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Home My WebLink AboutBuilding Permit #531-2011 - 1801 TURNPIKE STREET 1/7/2011TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: S',1--20 !/ Date Received Date Issued: / / '7/// IMPORTANT: Applicant must complete all items on this LOCATION \ S (N ___qX4A-� � ( V -1C SS MAP NO: 14&PARCEL ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ A ition ❑ Two or more family ❑ Industrial HoAlteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition Q E) fier t -� Septic' ®%Well OFloodplam f DWe, Hands j ®; Water_shediDistrict, ' _11®Water//Sewer` ., DESCRIPTION OF WORK TO BE PERFORM D: Ideication PI ase Type or Print Clearly) OWNER: Name: ti \1J\�� i�� Phone: —7 1�� CONTRACTOR Name: Address: � t1V • uz[.AD�C..� Phone: <Z 7 31 W 1__*1 Supervisor's Construction License: Sri E '2q SExp. Date: Home Improvement License: () /.4 Exp. Date: I .J /,A ARCH ITECUENGINEER'SLs`t u w\*4.tJ Phone: `20, 3L/_ Address: <-) V I di ts. 5� ory&, Reg. No. FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $925.00 PER S.F. Total Project Cost: $ t;, FEE: $ 2, U 4 0 Check No.: 3777r Receipt No.: �3�y NOTE: Persons contracting wit e ' tered contractors do not have access to u anty fund Sianatuie:of=iAaent/Owners ° „Siangture of contract TT �, Plans Submitted Plans Waived ❑ Certified Plot Plan 01 ' Stamped Plans-_q TYPE OF SEWERAGE DISPOSAL Public Sewer ❑Swimming Tanning/MassageBody Art ❑ 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 PLANNING & DEVELOPMENT COMME DATE REJECTED El DATE APPROVED 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: Conservation Decision: Comments 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.$10041000 fine 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 ❑ 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 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) ❑ Muss 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 Energy Compliance Report ❑ Engineering Affidavits for Engineered products SIOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit -n all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals hat the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording oust be submitted with the building application Doc: Doc -Building Permit Revised 2008mi Location /y0/ No. / — -2 -.0// Date „ORT„ TOWN OF NORTH ANDOVER A Certificate of Occupancy $ c ustt� Building/Frame Permit Fee $ 2 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 23547 Buffing Inspector Location �� % ' � A&,( � No. Date . � r ,.OR7q TOWN OF NORTH ANDOVER Oi �t�•o '�,h00 L Certificate of Occupancy $ f/) ,,ssACMUStt� Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 241 L8 � Building Inspector CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Permit Number 531-2011 Date: May 31, 2011 THIS CERTIFIES THAT THE BUILDING LOCATED ON 1801 Turnpike Street, North Andover, MA 01845 Genesis Health Care MAY BE OCCUPIED AS renovate 8 residence rooms IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: Fee: 100.00 Receipt: 24188 Genesis Health Care 1801 Turnpike Street North Andover, M A01845 uil ing Inspector N m X m m ,X,w YI m N v m v y • 'v C � d CO) Cl) CD n Z CO) CD r c C >' c CZ 5• CO) aCO -0 O CD -CD CLQ IF CCD O CD C CD CA C. v r 0 co CD � v CD. � rF CD CD 0 0 0 C O 0 Z C. m - O 0 cc O c CL to cc c to 0 CO) e.G co)CL 0. C ? ..y d y e Q CD m dco � O 0 '17 L r: C m .-► c 'r! °o = d d= CA y ? a .-►. a 0 CD Er w O O y Cr7 0,0'p ' O : mCD O .� 0 COY o. .' go ZC'� O y n �o7 co .y,� C� CL. �0 m y ' CD 71 O m CL -a4 2 CA Cl) m T m CO) 2 m mCA C37 �i '� orf Ca gi'�7 (D G CL '� '17 L r: C Ca 'r! °o PV C y y O Cr7 p? OQ � m N .'OCD CL co 0 CD 0: CA y C 'O O m oCD ma. .� CO) d d D1 = O C O !n•„ O CD . i. 1 oq go. 0 )Mh Cn C37 �i '� orf Ca gi'�7 (D G '� '17 L r: C Ca 'r! °o PV w oGa �' Cr7 p? OQ CL O H O t,y tb n . 'R I i6 -a I , 02106 L Y � e � � ( S/CHECKLIST- � ��. GENERALBU6NG N ENOT LIMITED TO ITEMS BELO� POST ALL LOT NUMBERS, ADDRESS, AND PERMIT (COPY OK)..or no inspections .� INSPECTIONS: (Minimum) Excavation, Footing, Foundation, Frame, Insulation, Final. �( FOOTINGS: Continuous Full 2x4 Keyway Continuous strip footings for interior columns v� FOUNDATION: Rebar as required J 1e Anchor bolts or straps Damproofing - Foundation drain - pipe/stone/fabric filter/cover and outlet connection. FRAME: Fireblock - over girts/plates between floor joist Penetrations for plumbing, heat, elec, etc. Walls at stair stringers. Windbrace corners and center bearing partition . \\ 1 Size ridge to provide full bearing at rafter cuts. / �� `� a/ 1V Hip and Valley rafters - watch bearing at walls. / Ridge &Hip -Provide proper connections. a?