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Building Permit #107-12 - 1780 OSGOOD STREET 8/5/2011
TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: IMPORTANT: Applicant must complete all items on this page LOCATION Print PROPERTY OWNER int TU N Unit# Print MAP NO: _-6-f 4-PARCEL: ZONING DISTRICT: Historic District yeCnno Machine Shop Village yeit 100 year-old structure ye TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family b4ndustrial ❑Alteration No. of units: ❑ Commercial kRepair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other I] Septic 0 We11 q Floodplain Wetlands ' 1 Watershed-District Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: 70 -k\L I �'�b LXS((tw3 n F(=rC 8S (Identification Please Type or Print Clearly) OWNER: Name: Phone: 77 7& `O OCj;)1 Address: 1 .7 8)U 0 SGOG D S CONTRACTOR Name: S J L L( Y_4 -t lV C Phone: `}78 6o q 6x70 Address: pct 4SU yv000 &' 11KA_ 1f71 ;.7eW7 1Y4V Supervisor's Construction License: 6 �! 8 g Exp. Date: Home Improvement License: /Y(00 1 ,� Exp. Date: 3 / t ARCHITECT/ENGINEER ZAX MASOP( Phone: 1206 50-_ v Address: '�'� �yL�2 PA-Rk 40,41-R Reg. No. 741 S�f� FEE SCHEDULE:BULDING PERMIT.,$12.00 PER$1000.00 OF THE TOTAL ESTIMATE COST BASED ON$125.00 PER S.F. Total Project Cost: $ �m o FEE: 6} 4- /00 Check No.: �y �* Receipt No.: ��� NO Persons ontrac ' g with unregistered contractors do not have access to the guaranty fund - S gna _re of'A en_Owner Sigriature_6ftdoritrador " �.. - _q -- � I Plans Submitted P5, 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 Signature COMMENTS HEALTH Reviewed on _ Signature COMMENTS 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 Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date 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 Z--I �w s �2- S S-0 0 ❑ Notified for pickup - Date Doc:.Building Permit Revised 2011 June/mi 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 i ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Perm Addition or Decks ❑ Building Permit Application ❑ GeFfified Sup.Feyeel Piet Ian v Workers Comp Affidavit ' ta'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 Li Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ 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 .Permi 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: Doc.Building Permit Revised 2008mi Locationy No. ��v � /2-- Date NORTp TOWN OF NORTH ANDOVER • POWCertificate of of Occupancy $ s °1 ...:.:.:... ti f�Cs Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Qr Check# ��-- 244 ,-- b Building Inspector Nab a JTI CONTRACTORS N A55REVIATI0N5 5YM50L LEGEND _ = EMT9 s KAus TO BE RW04W BUILDINGAI'P AVOY9 roeeN PI x 44xn%7R Q.01W • AT Lc- UNeN C44WT � :Ell � �T�Knu.S TO R9WN a" M MALE U aLD& OULP06 ..6 MW PACTUtdt �. "m ►Arms►+ 3 Nast MALLS cowat NOM tVF owl"Mawr r rveep=A= U o RENOVATIONS ctCYT res, mwA4 cAL NB4 tvWMZf MIAs acv WNDIM"MASONW JW mw ?IWCATM 1 o c4m coRROM NA 1W APFUCAZLE •— lol FaOM NUBHi aw Rs vesms icor o SCALA T L ® DOOR RMBER SM%TMT MSA Dom cot"m NSF m 6afA tC�T ® ND A�A 1780 OSGOOD STREET �, � A� rz NOm n"ATM .LAI "m I.Mc"'m l eUtc eLEeneICAL � RelutaTev MIL"F&M NORTH ANDOVER , MA 01845 � w � _ rm OCSTw9 TO 111 SECT S=Im .-Ay O #XL TTm so%f Ln MQ !!KIST 'W9TP16 S. EOR!fW7 IAT z Q EW r_'I BM sf4LAR O c!°u%M&O Ott' mcnpm VIM SM�eGFlcA7m � I�-o' PHASE I: INTERIOR FIT-OUT OF EXISTING E ,� wo s, Ve5"611 a4w acr CCU*MATM. OFFICES. NO WORK OUTSIDE THE PERIMETER m n°°R Tn"' n'."` QOO OF THE BUILDING. �eeK CASOW �T ww x weRAL oONtR ym yr VeRw w H Z I Z 61T 61'�7l, YY Y9TN NORIz NORIrartAL v z 1!- tn DRQ V41 NG L 15T �Q &ENERAL NOTES YIGINITY m Y GENERAL 1. CONTRACTOR TO ENSURE ALL CONSTRUCTION MATERIALS & METHODS TO MEET �4e ?� ,I'' rl tf s. T1.0 TITLE SHEET OR EXCEED ALL LOCAL CODE REQUIREMENTS. y► EXISTING PERMIT 2. NEW DIMENSIONS ARE TYPICALLY FROM FACE OF EXTERIOR SIDE OF STUD TO CENTERtf t r V�t SET " LINE OF INTERIOR STUD OR TO CENTER LINE OF OPENING. EXISTING DIMENSIONS r� I ax'' �. p` ' EX1.0 EXISTING FLOOR PLAN ARE FROM FACE OF STRUCTURE OR SHEATHING TO SAME. VERIFY ANY DISCREPANCIES �Ntr � 125DEMOLITION ISSUE DATE IN FIELD AND REPORT TO ARCHITECT PRIOR TO CONSTRUCTION. t+, , , :� D1.0 DEMOLITION FLOOR PLAN 07-21-11 3. THE GENERAL CONTRACTOR SHALL VERIFY ALL DETAILS AND DIMENSIONS BEFORE + ' DRAWN LAST PROCEEDING WITH WORK. SUBMIT ALL QUESTIONS TO THE ARCHITECT IN WRITING. r p— r. PROPOSED 4. PROVIDE ALL SHORING NECESSARY TO BRACE THE BUILDING DURING CONSTRUCTION. ', a Y y ,I �'" A1.0 1 ST FLOOR PLAN 07-21-11 sAr A1.1 ATTIC FLOOR PLAN DRAWN BY 5. PROVIDE ALL TEMPORARY WEATHER PROTECTION AS REQUIRED TO MAINTAIN THE A2.0 1ST FLOOR REFLECTED CEILING PLAN MW BUILDING IN HABITABLE AND DRY CONDITION THROUGHOUT THE CONSTRUCTION PERIOD. A3.0 SECTION A—A 6, ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO THE INTERNATIONAL BUILDING �'� r 4tui A3.1 SECTION B—B !DM�A II CHECKED BY CODE 2009 AND MASSACHUSETTS STATE BUILDING CODE—EIGHTH EDITION. a-, A4A ELEVATIONS �g�� JM 7. ANY CHANGES OR MODIFICATIONS TO THE DRAWINGS MADE BY THE CONTRACTOR MUST F., t ? - . A5A NOT USED .� JOB NO. BE APPROVED IN WRITING PRIOR TO THEIR EXECUTION A6.0 HC BATHROOM DETAILS A7.0 NOT USED .9658 1 1 11 8. ENGINEERING FOR HEATING, ELECTRICAL, PLUMBING (AND ARE PROTECTION) IS BY tT� a �opomux A8.0 DETAILS OTHERS AND/OR DESIGN BUILD. THE SCOPE OF WORK ANTICIPATE ONLY MINOR :_: A9.0 SCHEDULES LOWELL y RELOCATION AND INSTALLATION OF THESE ITEMS. ze " . ' O j STRUCTURAL Fq 5 T1 .0 OF PS S1.0 SLAB 1ST FLOOR PLAN THIS DRAWING 50ALE 15 BA5ED ON PRINTING AT IIXI'I _�A.n S2.0 ATTIC FRAMING PLAN cn Q U c o 0 V) oe 00 QS c O w CIO'-O" N uy 30'_2" 5Q'-10" O loopn 30 o " BAT } a 15'-'7" 8'-10" - '� °- HALL L OFFICE - n T FF-- — 5'-I rmopm ROOF AGGE55 LL, k in HATCH m 0 z m mO>z U r d00 j. OFFICE OPEN ' GARAGE Q�Z W OFFICE Z V V_ tL Z(L .i Ao I4'-4" 0 �J c r PERMIT 50'-2" 5a'-lo" SET io ED ARC ISSUE DATE MA C, 07-21-11 DRAWN LAST NO-9668 W07-21-11 �Ayo LQWELL DRAWN BY CALLED NORTH EXISTING FIRST FLOOR PLAN � MW CHECKED BY 4' 0 4' g' JM JOB NO. ---------------------- 1111 PHASE#1 EX 1 .0 WNSTMr-'nON Locus a O c{p'-p" 5cl 101, 30'-2" REMOVE HARDWAfm, DOOR SLAB 5 REMOVE EXI5TIN6 AND FRAMES COMPLETELY c 2 CEILING JOISTSO o SAVE J015T5 FOR REMOVE HARDWA�, DOOR SLABS PROPOSED AND FRAMES COMPLETELY (T'rp' CONDITIONS. ALL INTERIOR POOR-5) ? o 0 If \ � 0 Fi I II i s m .