� TOTAL $2Q r r Check# i s wilding Inspector