� 770)�r Cathedral roof rafters provide proper connections and use "Hun Stair stringers - watch cuts and heal support. Joist hangers - fully nailed w/ hanger nails. Sill plates 2-2X6 (1 PT) w/sill seal. 'S - GYt 1"id b" k t I I t b t f nd t' ns A ,V Window Schedule or Every Habitable Room Must Have: - Natural light equal to 8% of floor area. '/z of required glazing shall be openable. ( Bedrooms required min. 20x24 egress window or door. Vent attic spaces - "proper vent", soffit and required ridge vents. Firecode under stairs if used for storage FIREPLACES: Separate permit required. d tv Inspections at Footing - Smoke Chamber - Finish et c, Smooth parging, clean joints, 8" solid @ combust. DECKS: Lag to house, provide flashing. Rails min. 36 " high, Baluster max space 5" on center. Over 8' above grade, use 6x6 posts wllateral bracing. Lag all posts and rails. Pier footings down 48", Conc. pad at stair base. FINISH: Handrails returned to wall/newall post. l Guardrails required alongside open cellar stairs. Exterior grading complete. Certificate or occupancy required prior to occupying structure. Tem ora Stairs required for inspection s- so I ko or s ee p a e eanng a ou a io '/Z " air space at sides in foundation pockets. "— — S Is Lateral bracing at ends.— Certified calculations, required for Beams/LVL's Trusses. Solid bearing support for Headers/Beams etc. Ste- �. sy Check headroom clearances -stairways, under beams Attic Access. 22x30 headroom above). C�j�. . (min. w/3' Crawl space access. (min. 18x24). Bath fans to have duct to (not in soffit). A� 0 exhaust metal exterior Firecode S/R wood frame of "0° clearance fireplaces & stoves — ,V Window Schedule or Every Habitable Room Must Have: - Natural light equal to 8% of floor area. '/z of required glazing shall be openable. ( Bedrooms required min. 20x24 egress window or door. Vent attic spaces - "proper vent", soffit and required ridge vents. Firecode under stairs if used for storage FIREPLACES: Separate permit required. d tv Inspections at Footing - Smoke Chamber - Finish et c, Smooth parging, clean joints, 8" solid @ combust. DECKS: Lag to house, provide flashing. Rails min. 36 " high, Baluster max space 5" on center. Over 8' above grade, use 6x6 posts wllateral bracing. Lag all posts and rails. Pier footings down 48", Conc. pad at stair base. FINISH: Handrails returned to wall/newall post. l Guardrails required alongside open cellar stairs. Exterior grading complete. Certificate or occupancy required prior to occupying structure. Tem ora Stairs required for inspection l Re -inspection fee - $30.00 (Be Ready). c4 1 Certificate of occupancy required prior to occupying structure. 1 � �s \v 1 •J Q e' a l Re -inspection fee - $30.00 (Be Ready). c4 1 Certificate of occupancy required prior to occupying structure. 1 � �s \v 1 JORDAN O'CONNOR & ASSOCIATES 57 Maple Lane May 16, 2011 Petersham, MA 01366 Mr. Gerald Brown, Inspector of Buildings Town of North Andover Building Dept. 1600 Osgood Street North Andover, MA 01845 Re: Genesis Health Care Sutton Hill Center 1801 Turnpike Street North Andover, MA 01845 Partial First Floor Renovation Contractor: F. W. Madigan Co., Inc. Dear Mr. Brown: Final Affidavit: architects Tel. (508) 754-3475 Fax (508)754-3477 j oconnor@JOAarchitects. com The architectural work associated with the above referenced project is complete. Based upon site observations and to the best of my knowledge and belief all completed work has been done in accordance with the submitted construction documents and meets all pertinent state and local codes. b - k 5C4 A, date Ori mal Signature &Seal _J0M-4 Very truly yours, NOWS WWOME t MASS. , Jordan O'Connor, AIA copy: Mr. Ray Mead (Genesis), Ms. Amanda Normandin (JOA), Mr. Kurt Grundberg (FW4, file y. SEAMAN ENGINEERING CORPORATION 30 Faith Ave. Auburn, MA 01501508-832-3535 fx 508-832-3393 Date: May 10, 2011 To: Building Inspector Town of North Andover, MA Re: Certificate of Compliance Affidavit for Genesis Healthcare Sutton Hill Center Renovation project, 1801 Turnpike Street in North Andover, MA Building Official: This letter shall serve to confirm that Seaman Engineering Corporation has performed the necessary site inspections for the Fire Protection, HVAC and Plumbing portions of the Genesis Healthcare Sutton Hill Center Renovation project, 1801 Turnpike Street in North Andover, MA and find them essentially installed in accordance with our plans and specifications; and to the best of our knowledge and belief are in compliance with the applicable regulations and requirements of the Massachusetts State Building Code - Seventh Edition. .. - _ _ _ Seaman Engineering Corporation Kevin R. Seaman, P. E. President o KEVIN R. - SEAMAN r^, U MECHANICAL No. 38130 A° �/ST F�ss/O N At ENv Commonwealth of Massachusetts Registered Professional Mechanical License No. 38130 SHEPHERD ENGINEERING, INC. 1308 GRAFTON STREET $ WORCESTER, MA 01604 $ (508) 757 7793 $ FAX: (508) 753 2309 May 16, 2010 FINAL INSPECTION AFFIDAVIT - ELECTRICAL Inspector of Buildings North Andover Building Department 1600 Osgood Street North Andover, MA 01845 Re: Sutton Hill Patient Bedroom Renovation Genesis Healthcare 1801 Turnpike Street North Andover, MA In accordance with the Massachusetts State Building Code, I, Robert J. Figuerido, being a Registered Professional Engineer, or a representative of this company, has reviewed the electrical and fire alarm installations at the above referenced facility pertaining to the selective first interior patient bedroom renovations and hereby certify that to the best of our knowledge, the electrical and fire alarm systems for the above named project comply with the Contract Documents and meet the applicable provisions of the 7th Edition of the Massachusetts State Building Code 780 CMR, Section 116.0, 903.0, NFPA 72-2007and acceptable engineering practices, applicable laws, and ordinances for the proposed use for occupancy. N g ROBEia`F' K J. 0 FIG4R' 1DO ,o\o. 29029 Q Subscribed and sworn to before me this 16th day of May, 2011 My commission expires: September 13, 2013 r Location No. 3/ - il Date `%�/ TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check #��` 24188 Building In pector r:. CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Permit Number 531-2011 Date: May 31, 2011 THIS CERTEFIES THAT THE BUILDING LOCATED ON 1801 TUMDike $DVg, North Andover, MA 01845 Genesis Health Care MAY BE OCCUPIED AS Mfflyate 8 resiftee r00Ms iN ACCORDANCE WITH 'i HE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: Fee: 100.00 Receipt: 24188 Genesis Health Care 1801 Turnpike Street North, Andover, M A01945 if"ding 1n4 ctor µOR7H O7,.aa. i� SMO O i �as�cxus� CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Permit Number 531-2011 Date: May 31, 2011 THIS CERTIFIES THAT THE BUILDING LOCATED ON 1801 Turnpike Street, North Andover MA 01845 Genesis Health Care MAY BE OCCUPIED AS renovate 8 residence rooms IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY, Certificate Issued to: Fee: 100.00 Receipt: 24188 Genesis Health Care 1801 Turnpike Street North Andover, M A01845 0-4 Ifuil ing Inspector /1t CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Permit Number 531-2011 Date: May 31, 2011 THIS CERTIFIES THAT THE BUILDING LOCATED ON 1801 Turnpike Street, North Andover, MA 01845 Genesis Health Care MAY BE OCCUPIED AS renovate 8 residence rooms IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: Fee: 100.00 Receipt: 24188 Genesis Health Care 1801 Turnpike Street North Andover, M A01845 ui ing Inspector 01/07/2011 13:31 5087544483 FW MADIGAN CO INC PAGE 02 L:(lenw: 1 iwo - DATE (MMIDD1YyM AcORD,, CERTIFICATE OF LIABILITY INSURANCE 1 113 01201 0 PRODUCER 'THIS CL�RTIFICATE IS ISSUED AS A MATTER OF INFORMATION Sullivan Insurance Group, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 10 Chestnut Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW, Suite 1010 Worcester, MA 01608.2804 INSURED F.W. Madigan Co., Inc. 357 Chandler St P.O. Box 20670 Worcester, MA 01602 INSURERS AFFORDING COVERAGE INSURER A: Travelers INSURER B: INSURER C: INSURER D: INSURER E: THE POLICIES OP INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY OR OTHER DOCUMENT WITH RESPECT TO WHICH 7HI: ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECTTO ALL THE TERMS, 5 POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, MR MOIL P LICYEFFECTIVE TR A PO CYE)�Po� ION TYPE OF INSURANCE POLICY NUMBER M A GENERAL LIABILITY C085SX3750 04/01/10 04/01111 X COMMERCIAL GENERAL LIABILITY CLAIMS MADE ❑X OCCUR X PD Ded-2 500 GEN'LAGGREGATE LIMIT APPLIES PER: POLICY P 0 LOC A AUTOMOBILE LIABILITY 810855X3750 04/01/10 04101111 X ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS X HIREDAUTOS X NON-OWNEDAUT05 X Drive Other Car GARAGE LIABILITY I ANY AUTO EXCFSSNMBRELLA LIABILITY 7 OCCUR 0 CLAIMS MADE DEDUCTIBLE RETENTION S A WORKERS COMPENSATION AND 6524N472 07/01110 07!01111 EMPLOVEAS' LIABILITY OFYICER/MENY MBEA EXCLUDEECUTIVE II M descdE" under SPECIAL PROVISIONS bolo, OTHER DESCRIPTION OF OPERATIONS! LOCATIONS /VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT/ SPECIAL PROVISION$ RE: Sutton Hill Center 1801 Turnpike St N. Andover Ma 01845 Genesis Healthcare 200 Brickstone Square Andover , MA 01810 ACORD 25 (2001108) 1 of 2 a s137256/M134311 NAIC # PERIOD INDICATED. NOTWITHSTANDING 'CERTIFICATE MAY BE ISSUED OR (CLUSIONS AND CONDITIONS OF SUCH LIMITS EACH OOCURRENCE $1000000 AMAGE TO RENTED $300.000 MED EXP (ArfY one Dersan 15 000 PERSONAL& ADV INJUAY $1,000,000 GENERAL AGGREGATE .