� REMOVE ALL PLUMBING Q — I I FIXTURES, WASTE AND I \ I I InI I SUPPLIES. ^I-L AREAS f=OtR] REMOVE ALL CABINETRYPp D GONDITI NS. _ — L I COMPLETELY. m I � � o L ONTRACTOR TO REMOVE O Q ll! G H ALL HVAC IN WALLS AND --n I I CEILING A5 REQUIRED. d W w � � INTERIOR WALLS - REMOVE OVERHEAD r%1 Q z o ALL ELECTRICAL, WALL REMOVE HARD V- M DOOR SHEATHING AND 5TUD5 AND FRAMES COMPLETELYZ GOMPLETEI-'� (T-fl-) _ n 4-Q CD DEMO METAL 51DING FOR GI"IU REMOVE HARDWARE, DOOR SLAB STEM WALLSEE SHEETS A3.0 AND FRAMES COMPLETELY 8 A3.1 PERMIT REMOVE HARDWARE, SET �RC WINDOW SASHES AND � h/T ISSUE DATE FRAMES COMPLETELY 5q,_10" �� lkt-'MASO�c� 07-21-11 (TYP. ALL WINDOWS) „ �� in DRAWN LAST 30-258 ao'-O" No•96 07- -11 pw �QN���',' J WN BY L D DEMOLITION FLOOR PLAN MW O P CHECKED BY JM JOB NO. 1111 P .I Dl .0 GpNSTRUGTIOM N Q $ � o I 2 4 5 6 o 61'-10" ol " PHASE #1 to 32 " 15'-0" 20'-O" 201-0" 20'-0" > 10 10 a — cl II : II 1 i 11 II •- 8-O 10-5 6-5" q-I I 2'1'-2 = 16 j E N O o co) U)l Ill w p 4 13'-q" w 14'-10" J - '1'-6" ii'--�' S'-2" ® DN o 0 dJ KITCHENETTE 5TORA6YVOMENS� s'xs' ,LZ kHP BAT LANDING GARAGE / ♦- o O FILING 104 105 HALL SHOP AREA t YVI OFFICE 2co 102 103 t ® 6 0 4 112 115 Q r, h a O p t ® 107 t ((1 OFFICE AREA 1,872 5Q FT. $ ® coPr ® ® �' � I MEN z o HP BATW G YVOOD 5TAIR5 Q 11J I11V I � p OFFICE I 101 OFFICE 3 �; OFFICE 4 0 v>z z 108 �t IOq Q ' I NS © 14'-10" II'-10" 114-all lu ju Q V.I.F. IF POOR HEADE4� 7 RECEPT. Z NEEDS TO BE RA15EP BATH O Q�_ ON EXTERIOR DOORS O vZ[L � Q Q A NO STEP I I I 4" CMU STEP II 1 ® I© © VENEER m r� r� r-i r--I - - - - J - - - - - `J — PERMIT PORCH STRUCTURE AND NO STEP AT DOOR (TYPJ IV- la" SET ROOF PHASE #2 y �y ISSUE DATE I6'-s' � �o•gr35'� � 10 NOTE: DOOR,WINDOW, rn 07-21-11 2'4" 31'-0" 28'-q" FIN15H a WALL TYPES �� L� DRAWN LAST DESCRIPTIONS ARE FOUND ON A4.o 07-21-11 61'-10" H F P DRAWN BY PHASE #i MW CHECKED BY CALLEP N RT I5t FLOOR PLAN JM N SCALE:I/8"=I'-O" JOB NO. 4' 0 4' a 1111 Lj FIHASEA1 .0 UC CONSTRTION LOCus Q m NQS I Z 3 4 5 6 o f o PHASE I : 15'-0" 0 15'-0" 0 20'-0" 0 20'-0" 20'-0" V) d $ 0 20'-0" 75 C D o � o \ \—OPEN TO BELO } o 2X4 STUD WALL ® Ib" O.G. 5/5" SHEETROGK FINISH } o Oi MAINTAIN '7'-0" CL UNFINISHED AREA ATTIC AGGE55 DOOR CLEARANCE ON LANDING A? a \ / FROM STRUCTURE ABOVE O O ATTIC STORAGE DN O m m HANDRAIL ON BOTH 51DES m B X I-9 H R7" MAX o T 11" MIN. O � 0oc O / (NO FLOOR) \ — EXTEN51N NEAT <w q ' BOTTOM - (NON v>z -PUBLIC STAIR) z W � o %JzD a o � m IILrL� �J - - - - LJ - - - - - LJ - - - - LJ I PERMIT SET 2��'A ISSUE DATE 2'-I" 31'-O" 28'-9" 07-21-11 op No. 9658 k, DRAWN LAST 61'-10" o LOWELL `" 07-21-11 PHASE #1 OF MP gP DRAWN MBY CHECKED BY cALLry NORTH ATTIC FLOOR PLAN JM N SGALE:I/8"=1'-O" JOB NO. 4' 0 4' 8' 1111 - PHAW#I A1 . 1 coNSTRXTION LOCUS Q 01U Pa FI 5E C U 20'-0" 20'-0" 0) V) o E G 0OD o a H B TH 0 0 T FL FL FL FL FL HALL SHOP71 �z O FI E 102 FL FL IO FL 112 113 °�- 8 F�F� _ 13 o — i M p FL F FL E FL 10 FL F EX m I m GO B TH I N o FL FL FL o O FL FL FL FL FL rr- I10 _ M O�_ X O FI E I I O FF GE 4 N a v>z tu Q I LC FL FL FL FL FL FL FL T FL U W W (Y 0ELLLIL I I 0EX P.5 O O T A QzD V Q � I LJ — LJ — — — — LJ I BRED ARC HVAC UNIT $ REGI5TER5 TO �,� �1 R' fw,4Sy��F` PERMIT BE COORDINATED WITH �P O� � SET GENERAL CONTRACTOR ISSUE DATE n No, 9556 h °� � 07-21-11 3o LOWELL IMAWN LAST 10 61'-10" PHASE #1 l OF 119Ap5 07-21-11 DRAWN BY LIGHTING $ LIFE SAFETY LEGEND- MW NEW FIXTURES CHECKED BY FL 2X2 REGE55ED FLUORSCENTEMERGENCY LIGHTS G LED NORTH Ist FLOOR REFLECTED CEILING PLAN JM E N ILLUMINATED EXIT SCALE:i/5"=I'-O° JOB NO. � FL 2X4 RECESSED FLUOR50ENT -VEX W/ DIRECTIONAL a 0 4 s 1 11 1 ® PULL STATION PENDENT HUNG MERCURY g HORN-5TROBE M PHASE 01 n.0 O GONSTRUOTION LOCUS N Q m Cn o! o � O N � Qn O O EXISTING TO REMAIN EXISTING STEEL ROOF U TOP OF WALL a o T 4 6 PLYWOOD (GLUED & NAILED) CL FLOOR ,JOISTS @ I b" O.G. tm (R-30) FACED FI5ER6LA55 BATTS n a FINISH FLOOR abi FINISH CEILING O METAL 5112ING AGCOU5TIGAL 5U5PENDED CEILING EXI5TIN6 METAL o CONTINUOUS FLA5HIN6 WALL PANELS ZO GAP OVER CMU %8" SHEETROCK EACH SIDE 4" WOOD STUD ® I6" O.G. 6" WOOD STUD5 ® 16 O.G. �O o TOP OF MASONRY (BEARING WALL) 8' 5HEETROCK TYPE "X" v>Z a EXISTING STEEL COLUMN Q z OFFICE #4 HALL WOMEN5 BATH Ho z CMU VENEER Q 4" NEW CONCRETE SLAB v EXISTING STEEL Z FINISH FLOOR HORIZONTAL Z CLIPS - 0 LD FINISH FLOOR 11111�IIIIII=111111 CONTINUOUS CONCRETE FOOTING 2'-0" 111111-Illlllllll�— BEARIN66 DIRECTLY ON ORIGINAL 5LAB FTG. FTG. 771. 2" RI610 INSULATION \S�ERED,4RC PERMIT EXI5TIN6 CONCRETE FOUNDATION R• �� ��F SET EXISTING 4" CONCRETE SLAB 0 a ISSUE DATE o No, 9638 07-21-11 5E CTION A-A DRAWN LAST SGALE:I/4"=1'-0" oy SELL `� 07-21-11 2' 0 2' 4' DRAWN BY MW CHECKED BY JM JOB NO. 1111 121 PHAGE#I A3.0 CONSTRIr-TION N Q Q t U c .� V) Q� o a Lu c ATTIC ACCESS (DOOR) 0 0 EXISTING TO REMAIN EXI5TING STEEL ROOF U q TOP OF WALL 3 0 V o METAL GUARD RAIL O z o° ATTIC FLOOR BEYOND , ._ T r � a FINISH FLOOR Q � a FIN15H CEILING — — — — Wiz" DIAMETER — — — — METAL 5I0IN6 HANDRAIL BEYOND m Ln O c'7 0 CONTINUOUS FLA5HIN6 z Q GAP OVER BRICK / one O Sin TOP OF MASONRY 2Xb WOOD .l015T5 >Z o ;b ►�i ao bXb WOOD POSTS Q WW arc z = CMU VENEER / Z(K$ z - � �zQ � 9 FIN15H FLOOR "'OLD FINISH FLOOR !pliqp �J Q fQ Illdil®8111@=111119 P.T. 2X12 SIMPSON BASE CONNECTORS 2" RI610 IN51JAI TION IIIIII IIII9I=181111 STRINGERS (HOLD P05T I" ABOVE 5LA5) ���ED ARCM r R. MAS � EXISTING 4" CONCRETE SLAB EXISTING CONCRETE FOUNDATION ��' �� ®� PESRMIT No . 9G58 ISSUE DATE BUILDING 51^GTION 15-5o LO�ELL �� 07-21-11 DRAWN LAST 5GALE:1/4"=1'-0" TN F 07-21-11 2' 0 2' a' DRAWN BY MW CHECKED BY JM JOB NO. 1111 PHASE#I A3. 