$2.000-000 pRODUCTS•COMP/OPAGG 152,,000.000 COMBINED SINGLE LIMIT x1,000,000 (Eo accident) 601)ILYINJURY $ (Per Demo) BODILY $ arceidenl)RY PROPERTY DAMAGE $1,000,000 (Par accident) AUTO ONLY - EA ACCIDENT $ OTHER THAN FA ACC $ AUTO ONLY: AGG S EACHOCCURRENCE $ AGGREGATE S S $ X A&M U• DTH• E.L. EACH ACCI DENY $5001000 E,L. DISEASE- EA EMPLOYEE $500,000 EL DISEASE • POLICY LIMIT $500 000 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DAVE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 3n DAYS WRITTEN NOTICE TO THE CERTIFICATE MOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SMALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR AUTHORIZED REPRESENTATIVE JJs 0 ACORD CORPORATION 1988 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www. mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): F.W. Madigan Company, Inc. Address: 367 Chandler Street, PO Box 20670 City/State/Zip: Worcester, MA 01602 Phone #: 508-753-1459 Are you an employer? Check the appropriate box: 1. ® I am a employer with 29 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub -contractors have working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance. required.] 5. ❑ We are a corporation and its 3. ❑ I am a homeowner doing all work officers have exercised their myself. [No workers' comp. right of exemption per MGL insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. ® Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11. E] Plumbing repairs or additions 12.❑ Roof repairs 13. ❑ Other *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: Travelers Policy # or Self -ins. Lic. #: 6520472 Job Site Address: 1801 Turnpike Street Expiration Date: 7/1/11 City/State/Zip: N. Andover, MA 01845 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 agar' rst-t�violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations oft IA for insu#nce coverage verification. I do hereby c tify un at nd penalties of perjury that the information provided above is true and correct Si ature: Date: 44. 508-753-1459 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), addresses) 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 thea 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 sbould 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 lice to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington. Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 5-26-05 www.mass.gov/dia U) m x m m X m m y C d � d 'C O CD a Z y CDMMr C O y C-) c v CD CD O CL c� =r CD CDo C CD y 0.M y �• O CC COD C2 CO) O 1CD Z O o CD 0 CD m C �?o: =r-, = Q —. y O Q H noSOy =t Cl) ® m o HC2aC 3 Z m -*= H =r C= m CD - O m y p N :E =r m _ > D CR C n IMI O --k C) cl Z:Sii O H. a W a 0, C ? CA CL VJ CD m'N U1 � �= CD O d y ✓V �'f O NC d 11 c zea = a ►� y C �\ CO) "r m CA �. m sm CA ° `o p O X05 F 3 CDIN o m :� a3 �y� t.r1 Cn CO) v Y w 10 r: C o CL d C o b: n c_ O` o r m 3 cn c/1 b7 :p orf C/) 'p1 z ro ', rf n 7z ►n cn w gj oda w Jr,- Ci7 C. 7� kJy 0 c -' Massachusetts - Department of Puhlic Safety Board of Building Regulations and Standaj'ds Construction Supervisor License License: cs 88295 Restricted to: 00 KURT GR6�ERG 154 PROSPECT ST W BOYLSTON, MA 01583 z:e_ Jy—� � Expiration: 1/2842012 C'ummissioil eI. Tr#: 19067 i #IwAIA Document Al 01 2007 tan.dard Form of Agreement Between Owner and (Contractor wh re the basis of paymahl is a Stipulated Sum t'..: SIXTH day of DECEMBER Aqi � MENT trade as of the in-thi year TWO THOUSAND TEN Vn.wordy, indicate day, month and year) gI WEEN the Owner'. HealthC.are (Mime, address•and other information) 200 Bri cksto-ne Square This document has important legal Andover, MA 0181.0 consequences. Consultation with an attorney is encouraged with respect to its completion or • modification. AIA Document A201m-2007, ^, ....'� General Conditions of the �•.::,. '�' �:''�' ;-_ 1<.'� Contract for Construction, is and rhe coritra�tor:.. F.W. Mad i gan;:t-i}m� ty, Inc . adopted In this documAnt by Nairte, address Curd other information) 367 Ch andi-ero ireet reference. Do not use With other general conditions this O67� PO a , document is,rn!atd�' 410r. qsf r, MA 01602 ...�.: ..tJ.'h J.. t' . _ .. Sutton Center ... n Hi 1 1 ., lgct�tio�%�X3id;:;d¢taiYeddescription) 1801 Turnpike Street North Andoverp MA 01845 7. The.Architect: Jordan O'Conner & Associates .(.Nmik address and other infiormation} 57 Maple Lane Petershaff,O 01366 The Owner and Contractor agree as follows. AIA Document A1otn" –2007. Copyright ®1915,1918, 1925,1937, 7951,1959, 1981,1963,1987,1974, 1977,19eo,1987, 1991,1997 and 2007 by The Init. American Institute of Architects. All rtgt+ra reserved. WARNING! This AiO nocument 1s protectod by u.S. copyright t.aw and International Treaties. Unatuthorized reproduction or distribution of this Ale Document, or any portion of it, may result in severe civil and criminal peRaitiea, and will be prosecuted to the maximum extent pos3ible under the law. Purchasers are permitted to reproduce ten (10) copies or this document when completed. To ..i A 1 1'—t-14 rinr„mo m ,•-mwl ThA Amariran lnsfitute of ArchitWs' legal Counsel, copyrlght@aia.org, $• 9.1.5 The Drawings_ (Either list the Drawings here or refer to an exhibit attached to this Agreement) Number Title Date Rider 9.1.7.2-F.W, Madigan Company, Inc. Proposal, dated 1.1/11/10 (6 pages) VX6t APP licable _new v::• . Date November 5� ( p 71% November 9• X10 19 November 10, 2010 4 November 11, 2010 3 November 16, 2010 2 riding trquirements are not part of the Contract Documents uWess the bidding in this Article 4. any, .Portlaiuolg part of the Contract Doo lvt$' 01T-2007, Digital Data protocp� �p�ie by the pages. or the following: r A; * r R y, listed ffi _ invents that b,to- -forma � ` air � PetttC"d part of the Contract Documents, AIA, ,1�o�ur 01- 7utrer4ur7t as advertisement or invitation to bid, Instructions *tors, sample r of the Contract Documents unless enumerated reement. They itded to be part of the Contract Documents.) �` pany, Inc. Estimate No. 10078, ,d�e'(ovember 12, 2010 ed to as Rider 9.1.7.2: a BONDS `arid maintain insurance and provide bonds as set forth in Article 11 of AIA Document if any, and limits of liability for insu,anee required in Article 11 ofAU ,Docwnenr into as of the day day M+rd,eniar Project Manager (Printed name and title) 4 'f •n writtelk 0:.t�v Franc` lS adigan III, President (Printed name and title) CAU11ON: You should sign an original AIA Contract Document, on which this text appsars In RED. An original assures that changes will not be obscured, (nit AIA Document A1o1n 2007, CopyrigritO 191ti, 191a, 19zs, 1937.1951, 1958, 1961, seas,19t37, 4974,1sTl, 1960, 1907,1991, 19B7 and 2007 by The American Institute of Architects, All rights reserved. WARNING: This AIAoDocument is protected by U.S. Copyright -Law and Intornatlorml iYeatles. Unauthorized reproduction or distribution of this AIA® Document, or any portion of it, may result in severe civil and crlminal penalties, and will be 7 t proseeUtod to the maximum extent possible undtr the iflw. pur&a59rs are permitted to reproduce ten (10) copies of this document when completed. To report copyright vlolattons of AIA Contract Documents, e-mail The American Institute of Architects' legal counsel, copyright@ eia,org, A -6 -The Addenda, if any, Number T. ;`;:..', +`., •' .:_.:,;.;: is cu .::1"f�=:.: .• j^... � vi, •s: .sem g l,� 4 . •' f r ;fa istli re:au�y; idd�tia ul;?�¢C f 7;.p 'b"�,��Lrt,�: rt). es ihat'�csc; ..�Of•�t7: •.. g`TE '�,�•., • •^:i�rifts:;tl?je C.�ntrtictor's;li' VX6t APP licable _new v::• . Date November 5� ( p 71% November 9• X10 19 November 10, 2010 4 November 11, 2010 3 November 16, 2010 2 riding trquirements are not part of the Contract Documents uWess the bidding in this Article 4. any, .Portlaiuolg part of the Contract Doo lvt$' 01T-2007, Digital Data protocp� �p�ie by the pages. or the following: r A; * r R y, listed ffi _ invents that b,to- -forma � ` air � PetttC"d part of the Contract Documents, AIA, ,1�o�ur 01- 7utrer4ur7t as advertisement or invitation to bid, Instructions *tors, sample r of the Contract Documents unless enumerated reement. They itded to be part of the Contract Documents.) �` pany, Inc. Estimate No. 10078, ,d�e'(ovember 12, 2010 ed to as Rider 9.1.7.2: a BONDS `arid maintain insurance and provide bonds as set forth in Article 11 of AIA Document if any, and limits of liability for insu,anee required in Article 11 ofAU ,Docwnenr into as of the day day M+rd,eniar Project Manager (Printed name and title) 4 'f •n writtelk 0:.t�v Franc` lS adigan III, President (Printed name and title) CAU11ON: You should sign an original AIA Contract Document, on which this text appsars In RED. An original assures that changes will not be obscured, (nit AIA Document A1o1n 2007, CopyrigritO 191ti, 191a, 19zs, 1937.1951, 1958, 1961, seas,19t37, 4974,1sTl, 1960, 1907,1991, 19B7 and 2007 by The American Institute of Architects, All rights reserved. WARNING: This AIAoDocument is protected by U.S. Copyright -Law and Intornatlorml