1 CONSTRUCTION V) Q I 2 3 4 5 6 Ue ° V) of C) W FINISH FLOOR FINI5HGEILIN6 - - - - - � - - - - - � - - - - - � � ^ I I EXI5TIN6 METAL 51DI 0 0 Hi � II IIII i ► U � O I I I I I I 1 ► il 7H] l lll � l lltlll� l � l 1 � TOP OF MASONR _ ►K v o 344 u 0 ,E 41 D FINISH FLOOR FIN15H FLOOR •� a V = N a OLD FIN15H FLOOR FUTURE COVERED ENTRY RAISE DOOR HEADER BECAUSE OF NEW SLAB 4° CMU VENEER(NEW) APPROX. FINISH GRADE i CONCRETE LANDING SLOPE Q n a WINDOW HEADER5 TO MATCH @ T-O°A.F.F. PAVEMENT 1:20 SLOPE DOWN TO PARKING NORTH ELEVATION SCALE:I/8"=I'-O" 4' ° 4' 8' cf) O ttl p � °4w Qoo < G B A <Z i EXISTING STEEL ROOF Z QW t w Top QF WAI I FUTURE COVERED ENTRY O Z IL FIN15H FLOOR EXI571N6 METAL 51DiNG ` o FIN15H CEILING — — I 0 RED ARC. ► I 4 y� O� � PERMIT - � METAL CORNER TRIM I I SET REPLACE ANY DAMAGE TRIM I I No. 9656 A ISSUE DATE ► o FINIFLOOR LOWELL y 07-21-11 SH Z� J DRAWN LAST OLD FIN15H FLOOR f��APPROX.FINISH GRADE N SAS 07-21-11 DRAWN BY 5OUTH ELEVATION MW SrALE:I/8"=1'-0" CHECKED BY 4' 0 4' a' i M JOB NO. 1111 1.21 PHASE#I A4.0 WNSTRUGTION (on Q U 0 •2*- N O O V) 0 1101 91119 AND ACID ETCHED OR ROUGHENED SURFACE O C -I Two 42"LONG bRAB BARS.ALL DIS OR OTHER=vitas 1 5 W ABOVE THE BARS. FLUSH CONTROL-HAND I \ OPERATED ON WIDE SIDE 4, { AOMEN5 U Q GRAB BARS I V DIAMETER 3 / HP BATH g ui SINK HEIGHTS NOT EXCEED HEIGHT�94" _... I Ob v AT THE RIM A.FP..SINKS SMALL ALSO EXTEND tV 3 A MINIMUM OF 22"FROM TME YVAL.I_TO THE LL FRONT OF THE SINK OR GaINTEf¢. Q J 521 CMR 50.00: PUBLIC TOILE-T ROOMS 3 O 301 GENERAL •� Each public toilet room provided on a site or in a building shall comply with 521 CMR. An unobstructed CLEAR FLOOR SPADE GAL .ED NORTH H.G. BATHROOM DETAIL PLAN a An nturning space complying w .3 with 521 CMR 6 ,N&Ieelchair Turning Space shall be provided within an accessible toilet room.The clear floor space of SCALE:1/6"=1'-O" Q a fixtures and controls,the accessible route,and the turning space may overlap. A.A coat hook shall be provided at a maxlmum height of 54 Inches(54' - 13'i2mm)above 4' 0 4' 9' the floor. 30.9 51NK Sinks,including vanities,shall comply with the Following: 30.9.1 Clear floor space: A cloar floor space complying with 521 CMR 6.3,Meelchair Ln Turning Space shall be provided in Pront of a sink to allow forward approach. FINISH CEILING FINISH CEILING, The clear floor space shall be on an accessible route and shall extend no more O than a maximum of I9 Inches(19" - 483mm)underneath the sink. Z Q 30.9.4 Depth Sink depth shall not exceed six inches 6? inches(6?" = 165mm). I'o' aa,, Q 30.95 Pipina: Sink traps and drains shall be located as close to rear wolfs as possible. — Hot water and drain pipes exposed under sinks shall be recessed,Insulated,or guarded. J a O J There shall be no sharp or abrasive surfaces under sinks. ` (IJ Q 30.9.6 Faucets: Faucets shall be operable with one hand and shall not require tight Q z Q Q grasping,pinching,of twisting of the wrist.Lever-operated,push-type,touch-type,or �, electronically controlled mechanisms are acceptable designs. If self-closing valuta are FINISH FLOOR FINISH FLOOR used the faucet shall remain open for at least ten seconds. V W U J 50.11 MIRROR GONTINUOUB TOILET PAPER VINYL COVE BASE The top of any shelf and or bottom of any mirror that is provided above a sink shot I be Flow DiSP R Z z set with the bottom edge of the reflecting surface no higher than 40 Inches(40" = Q < m 1016mm)above the finish floor. WATER CLOSET SHALL BE 17'TO IQ'HIGH 30.12 DISPENSERS MEASURED TO TOP of C4-OT. v Z(L Towel dispensers,drying devices,or other types of devices and dispensers shall have atQ s least one of each device mounted Aithtn the zone of reach.At least one of each device A BATHROOM ELEV. rB�BATHROOM ELEV. shall be located within reach of a person using the accessible sink and shall comply Aith 50ALE:1/8"=1'-O" SCALE:1/w r-O" J ff Oer tl 4' 0 4' 8. 4' 0 4' 8' M 43 30.13�ONTRO�L5 AND REGEPTAGI S If controls,receptacles,or other equipment Is provided,then at least one of each shall r be on on accessible route and shall comply Atth 521 CMR 39.00: CONTROLS. RED A FINISH CEILING FINIsIiCEILING 6 .1 �. M'q c��l` PERMIT 0� DIAGONAL S' t<`O� SET n ISSUE DATE PAPER TOi"L. BOTTOM `8• Y f0, �ci8 !,. 07-21-11 WASTE `0p LOWELL �� § 'y DRAWN LAST FINK n FINISH FLOOR F �S 107-21-11 wmOR VINYL COVE BASE DRAWN BY SRRLAR COXMR TOP ' F:M��AW 64TRAPSAND DRAINS SHALLMW TED TO THE REAR YiAL L A5A5 Po5S15LE.V~TRAP OYPJ CHECKED BY BATHROOM ELEV. LD1 BATHROOM ELEV. JM SCALE:1/8"=1'-O" SCALE:1/8"=1'-O" JOB NO. 4' 0 4' e' 4' 0 4' 8' 1111 PHASE sl AO■O CONSTRUCTION LMS N _Q ro N Q � •� p 0 N STEEL cSIDING ° s FLASHING GMU TIES A5 2" RIGID INSULATION75 REQUIRED WEEP HOLE NEW 4" CONCRETE SLAB � L 00 GMUMORTAR ME ORIGINAL CONCRETE SLAB 0 o VENEER ( AIRSPACE Y2' DEN5EGLA55 ' U .e 5TUD WALL . . A�z CL ...a:"..a: —' I I I I•I I I I I I I I I I I I I I I I•I I I I I I I I I gi p " o i �a Q n a I FLA5HING DETAIL - 5ECTION K:2_'� MA50NRY DETAIL - 5ECTION r5 MA50NRY DETAIL - 5ECTION i3 SCALE:I"=1'-O" 8 5GALE:I'*'-0" 8 SGALE:III=1'-O" 6" 0 6` 1' 6" 0 6` 1' 6` 0 6" 1' I fib' LIGHT GAGE STEEL METAL STUD Z YY DEN5E GLA55 TEEL COLUMN w O 4 GAP Q Z � z TILE OR METAL GAP 1 LIGHT GAGE STEEL NEW CONCRETE SLAB Z D LET -IN STEEL PLATE 0 o WRAP 5TEEL W/ (GALVANIZED) LT. GAGE STUDS F.O. EXISTING Y4" 5UFFIGIENT TO 5EAL L.SLAB EDGE CAVITY ONLY CONCRETE 5TEM WALL PERMIT CONCRETE RED qRC SET BACKER 4„ GMU ISSUE DATE ROD SEAL GLDES E VENEER �� �P s®y��'� 07-21-11 TILE OR No. 9658 DRAWN LAST METAL GAP LUMN t 07-21-11 LOWELL '� LIGHT GAGE 5 Oy DRAWN BY STEEL 5TUD �t OF s MW MP s .. „ CHECKED BY 4 COLUMN/MA50NRY DETAIL - PLAN 5 C0LUMN/MA50NRY DETAIL - SECJMTION JOB N0. -SGALEW*'-O" S 5GALE:I"=I'-O" 1111 6` 0 6` 6. 0 6" �. PHASE#1 A8.0 GONSTRUGTION N Q m N a .