iYeatles. Unauthorized reproduction or distribution of this AIA® Document, or any portion of it, may result in severe civil and crlminal penalties, and will be 7 t proseeUtod to the maximum extent possible undtr the iflw. pur&a59rs are permitted to reproduce ten (10) copies of this document when completed. To report copyright vlolattons of AIA Contract Documents, e-mail The American Institute of Architects' legal counsel, copyright@ eia,org, 4 , MADIGAN FW. MADIGAN COMPANY, INC. Sutton Hill Center 1801 Turnpike Street North Andover, MA 01845 Job # 10-034 Schedule of Values Selective Demo $6,800 Partitions/Soffits/Carpentry $24,000 Flooring $50,918 Paint / Wall Covering $18,682 Fire Protection $6,900 Plumbing $26,200 HVAC $2,000 Electrical $34,500 Total $170,000 GENERAL CONTRACTING € CONSTRUCTION MANAGEMENT , DESIGN/BUILD 367 CHANDLER STREET P.O. BOX 20670,, WORCESTER, MASSACHUSETTS 01602 o. TEL: 508-753-1459,). FAx: 508-754-4483 www.fwmadigan.com SHEPHERD ENGINEERING, INC, 1308 GRAFTON STREET • WORCESTER, MA 01604 • (508) 757 7793 • FAX: (508) 753 2309 Upon the activation of a smoke detector, manual pull station or a sprinkler flow switch, the following shall occur: a. All fire alarm visuals within the building of alarm shall be activated. b. All fire alarm horns within the building of alarm shall be activated. b. CPU shall record the alarm; description of event shall be displayed onInformation Management System computer. C. Fire department shall be notified via the existing monitoring system approved by the Town of North Andover. Upon the activation of an existing duct smoke detector, the following shall occur: a. All fire alarm visuals within the building of alarm shall be activated. b. All fire alarm horns within the building of alarm shall be activated. C. HVAC units shall be shutdown as required. d. Fire department shall be notified. Upon the activation of an existing sprinkler system tamper switch, the following shall occur: a. Trouble shall be annunciated on the fire alarm panel requiring acknowledgement and investigation. 2. Building and site access — Not part of this project 3. Fire hydrants —Not part of this project 4. Type/description and design layout of the automatic sprinkler system 5. Automatic sprinkler systems control equipment 6. Type/description and design layout of the automatic standpipe system — 7. Standpipe hose valves —Not part of this project 8. Fire department Siamese connections — Not part of this project 9. Type/description and design layout of the fire protective signaling system Relocation of existing photo -electric smoke detectors within the corridor space. Installation of a new ADA compliant strobe in the Staff Toilet. All new visual notification appliances shall be mounted 80 inches above the finished floor to the bottom of the devices. Existing audio/visuals currently located within the existing corridors are to remain. Existing smoke detectors will be relocated into the new accessible ceilings. 10. Fire protective signaling system control equipment and remote annunciator location The existing main fire alarm signaling control equipment is conventional zoned, Simplex Co. 4005 series. 11. Type/description and design layout of the smoke control or exhaust system - Not part of this project 12. Smoke control system control equipment location - Not part of this project Sutton Hill Center — Partial First Floor Renovation Page 2 SHEPHERD ENGINEERING, INC, 1308 GRAFTON STREET • WORCESTER, MA 01604 • (508) 757 7793 • FAX: ( 08) 753 2309 13. Building life safety system feature integrated into fire protective signaling system See 9. & 10. 14. Type/description and design layout for the fire extinguishing systems — 15. Fire extinguishing system control equipment location — 16. Fire protection system room location - 17. Fire protection equipment identification and operation signs - 18. Fire protection systems alarm/supervisory signal transmission method and location The existing control panel is capable of multiple 24VDC-power outputs. All auxiliary manual controls are supervised so that all switches must be returned to the normal automatic position to clear system trouble. Each independently supervised circuit shall include discrete panel readout to indicate disarrangement conditions per circuit. The incoming power to the system shall be supervised so that any power failure must be audibly and visually indicated at the control panel. A green "power on" LED shall be displayed continuously while incoming power is present. The System Expansion Modules shall be electrically supervised for module placement. Should a module become disconnected from the controls, the system trouble indicator must illuminate and audible trouble signal must sound. The system shall contain multiple supervised signaling line circuits. The alarm activation of any initiation circuit shall not prevent the subsequent alarm operation of any other initiation circuit. There shall be independently supervised and independently fused indicating appliance circuits for alarm horns and flashing alarm lamps. Disarrangement conditions of any circuit shall not affect the operation of other circuits. The system shall have provisions for disabling and enabling all circuits individually for maintenance or testing purposes. 19. Testing Criteria to be used for final system acceptance All fire protection systems shall be tested as a system with all equipment ready for operation. Tests shall be performed on the following equipment and devices: Alarm notification devices and circuits Alarm indicating appliances and circuits Supervisory -signal initiating devices and circuits Signaling line circuits Primary and secondary power supplies The tests shall meet all the requirements of NFPA 72-2007, the 7th edition Commonwealth of Massachusetts 780 CMR 903.0, Section 2-08 Alarm Systems and the North Andover Fire Department Fire Alarm Standards. END OF NARRATIVE Sutton Hill Center — Partial First Floor Renovation Page 3 CONSTRUCTION CONTROL AFFIDAVIT PROJECT NUMBER: DATE: 12-10-10 PROJECT TITLE: Genesis HealthCare Sutton Hill Center PROJECT LOCATION: 1801 Turnpike Street, North Andover, MA NAME OF BUILDING: Genesis HealthCare Sutton Hill Center NATURE OF PROJECT: Renovate wing of existing structure IN ACCORDANCE WITH SECTION 116.0 OF THE MASSACHUSETTS STATE BUILDING CODE, I, Kevin R. Seaman REGISTRATION NO. 38130 BEING A REGISTERED PROFESSIONAL ENGINEER HEREBY CERTIFY THAT I HAVE PREPARED OR DIRECTLY SUPERVISED THE PREPARATION OF ALL DESIGN PLANS, COMPUTATIONS, AND SPECIFICATIONS CONCERNING: X HVAC ARCHITECTURAL STRUCTURAL MECHANICAL X FIRE PROTECTION ELECTRICAL X OTHER (SPECIFY) PLUMBING FOR THE ABOVE NAMED PROJECT AND THAT, TO THE BEST OF MY KNOWLEDGE, SUCH PLANS, COMPUTATIONS AND SPECIFICATIONS MEET THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE, ALL ACCEPTABLE ENGINEERNG PRACTICES, AND ALL APPLICABLE LAWS AND ORDINANCES FOR THE PROPOSED USE AND OCCUPANCY. I FURTHER CERTIFY THAT I SHALL PERFORM THE NECESSARY PROFESSIONAL SERVICES AND BE PRESENT ON THE CONSTRUCTION SITE ON A REGULAR AND PERIODIC BASIS TO DETERMINE THAT THE WORK IS PROCEEDING IN ACCORDANCE WITH THE DOCUMENTS APPROVED FOR THE BUILDING PERMIT AND SHALL BE RESPONSIBLE FOR THE FOLLOWING AS SPECIFIED IN SECTION 780 CMR 116.0, 7th EDITION OF THE MASSACHUSETTS STATE BUILDING CODE. PSI" OF j SIP, 9 SEAL o� KEVIN F? SEAMAN MEC KCAL 8130 GNATURE Construction Control Affidavit The Seventh Edition of the Massachusetts State Building Code, per section 116.0, requires most buildings to be designed and built under the supervision of a Massachusetts Registered Architect. In some instances a Registered Professional Engineer may provide incidental architectural services when associated with their design work. It is the responsibility of the Registered Professional completing this form to insure compliance with the law. ADDRESS: 1801 Turnpike Street PROJECT TITLE: Genesis Healthcare Sutton Hill Center Renovation NATURE OF PROJECT: Interior Renovation SCOPE OF PROFESSIONAL WORK: Architectural NAME OF ARCHITECT/ENGINEER: Jordan O'Connor, AIA REG.# 7655 In accordance with Section 116 of the Massachusetts State Building Code and in compliance with the Massachusetts General Law section 112, I hereby state that I am the Massachusetts Registered Professional Architect/Engineer responsible for the preparation of the plans and specifications for the following sections of the project: Entire Project X Architectural _ Structural _ Mechanical Fire Protection Electrical Other To the best of my knowledge and belief these plans conform to all of the requirements of the seventh edition of the Massachusetts State Building Code, all applicable laws and ordinances, and acceptable engineering practices. I further state that I shall perform all of the necessary professional services required to insure that this project is constructed in accordance with the approved plans, Building Code summary and specifications including periodic site visits and the submission of periodic project compliance reports to the Building Dept. day of My Commission expires `�� k Z' - 2d t ^% SHEPHERD ENGINEERING, INC. 1308 GRAFTON STREET - WORCESTER, MA 01604 - (508) 757 7793 - FAX: (508) 753 2309 Genesis Healthcare Facility Sutton Hill Center —Partial First Floor Renovations �� 11A OF - 1801 Turnpike Street �� 1toaERT North Andover, MA o J. December 8, 2010 FIGUERiDp -PNo. 29029 Q 780 CMR 903.1.1- Fire Protection Construction Documents r NA 1. 