`• U c AIN00A 5GHEDULE •� V) gg� IIXITQaOW• ROiOM LGGATION fflW SIZE Y'bcH W—HT I PRAM bLAY MMES WALL TYPES � E FIRST FLOOR --®WALL TYPE #O - EXISTING WALLS TO REMAIN c 'b5 K I sLrost AtoTe 421 owwE AREA IMM 46'x 76• T'o• M3TAL I T» �n>=1aIaR A2 SLIDER WM ry of FWE ARRA Ihm e6•x e6" r.a'M. Mason M?TAL IWWL.A7® N5ItATm ExTEitIOR rarroaw - �I WALL TYPE #1 - ONE LAYER %` GYPSUM BOARD TYPE "X" 5 W ON EACH 510E OF 2X4 (OR 2X6 PLUMBING WALL) WOOD STUD WALL ® 16" O.G. ao ^ WALL TYPE #2 - ONE LAYER 5/6" GYPSUM BOARD TYPE w, 0 0 $ ON EACH 51DE OF 2X4 WOOD STUD WALL ® 16" O.G. WALL HEIGHT 8'-6" TALL UQ n I. C0hWWTOR To VMFY vWSM OF ALL EMnr16 wWM%IN A.F.F. WITH 3/4" WOOD GAP. s.VMkil Y SMOt veil+OV#Ot =^ L a �g WALL TYPE #3 - ONE LAYER 5/a' GYPSUM BOARD TYPE "X" a ON INSIDE EDGE OF 2X4" WOOD STUD WALL ® 16" O.G. WALL . J LL (STE S:H[Dmu yeDTM 3 Y2" FOIL FACE FIBERGLASS BATT. cS�E' $VHr61A.i, WALL TYPE #4 - ONE LAYER %" 6YP5UM BOARD TYPE "X" W- 0- FQPj ON IN51DE EDGE OF 2X6 WOOD STUD WALL ® 16" O.G. WALL . S 3 Yz" FOIL PAGE FI$ER6LA55 BATT. i 1" a a S.. FIN15H 5GHEDULE POOR TYPES ROOM ROOM FLOOR WALL5 GEILIN6 CEEIT INS REMARKS th o RECEPTION 100 TILE 6YP/PTD 2X2 AGCOUSTIGAL 8'-0" A.F.F. O ®O� ��� ��� OFFICE #1 101 CARPET GYP 2X2 AGGOU5TIGAL 8'-0" A.F.F. _ OFFICE #2 102 CARPET 6YP/PTD 2X2 ACCOUSTICAL 8'-0" A.F.F. F- FILINGS 105 CARPET 6YP TD 2X2 AGCOU5TICAL 6'-0" A.F.F. <11.1 KITCHENETTE 104 ITILE 6YP 2X2 ACGOUSTIGAL 5'-0" A.F.F. v>Z DOOR SCHEOIJI r-- STORAGE 105 ITILE 6YP/PTD 2X2 ACCO1,15TIGAL 8'-0" A.F.F. Q 6 Q • size EXIST]MATERIAL SKNG ROUGH oPN6' HDY92 GOMNIENTS HALL BATHROO 106 TILE 6YP/PTD 2X2 AGCOUSTIGAL 8'-O" A.F.F. Z r HALL 10'f CARPET GYP 2X2 AGCOUSTIGAL 8'-O" A.F.F. W lit a OI 36 X 84 X 19/4" NEW HOLLOW METAL/6LAZIN6 A RH SY CONTRACTOR CLASSROOM INSULATED-13/4"THICK �— ({) Z 02 96 x 64 X 1 3/6" NEW METAL JAMB OAK DOOR SLAB B RHI SY CONTRACTOR PA55AGE INTERIOR DOOR OFFICE #3 108 CARPET GYP 2X2 ACCOU5TICAL 8'-0" A.FP. Z Q 03 96 X 154 X 1 9/8" NEA METAL JAMB-0AK DOOR SLAB LH W CONTRACTOR PA55AbE INTi3210R DOOR OFFICE #4 IOq CARPET GYP 2X2 AGGOUSTIGAL 8'-O" ,q.F.F. 04 36 X 84 X 1 9/8" NEW METAL JAMB-OAK DOOR SLAB B RH BY CONTRACTOR PASSAGE INTERIOR DOOR MENS BATHROOM 110 TILE GYP 2X2 A(:,COUSTIGAL 8'-0" A.F.F. O Z B 05 36 X 64 X 1 9/8' NEW METAL JAMB-OAK DOOR SLAB B LH 9Y CONTRACTOR PA55ABE INTERIOR DOOR BATHROOM III TILE LSYp 2X2 AGGOUSTIGAL 8'-O" A.F.F. 06 36 X 64 X 1 3/8' NEW METAL JAMOAK DOOR SLAB S RH BY CONTRACTOR PA5SA6E INTERIOR DOOR ^ 0 01 36 X 84 X 19/8' NEA METAL JAM 0-OAK DOOR SLAB 9 LH BY CONTRACTOR PRIVACY INTERIOR DOOR HALL 112 TILE 6YP/P7D 2X2 AGGOUSTIGAL 8'-0" A.F.F. iz41 pp 08 36 X 64 X 1 5/4' NEA METAL JAMB-0AK DOOR SLAB B LN BY CONTRACTOR PASSAGE INSULATED-19/4'THICK GARAGE -fin fj 04 36 X 54 X 1 3/6" NEW METAL JAMB-OAK DOOR SLAB 9 RH BY CONTRACTOR PRIVACY INTERIOR DOOR - a�IrOjS 10 96 X 84 X 1 3/4' NEW METAL JAMB O.DOOR SLAB 9 RH BY GONTRAGTOR P'MVAGY INSULATED-13/4'THICK M 11 96 X 84 X 1 9/4' NEA METAL JAMB-OAK DOOR 5LA5LH BY CONTRACTOR GL -16ROOM INSULATED-19 4 THICK -in T- DOOR NOTES - BY 0ONTRAGTOR - VERIFY w/ OWNER PERMIT A)ALL HARDWARE SHALL BE S-SERIES BY SCHLA6Ef RESIDENTIAL/L 16W SET COMMERCIAL USE OR EQUALLY APPROVED.ALL DOOR HARDWARE MALL BE ADA.APPROVED AND MEET THE 1l�ACCESS CODE. L� ISSUE DATE B)ALL BUTT HINGES ON INTERIOR DOORS SHALL HAVE NON-REMOVABLE PINS(NRP). R �Sy/TF 07-21-11 61 ALL HINGES SHALL BE 4 112X 4 I/2 INCHES AS SCHEDULED FOR 1 9/4 INCH DOORS, �Q• O$O- DRAWN LAST OR 5 1/2 INCHES FOR 1 9/6 INCH DOORS.ALL DOORS OVER 40 INCHES SHALL HAVE FB5166 HIN6E5.DOORS SHALL HAVE OFFSET HINGES TO ALLOYV FOR 180 DEGREE 5MUN6, ViHERE APPLICABLE. n No. 9658 to 07-21-11 D)CONTRACTOR TO FIELD VERIFY WITH DOOR MANUFACTURER ALL DOOR �O LOWELL ROUGH OPENINGS.GONTIRACTOR TO FIELD VERIFY JAMB DEPTH. J� E)PROVIDE CONCAVE WALL STOPS ON ALL COMMERCIAL AND STAIRWAY '� MW Q' DOORS(TYP) F)THE HARDWARE SETS ARE INDICATED ON THE DRAWINGS AND LIST THE ITEMS OF HARDWARE H OF MPSS CHECKED BY REQUIRED FOR EACH OPEWN6.IT 19 THE CONTRACTORS RESPONSIBILITY TO ACCURATELY FURNISHED A THE PROPER 512£9,QUANTITIES,HEIGHT"'AND FUNCTIONS,A9 REQUIRED 13Y THESE SPECIFICATIONS AND A5 RECOMMENPED BY THE VARIOL15 MANIFAGTIIRF..RS JOB NO. CATAL.OSUE INFORMATION. t4)1T IS INTENT OF THE HARDWARE SETS To PROVIDE HARDWARE FOR ALL DOORS.IF A DOOR IS NOT 1111 5C+WULED TO HAVE HARDWARE,IT SHALL BE PROVIOW WITH HARPINA IE SIMILAR TO OTHER DOORS OR HARDWARE AS ALLOWED BY 6000 HARDWARE PRACTICE. A9.0 to Q c � Q x 6 5 � �- 4 2 3 20'-O" Vf P -1 20'-O.. °° HS 20-O U 15-O I5'-0" " 3 ° I V o I � 3: t a EXSITNG FOUNDATION WALL ` INSULATION TO TURN UP AGAINST 21_4 POUR FOUNDATION FOOTING ON EXISUND PERIMETER N - TYPICAL ARO TOP OF EXISTING SLAB NO O ' RIG1D INSULATION UNDER THESE FOOTINGS - SEE SECTION A-A chi 4 Ul g _ ! ON A3.O �O 4" CONCRETE SLAB 0 2,. RIGID INSUALTION UNDER NEW SLAB O, p�/ER EXISTING SLABS W UJ U B 0 z ,n SAW GUT EXPAN51ON JOINT `- O3za- EXISTING STEEL COLUMNS (TYP) �t p O T �J tip in r PERMIT SET A I O� ISSUE DATE I I 07-21-11 r� � _ DRAWN LAST �J L _ _ _ _ _ _ - - - - 07-21-11 J DRAWN BY .e 9E°rat �' 0� MW CHECKED BY 31'-O" JM 2-111 61'-10" dog NO. PH SE#I 1111 5LAB 1ST FLOOR M-A`NTH O FHAS4 c4Ty57RUGT10N LOCUS N _Q m Q c�� • O0. E 6 .kgs b►-Io cn nc o ' PHA5E 1 a 15'-O" 15'-O" 20'-O" 20'-O" 20'-O" -' g 19 W N NEW 2X6 STUD WALL ® O E n lb" O.G.(TYP) U Q n p G � oLL J r 2 x 12 ATTIC O O_ FLOOR JOISTS V ® Ib" O.G. ti- F- Q ► r HDR= b" ANGLE PLATE 16 GAGE BOX ^ ° HDR — HEADER AT OPENINGS IN HEARING Q EXISTING STEEL COLUMN I WALL( ) m I m _ 8 I ° STAIR FRAMING SEE A3.1 O < IT 2x 12 ATTIC FEW a FLOOR JOISTS Q O O ® 16" O.G. - IX z W U) in F- S1 z z�zr 0Z� � Q ,=Q �J A PERMIT �-' - - - - -`J - - - - - `' - - - - �J SET NEW 2X6 5TUD WALL ® ISSUE DATE Ib" O.G.(TYPJ ✓` OF 07-21-11 DRAWN LAST 07-21-1 1 rnFACnfi'#AL DRAWN BY '069bl'-10" a +F1w41142 MW PHASE #1c�O10T � L CHECKED BY GALLE=D NORTH ATTIC FRAMING PLAN JM N SCALE:I/8"=I'-O" JOB NO. • 4' 0 4 8' rlf.'M 1111 ----------------- sz.o PHASE 01 GONSTRUGTION AORTH - Town of Andover .. No. as s. over, 1VI T Q LAKE COCHICHEWICK V RATED P' 1 S BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System i I /►� BUILDING INSPECTOR THIS CERTIFIES THAT.............� .......S.S� .. .......... .�....�� ...... ............................... .... Foundation has permission to erect........................................ buildings on .....' .. ... 5 ....A. Rough 1 .b s .... .......:........ j t0 be OCCUpled as....... ........ ....................................... Chimney provided that the person accepting this permit s I in every respect c form to the terms of the application on file in 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 I PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR r �• . UNLESS CONSTRU O S Rough Mob ................ .............................................................. . Service BUILDING 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. Agreement Between Owner and Contractor This Agreement between Owner and Contractor(the agreement)is effective July 27,2011. BETWEEN: D.A. Sullivan(the contractor)a company organized and existing under the laws of the State of Massachusetts in the Town of Wilmington,MA. AND: J.Tropeano,Inc. (the Owner)a corporation organized and existing under the laws of the State of Massachusetts with its head office located at 1780 Osgood Street in North Andover,MA. WHEREAS,Owner finds that the Contractor is qualified to perform the work,all relevant factors considered,and that such performance will be in furtherance of Owner's business. NOW,THEREFORE,in consideration of the mutual covenants set forth herein and intending to be legally bound,the parties hereto agree as follows: 1. MATERIAL AND LABOR PROVIDED. The contractor agrees to provide all of the material and labor required to perform the following work for the complete renovation of 1780 Osgood Street in North Andover,MA as shown by the drawings and described in the specifications prepared by Jay R.Mason of Architectural Consulting Services and Engineering Services by LJR Engineering of North Reading,MA and provided by the Owner,which are identified by the signatures of the parties to this agreement and which form a part o this agreement. The Contractor agrees to provide and pay for all materials,tools and equipment required for the prosecution and timely completion of the work. Unless otherwise specified,all materials shall be new and of good quality. In the prosecution of the work,the Contractor shall employ a sufficient number of workers skilled in their trades to suitably perform the work. 2. PAYMENT The Owner hereby agrees to pay the Contractor,for the aforesaid materials and labor,the sum of $150,000.00 in a timely basis as agreed upon between Owner and Contractor at a further date. 3. COMPLETION OF THE WORK The contractor agrees that the various portions of the above-described work shall be completed on or before December 31,2011 and the entire above-described work shall be completed no later than April 1,2012. 4. MODIFICATIONS TO THE WORK All changes and deviations in the work ordered by the Owner must be in writing,the contract sum being increased or decreased accordingly by the Contractor. Any claims for increases in the cost of the work must be presented by the Contractor to the Owner in Writing,and written approval of the Owner shall be obtained by the Contractor before proceeding with the ordered change or revision. 5. ACCESS The Owner,Owner's representative and public authorities shall at all times have access to the work. 6. CONFORMITY WITH DRAWINGS AND SPECIFICATIONS The Contractor agrees to re-execute any work which does not conform to the drawings and specifications,warrants the work performed,and agrees tot remedy any defects resulting,from faulty materials or workmanship which shall become evident during a period of one year after completion of the work. 7. INSURANCE COVERAGE The Owner agrees to maintain full insurance on the above-described work during the progress of the work,in his own name and that of the Contractor. The Contractor agrees to obtain insurance to protect himself against claims for property damage, bodily injury or death due to his performance of this agreement as well as workman's' compensation as dictated by the State of Massachusetts. 8. Neither the Owner nor Contractor shall have the right to assign any rights or interest occurring under this agreement without the written consent of the other,nor shall the Contractor assign any sums due, or to become due,to him under the provisions of this agreement. 9. GOVERNING LAW This agreement shall be interpreted under the laws of the State of Massachusetts. 10. ATTORNEY'S FEES Attorney's fees and court costs shall be paid by the defendant in the event that judgment must be and is,obtained to enforce this agreement of any breech thereof. IN WITNESS WHEREOF,the parties hereto have executed this Agreement as of the day and year first above written. O R CONTRA Authorized Signature Authorized Signature Print Name and Title Print Name and Title r The Commonwealth of Massachusetts Department of IndustrialAccidents 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 Legitbly Name(Business/Organization/Individual): GA SvL ,t VAN Address:_ ;?`r 459wr/p fly City/State/Zip: 1A MW6171A.I 0 JM 2 Phone#: Rel C S`7 a cy;) P Are you an employer?Check the appropriate box: Type of project(required): 1.❑ 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.t 7. Wernodeling ship and have no employees These sub-contractors have 8. [❑Demolition working for me in any capacity. workers' comp.insurance. g, ❑Building addition [No workers' comp.insurance S. ❑ We are a corporation and its 10.❑Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 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' comp.insurance required.] 13.0 Other *.Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. T Homeov iers who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. lContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp,policy information. -lain an employer that is providing workers'compensation insurancefor my employees. Below is the policy and job site information. Insurance Company Name: If Policy#or Self-ins.Lie.