1. a. Basis (methodology) of design Section 1- Building Description Building Type 12. Section 2 - Applicable Laws Regulations and Standards 0 780 CMR 7th Edition Massachusetts State Building Code. o NFPA 72— 2007 edition standards. o Sections of M.G.L. 148 — Fire Prevention. o Sections of 527 CMR — Fire Prevention Regulations. o Approved local by-laws or ordinances — Section 2-08 Alarm Systems. 0 Section 3 - Design Responsibility for Fire Protection S, stems Shepherd Engineering, Inc. 1308 Grafton Street Worcester, MA 01604 (508)757-7793 Robert J. Figuerido MA PE# 29029 Section 4 - Fire Protection Systems Being Installed Installation of zoned, hardwired fire alarm devices to protect the renovated first floor patient rooms located within the existing nursing home facility. The existing devices will be relocated into the new ceiling assembly to protect the existing spaces. New ADA compliant strobe will be installed within the existing staff toilet room. The existing audio-visual devices located within eh corridor space will remain. Devices shall be installed to meet the requirements of ADA and NFPA-72 (2007). Section 5 - Features Used in the Design Methodology Building occupants will be notified of an alarm condition through the use of new ADA compliant audio/visual units, individually, by space. Upon completion of the installation fire alarm manufacturer of a factory trained technician shall test the system devices as outlined in NFPA 72 - 2007, edition and 780 CMR, 7th edition, Massachusetts State Building Code, Chapter 9 as required. In addition, all alarms and trouble conditions will sound at the fire alarm control panel until acknowledged and reset. Section 6 - Special Consideration and Description Not Applicable 1. b. Sequence of Operation Section 1: Sutton Hill Center — Partial First Floor Renovation Page 1 NORTH ANDOVER CONSTRUCTION CONTROL PROJECT NUMBER: PROJECT TITLE: Genesis Health Care Facility PROJECT LOCATION: 1801 Turnpike Street NAME OF BUILDING: Sutton Hill Center NATURE OF PROJECT: Renovations to Selective First Floor Bedrooms IN ACCORDANCE WITH SECTION 116.0 OF THE MASSACHUSETTS STATE BUILDING CODE, I, Robert J. Figuerido, REGISTRATION NO. 29029, BEING A REGISTERED PROFESSIONAL ENGINEER/ARCHITECT HEREBY CERTIFY THAT I HAVE PREPARED OR DIRECTLY SUPERVISED THE PREPARATION OF ALL DESIGN PLANS, COMPUTATIONS, AND SPECIFICATIONS CONCERNING: Entire Project Architectural Structural Other Mechanical Fire Protection Electrical X FOR THE ABOVE NAMED PROJECT AND THAT, TO THE BEST OF MY KNOWLEDGE, SUCH PLANS, COMPUTATIONS AND SPECIFICATIONS MEET THE APPLICABLE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE, ALL ACCEPTABLE ENGINEERING PRACTICES AND ALL APPLICABLE LAWS AND ORDINANCES FOR THE PROPOSED USE AND OCCUPANCY. I FURTHER CERTIFY THAT I SHALL PERFORM THE NECESSARY PROFESSIONAL SERVICES AND BE PRESENT ON THE CONSTRUCTION SITE ON A REGULAR AND PERIODIC BASIS TO DETERMINE THAT THE WORK IS PROCEEDING IN ACCORDANCE WITH THE DOCUMENTS AS SPECIFIED IN SECTION 116.2.2. 1. Review of shop drawings, samples and other submittals of the contractor as required by the construction contract documents as submitted for building permit, and approval for conformance to the design concept. 2. Review and approval of the quality control procedures for all code -required controlled materials. 3. Special architectural of engineering professional inspection of critical construction components requiring controlled materials or construction specified in the accepted engineering practice standards listed in Appendix A. Pursuant to Section 116.2.3, 1 shall submit required progress reports together with pertinent comments to the Westborough Building Official. Upon completion of the work, I shall submit a final report as to the safisfactory completion and readiness of the project for occupancy. This report shall include date of final inspection and an.or SEAL: Signature SUBSCRIBED AND SWORN TO BEFORE ME THIS 8th DAY OF December , 2010 NOTARY PUBLIC MY COMMISSION EXPIRES ON September 13. 2013 Plans Submitted Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans C� 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 ❑ ❑ "D - 7 C. M -NTS _ /A ,T v CONSERVATION COMMENTS HEALTH COMMENTS x DATE REJECTED DATE APPROVED IN DATE REJECTED DATE APPROVED ❑■ 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 Located at 384 Osgood Street FIRE DEPARTMENT Temp Dumpster on site yes no, COMMENTS