#: VY G Oy f u 0/Y`1 0 Expiration Date: Job Site Address:_ / 79c) G 36600 5-1- City/State/Zip: ya aA/,Oel/�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$250.00 a day against the violator. Be advised that a copy ofthis statement may be forwarded to the Office of Investigations of the DTA f r insurance coverage verification. i 711 do:7zereby cert! r th ains e3zzdtP of pperjury that the informationprovided aboveis true andcorrect.e: Date: Q / Phone#: rt'7� Q�(U Official use only. Do not write in this area,to be completedby city or town official. City or Town: Permit/License# Issuing Authority(circle one): I.Board of Health 2.Building Department 3.City/Town Clerk 4.EIectrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#: AUG/01/2011/MON 10: 40 Ali A&Fr Fowler Insurance FAX No, 1-970-664-2209 P, 001/001 CERTIFICATE OF LIABILITY INSURANCE '°ArE(mm/aaYVYr) THS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY1 THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(SI, AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the cerflficate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION 1$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). j PRODUCER CONTACT NAME; A .& K Fowler Insurance LLC PHONE97$ 664-0365-- FA (P715) {64-27.09 X00 Park Street North Reading, MA 01864 PRODUCER 1652 INSURER(S) AFFORDINIS COVERAGE NAIL9 INSURED INSURER A:Westorn World Insurance Company D.A. Sullivan Inc, INSURERs:Merohants Insurance Croup 29 Ashwood Ave. INSURER c:National Union Fire Insuranc® C Wilmington/ MA 01887 INSURER D: 1 NSU RER E: I NSU RER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS I$TO CERTIFY THAT THE POLICIE$OF IN,13URANCE LISTED BELQW 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 SEEN REDUCED BY PAID CLAIMS. IP OU CY EXP LTR TYPE OF INSURANCE ADDL3UBR POLICYNUMBER MMILOONYY MM/DDIYYYY UNTSI GENERAL LIABILITY EACH OCCURRENCE $ 5001000 A X COMMERCIALCENEFALLIABILITY NPP13184-12 7/23/11 7/23/12 DAMAGEpgEmIsEs( RENTED 50 b00 CLAIMS-MADE FXI OCCUR MED EXP(Ary one perm) 11000 PERSONAL&ADV INJURY $ 500,000 i GENERAL AGGREGATE $ 1 1000,000 GEMLAGGREGATELIMITAPPLIES PER, PROOIICTS-COMPIOP'G $ Q QQ POLICY 71 pR?7 F71 LOC AUTOMOBILEUA131UTY 0ONRINED81NGLELIMTr 500 000 B ANYAUTO MCA7014354 4/25/11 4/25/12 (Eeac�idark) BODILY INJURY(Per pecan) $ ALL 0 W NED AUTOS BODILY INJURY(Per accident) $ X SGHEDULEDAtROS PROPETYryDAMAGE X HIREDAUTOS (Pereacident) $ X NON-OWNEDAUTOS UMBRELLALIAB OCCUR EACHOCCURRENCE 1 EXCESS LIAR 1. m,. 'ATF DEDUCTIBLE RETENTION $ $ C MRKeRSGOMPENSATiONWC006BB1a70 12/21/1p 12/21/11 WC$TATU- OTH- AND EMPLOYERS LIABILITY Y/N ANY PROPRIEMR/PARTNEPJEXECUTVE E.L.EACH ACCICENT $ 100 000 OFFICERIMEMBER EXCLUDED? N/A (Mandatory In NH) ff E.L.DISEASE-EA EN6>LOYEE $ 100,000 yyes describe under DE$(�RIPTtONOFOPE RATIONS below E.L.DI$EA$E-POLICY LIMIT $ 5QQ,000 I DESCRIPTIONOFOPERATIONS I LOCATIONS/VEHICLES (A'ffBCitACDRD101,AdrB'tSonelRarn3rkeSchetlt,le,tTmoreapnceieregtil�etl} Insurance v7.—r1ficatlon I CERTIFICATE HOLDER CANCELLATION i SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BEC CELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BF DELIVERED IN Town of North Andover ACCORDANCE WITH TME POLICY PROVISIONS. North Andover, Ma 01845 AUTHOMZrD REPRESENTAMVE Kerri A. Boutin, CIC CRM CISR sQ 1988-2009 ACORD CORPORATION. All rights reserved. ACORD 26(2009109) The ACORD name and logo are registered marks of ACORD pat N'iI'Ti ;t .:., ntRf1 {fld'av R'l�etE ,t 6989 Restricted) tO- 00 Y DENNIS SULLIVAN r M' 29 ASHWOOD AVE w WILMINGTON, MA 01887 _,, ' , 1/30/2012 14510 DEPARTMENT OF PUBLIC SAFETY Hoisting Engineer License Number: HE 047573 Expires: 01/30/2012 Tr.no: 12450 Restricted: 1 B,2A,4A DENNIS SULLIVAN 29 ASHWOOD AVE Z WILMINGTON, MA 01887 Commissioner Office o/Cos merAWAAAr&g In/9s egIII iii smcss egu a on HOME IMPROVEMENT CONTRACTOR Registration: 146092 Type: l\R"TL /V Expiration: 3/24/2013 Private Corporatior D A.``SULLIVAN, INC. I DENNIS SULLIVAN 29 ASHWOOD AVE. WILMINGTON, MA 01887 Undersecretary y MEDICAL /EXAMINER'S CERTIFICATE I certify that I have examined/mac r'dI f 1 r� f/ n accordance with the Federal Motor Carrier Safety'Regulations(49 CFR 391.41-391.49)and with knowledge of the driving duties,I find this person is qualified:and,if applicable.only when: ❑wearing corrective lenses ❑driving within an exempt intracity,zone(49 CFH 391.62) EJ wearing hearing aid ❑accompanied by a Skill Performance Evaluation Certificate(SPE) ❑accompanied by a___waiver/exemption ❑qualified by operation of 49 CFR 391.64 The information I have provi arding this physical examination is true and complete.A complete examination form with any aYachment e les my findin s completely and correctly.and is on file in my office. SIGNATURC OF MEDICAL EXAMINER _ TELEPHONE DATE MEDICAL EXAMINER'S NA IiJT) +' D LJ DO n Ch epr-tor n Physician 1 Ativanced i Assistant Practice Nurse ' EDICAL EXAMINER'S I_ICENSk#OR CERTIFICATE NO ISSUING STATE SIGSATU OF DRI ri r r/` DRIVER S LICENSE NO. STATE ADDRESS OF DRIVER AA S i t�:e�ot! / ' �`I P M� ,,;t,f�e%$ 0W7 7 •MEDICAL CERTIFICATE EXPIRATION DATE DISTRIBUTION:',COPYTO THE DRIVER.1 COPYTO THE MOTOR CARRIER 08/02/2011 22: 24 17752545097 JAY MASON ACS PAGE 02 COMcheck Software Version 3.8.2 Envelope Compliance Certificate 2009 IECC Section 1: Project Information Project Type: New Construction Project Title: JTI CONTRACTORS Construction Site: Owner/Agent: Designer/Contrarctor: 1780 OSGOOD STREET Jay Mason,AIA NORTH ANDOVER,MA 01845 ARCHITECTURAL CONSULTING SERVICi S 77 TYLER PAPK LOWELL, MA 01351 978.459-2,004 JAYMASON cdCOMCAST.NET Section 2: General Information ! Building Location(tor weather data); North Andover,Massachusetts Climate Zone: 5a Buildinq Type for Envelope Requirements: Non-Residential Vertical Glazing/Wall Area Pct.: 7% Activity Type(s) Floor Area Office 1855 Section 3; Requirements Checklist - <. +•..: • e C - .�... i r �� ��16Y{ri��.19dldldldYl���tVEYd�if90�91RY�Y1{ Climate-Specific Requirements: Component Name/Description Gross cavity Cont. Proposed Budget Area or R-Value R^Value U-Factor U-Factorial _ Perimeter Floor 1;Slab-On-Grade,Unheated,H, __-- orizontal without vertical 4 ft. 1855 --- g,0 --- --- Exterior Wall 1;Wood-Frarned, 16"o,c. 1652 21.0 0.0 0.062 0.0513 Window 1; Metal Frame with Thermal Break°Double Pane with 114 --- --- 0.330 0.1950 Low-E,Clear,SHGG 0,30 Door 1: Insulated Meta;,Swinging 60 --- 0.350 0.700 Root 1;Attic Roof with Wood Joists 1355 30,0 0.0 0.034 0.027 (a)Budget U-factors are used for software baseline calculations ONLY,and are not code requirements. Air Leakage, Component Certification, and Vapor Retarder Requirements: 0 1. All joints and penetrations are caulked,gasketed or covered with a moisture vapor-permeable wrapping material Installed in accordance with the manufacturers installation instructions. 2, Windows,doors,and skylights certified as meeting leakage requirements. 3. Component R-values 8.U•factors labeled as certified. 4. No roof insulation is installed on a suspended ceiling with removable ceiling panels. F1 5, 'Other'components have supporting documentation for proposed U•Factors. g, Insulation installed ar..carding to manufacturer's instructions,in substantial contact with the surface being insulated.and in a mariner that achieves the rated R-value without compressing tho insulation. ❑ 7. Stair,elevator shaft vents,and other outdoor air intake and exhaust openings in the building envelope are equipped with motorized dampers. Project Title: JTI GONTRACTOR5 Report date' 08/02/11 Data filename:CATEMPORARY\temporarylJOBS 2011\JTL NORTH ANDOVER. MA\080211 JTI GOMCHECK.cck Page 1 of Q 08/02/2011 22:24 17752545057 JAY MASON ACS PAGE 04 OFFICE OF BUILDING INSPECTOR TOWN OF NORTH ANDOVER j CQNSTRUCT!QN GONTN PROJECT AUMISOR; 1 PROJECT-rITLE=_,,,,,.�'T+( zf '8: �— fir X2 T 1 17Sa osc PRU.TEC.T'!!dclA'rl0lv:____�_______ .�- -•�'y--��-'-��� " NAME OF OUILVINA;.,,.��, i NATURE OF PROJISOTA I�rC��t PSS � �d'�Ir�T1n� f I���°� ��'�,6-A� �� n(� "S• �' IN AQ:-pRDANgE WITH ARTICLE 116 OF THE MASSACHUSE07S STATE SUILDING CODE, t~ � REGISTRATION NO. 9 BEING A.REGIST�RER PROFESSIONAL ENOI'NEERIARCHITECH HERE13Y CERTIF=Y THAT 1 HAVE PREPARED-OR DIRECTLY SUeEkV_ ISED THE PRePARA TION OF ALL DESIGN PLANS. COMPUTATIONS'AND SPl~CIFICATIONS CONCERNING; ENTIRE PR.OJ CT 0 ARCHITECTURAL 9 STRUCTURAL Q MECHANICAL FIRE t�RoTrz-cj-ION 0 ELECTRICAL. L.f OTHIFFIZ(SPECIFY} FOR-THE DOVE.N, LAMED PROJECT AND THAT,TO THE I3I=$T OF MY KNOWLEGE,BUCH PLANS, COMPUTATIONS Ai ,D SPECIFICATIONS MEET THE APPUCADI-E PROVISION OF THE MASSACHUSETTS STATEBi111-11ING C'11E,ALL ACCEPTABLE ENGINEERING PRATICIFS. AND APP-ICASL.E LAWS AND ORDINANCES FOR THE PROPOSEp USE AND OCCUPANCY. I FURTHER CERTIFY THAT I SFIALL PERFORM THE NECESSARY PROFESSIONAL SERVICES AND B EPRESENT ON TH GONSTRUCTION SITE ON A 11F.GULAII AND'1*EE1IO01C BASIS TO I1�RMINE THAT THE 1NOfZK IS PR©0EF� DIN1b IN ACCORDANCE WITH THE 00CUMENTS APPROVED FOR THE PUiLDING PERMIT AND SHAD.BE RESPONSIBLE FOR THE FOLLOWING AS SPECIPIED IN SECTION 118.0 1, Reyi,�w, for coliforrnance to the design Concept, shop drawings, sampims and other submittals whidi are sub6itted by the contractor In accordance with the requirements of tha constilic"on documents. 2. Rowiqw and approval of the quality control procedures for all code-required contralied tnateriols.. 3. Be p;asenf at I�wvsls appropriate to the stage of construcl1on to borne, generally fsmillar witbF.Rhe prograw and quallty of the"rk and to detertt•Ina, In general, if the wont 19 thing performed in manner consistent with the construction documents. PURSLI/'�NT TO 8PCTION 1113.2.2 1 SHALL SUBMIT WEEKLY, A PROGRESS RE=QRT TOGETHER WITS PERTINENT COMMENTS TO.THE NORTH ANDOVER BUILDING INSPECTOR. UPON COMPLETION OF THE WORK, I $HALL-SUBMIT A FINAL REPORT AS TO THE SAT �. SATISFACTORY `OMPLETiON AND READINESS OF THE PROJI-CT FOR MOUPANCY. SUBSCRIBED ANO SWORN TO 13EFORE ME THIS DAY OF 99 NOTARY PUBLICI. MY COMMISSION E-VIRES_,.__^__ 03/02/2011 22:24 17752545097 JAY MASON ACS PAGE 03 L) P,. Cargo doors and loading dock doors are weather scaled. 9. Recessed lighting fixtures ingta.11ad in the building envelope are Typo IC raced as meeting ASTM E283.are sealed with gasket or caulk. 10.Building entrance doors have a vestiblrie equipped with closing devices. Exceptions; wilding entrances witr revolving doors. C] Doors that open directly from a space less than 3000 sq.ft. in area, Section 4- Compliance Statement Compliance Statement: The proposed envelope design represented in this document is consistent with the building plans, specifications and other calculation;submitted with this permit application,The proposed envelope system has been deSirgned to meet the 2009 IEGC requirements in 00McheckVersion 3.8.2 and to comply with the mandatory requirements in the Requirements Checklist. ,JAY_fiZ ante Title Sign ,,e Date Project Title: JTI CONTRACTORS Report date' 08/02/11 Data fitename:C:ITEMPORARYItemporarylJODS 2011,,JTL NORTH ANDOVER, MA1080211 JTI COMCHECK.cck Paye 2 of 2 08/02/2011 22:24 17752545097 JAY MASON ACS PAGE 01 Arc hitecturolConsultin Services TRANSMITTAL 77 Tyler Park,Lowell, MA 01851 Jay R.Mason,AIA,LEER AP Ph:970.459.2004 Emall:jayc2ACSLoweil,Com Fax:778.254.5097 www.acsiowell.com Project: JTI Construction Date: 8/2/11 To: Dennis Sullivan- PH 978-604-6070, FX 978-658-6466 From: Jay Mason Re: COMcheck Energy Report Number of pages to follow: _3_ Item: C rP rt _OMcheGk ,Iao 2 pagers Item: Affidavit (NOT notarized) 1 trap Item: pages Total: 3 pages Hi Dennis, Here's the energy report and the affidavit.The affidavit that North Andover uses looks like it requires a notary, I have a long meeting scheduled in am,so I'll leave around noon to get the affidavit notarized, I've attached one without the notary in case you want to try to submit without. I'll call you as soon as I have it notarized. Let me know if you have any questions, thanks, ARCHITECTURAL CONSULTINC; SERVICES Jay Mason,AIA LEED AP North Andover Board of Assessors Public Access Page 1 of 1 NORTh North Andover Board of Assessors �9SSACNUS�tM- Property Record Card Click Seal To Return Parcel ID:210/061.0-0011-0000.0 FY:2011 Community:North Andover SKETCH PHOTO Search for Parcels Sketch No Picture Search for Sales Available l l a b l Summary Residence Detached Structure Location: 1780 OSGOOD STREET Condo Owner Name: TROPEANO INC,J Owner Address: 1780 OSGOOD STREET Commercial City: NORTH ANDOVER State: MA Zip: 01845 Neighborhood:34-4 Land Area: 3.22 acres Use Code: 440-IND-DEV-LAND Total Finished Area: 0 sqft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 343,300 343,300 Building Value: 0 0 Land Value: 343,300 343,300 Market and Value: 343,300 Chapter Land Value: LATEST SALE Sale Price: 55,000 Sale Date: 04/26/1984 Arms Length Sale Code: Y-YES-VALID Grantor: Cert Doc: Book: 01801 Page: 0206 http://csc-ma.us/PROPAPP/display.do?linkld=1704084&town=NandoverPubAcc 4/29/2011 Property Record Card PARCEL_ID:210/061.0-0011-0000.0 MAP:061.0 BLOCK:0011 LOT:0000.0 PARCEL ADDRESS:1780 OSGOOD STREET FY:2011 PARCEL INFORMATION Use-Code: 440 Sale Price: 55,000 Book: 01801 Road Type: T Inspect Date: 06/22/2006 Tax Class: T Sale Date: 04/26/84 Page: 0206 Rd Condition: P Meas Date: 06/22/2006 Owner: Tot Fin Area: 0 Sale Type: P Cert/Doc: Traffic: M Entrance: C TROPEANO INC,J Tot Land Area: 3.22 Sale Valid: Y water: Collect Id: RRC Address: Grantor: Sewer: Inspect Reas: R 1780 OSGOOD STREET NORTH ANDOVER MA 01845 Exempt-B/L% I Resid-B/L% / Comm-B/L"0/100 Indust-B/L% / Open Sp-B/L% I LAND INFORMATION NBHD CODE: 34 NBHD CLASS:4 ZONE: 12 Seg Type Code Method Sq-Ft Acres Influ-Y/N Value Class 1 P 440 S 87120 2.000 331,056 2 R 440 A 0 1.220 12,200 VALUATION INFORMATION Current Total: 343,300 Bldg: 0 Land: 343,300 MktLnd: 343,300 Prior Total: 343,300 Bldg: 0 Land: 343,300 MktLnd: 343,300 SKETCH PHOTO No _I - ct r AV bileParcel ID:210/061.0-0011-0000.0 as of 4/29/11 Page 1 of 1 i Date.. ............................ NORTI{ TOWN OF NORTH ANDOVER p PERMIT FOR WIRING Thiscertifies that ............................................................................................. has permission to perform ............ (I wiring in the building of......,/�..�..-:.......::: ?.......r?........................................... �j l' at..�.. .. 0 *rsr.- -4 . ..... ,North Ando �r,Mass. .f aA Fee I........... Lic.No.�..4 ............. . ��,: (!k: ..'... ... LECMICAL INSPEC'�DR� y Check #,= p, 9.i 35 i r _ Commonueah ol Madach �e� Official Use Only cc�� cc77 Permit No. Apad,.,d of- ire Service. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. ]/07] (leaveblank) 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 TYPS ALL INFO] , TION) Date: A Z&Z/ r:i City or Town of: Com., To the nor of Wires: By this application the undersigfied gives notic6 of his or her intention to perform the electrical work described below. Location(Street&Number) Owner or Tenant Telephone No. /OM-X7 d<— Owner's Address ,q Is this permit in conjunction with a building permit? Yes ❑ No (Check Appropriate Box) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: X, ' Completion o the following table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- ❑ o.o Emergency Lighting rnd, rnd. Batte Units No.of Receptacle Outlets No,of Oil Burners FIRE ALARMS I No.of Zones No.of Switches No.of Gas Burners o.of Detection and In tiating Devices No.of Ranges No.of Air Cond. Tonal No,of Alerting Devices No.of Waste Disposers Heat Pump Number Tons W No.of Self-Contained Totals: -1---*" ..."".•.. Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection y No,of Dryers Heating Appliances Kms, Security Syevices or E uivalent stems:* No.of Water No.of o.of No.of D KW Data Wiring: Heaters Signs Ballasts No.of Dvices or Equivalent No. Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or E uivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires, Estimated Value of Electrical Work: '7— (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. 14 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 0 BOND ❑ OTHER ❑ (Specify:) I certify, under thepains andAktldes ofperjury,that the information on this application is true and complete. FIRM NAME: Aries Electrical Service and Controls LLLC, LIC.N015650a Nor and Michaud �.. Licensee: Signatu.•� - �`--y--�--�• - -�-•y LIC.NO.• 3 4 5 9 4 e (If applicable,enter"exempt•'in the license number line.) Bus.Tet.No.• 978 h870544 Address: 290 Broadway suite 117 Methuen ma 01844 Alt•Tel.No.: *Per M.G.L.c. 147,s.57-61,security work requires Department of Public 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 El owner ❑owner's at�en Owner/Agent Signature WE: $ Telephone No. PERMIT F � - The Commonwealth of Massachusetts Department of In dustrial Accidents Office of Investigations 600 Washington Street- Boston, M4-02111 www.mass.gov/dia Workers' Compensation Insurance Mfidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Ledbly Name (Business/Organization/Individual):���J�—� Address: �y'�, �?� 7XI/ - City/State/Zig 7i'� /1� iG >9 /��� Phone#: - �'�� egSMY Are you an employer? Check the appropriate bog: Type of project(required): 1.❑ 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 2.12 I am a sole proprietor or partner- listed on the attached sheet.t 7• ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working forme 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.❑ 1 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.] *A applicant,that checks box nl 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 their workers'comp,policy information. I am an employer that isproviding workers'compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name: Policy#or Self-ins. Lic.#: Expiration Date: Job Site Address: / eO /J:<S6 P,d S T� 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. 'r I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Signature: Date•���/��//(/ Phone#: �� T G 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 Vocal 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 a t w ppIican . ho has not produced acceptable evidence o f 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 certificates of insurance. Limited LiabilitY Companies(LLC)or Limited LiabilitY Partnershi s(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 permittlicense 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 filled out each year. Where a home owner or citizen is obtaining a license or permit not related to an business or commercial venture Y g P Y (i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington. Street Boston, MA 0:2111 Tel. # 617-7274900 ext 406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 5-26-05 wmArw.mass.gov/dia