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HomeMy WebLinkAboutBuilding Permit #143-11 - 4 HIGH STREET 8/20/2010 BUILDING PERMIT cF t,oy DT TOWN OF NORTH ANDOVER ?'_ APPLICATION FOR PLAN EXAMINATION ' /� �// Permit NO:� Date Received � �• �` Date Issued: /d IMPORTANT:Applicant must complete all items on this a y, P ge (( YL ,l 'Y'vc`!JY^F'.•;,.tllc.er ' .�'- J .a.`n`^'�. a-,+.z 1 wi s Lrs, xR 1 r+ '� I FIR { r•.�-3r.y? _v eF '` r Pin �1 o5i ""�T n i z r d e �s ti r�'i-eZ `Tp t,y, , r' [Yr L .in - Y , hal} ,. •Z' x yj , r s'. i 1i „f-�5 G 31 i i�'F� r;� ins a •"r ,, y1�� 'F s `S'` 'hl.�,. _ E,j<-_ s �9�a•.... _..s�' L�1�.L�N•*-si,-�l.g`.F-� '�i_••->r'tt., '.: �;. e..._s�`?r,1 i.[ 1..�'x .-•^ y'e, e' f' . 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TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Addition Two or more.family Industrial Alteration No. of units: Commercial Repair, replacement-- Assessory Bldg Others: Demolition Other _ r =14a"0051 +� ,� �,r'.[y-�.�r�' > '+s c::r..' a.'..V•...gry�:... e�1L1er,"005'M`r 3 a"'� i + �a 1 ,L M�: z•a=�. ��,r t F*�l a 4"r.�, CaYYQirym `",. � ( ,-`��"-` �,., .. .....�.. ..`ac.. r.�f H ''G,L �7 P_ jllr_¢",.'IT,-.R�G� o ; -�`it ,Yr"".Y,"'�"-�' *b v� tiA+� ri..yt:T' -S 4 �'' .''er�' •r 'c' Yi�^ '�il.i+Fb n ',u;E ..r. ti..a =,„� r••�,.4-�.�r..,.1�...� _a?�..a� :.�l,..v�"r'��`�� ��'1vr'�, �h DESCRIPTION OF WORK TO BE PREFORMED: ' Q Identification P ase Type or Print Clearly) OWNER: Name: ��� � �' �� �-{- yy� �n-�- Phone: 3 t'� 6 55 ­7%q 5 Address:, �'.�' -j D u g�'�'E'��cyz�.T�. ¢�"b.>".,°-�r'� >�1.� 7--r,.n.-�.yr-k aa, !k'�. -�.tt'�>' 1-:r P fir- � r. �..�r. ,y1.,_.7+.'�. 7^�.`+s•� �'`�' .e._Cf�-„ �'' {7 •',3'S ��.5 c �. : E„xr �s.uo�, ur .r: `s”'-n —h, �i -.,F �s-*• [•,3:c"1^:Cr'Pit,..�"d "^'yrr�'Fs. �'�-ru'-...�.�` 's• '�-�s. ��7Jil�i':�. � �� �aZ- 'i•• �^•xa �c �- � _ F'fr -' c 1 •"ti `s`^n[ � .rl� ,,,r�,SFYv 5�Fe. rfi.r t�'•sra- 1 v... } �.� �y `rM�s ¢ 4�t °�. +`- _�' .�`.y - ,4 oy u�."-��, r� i• s16 "�` 3 n w - ---7 drr' r a ,r-a I, � ,�r1'a k F '�i��>� "u Y`t`7r�_ „'^rs;B l�k}.� l.frq,RiSe•,29 [�+r •_r2 ` nsi'`f'4r ".'r�E 4��-'.c•y�Ld1� 1 tirCrimv� r'"'-r'•�-t ��+�s'9I_kF',.�-�*. �*`F-�sw' �' •K,.,.;s�„�?'7`[-` g'.�.'�l 45 .y•t i�z':' ..,f S. .�� � . y ill Wu_J+«;*;.- v r'.ti..t".i m a'•L[v '�- n 7 r'� ,� 1 ds. i 1 �h,� AI t-X�•yt3" ,1 X 5•I[' i7j r7 `` ���.n� k i S7 r 1 n e r ey_t �T''a a:h� 1�a i ''Y s � Nr,�'-•rs[ ��-F �.c } ..is _r.:.,Z_ �s"� !�"�>•'r.. n;�zciptt',"��o���`�a: ...r���`r'Lh,n.Y= tl�Y��el'AS C.��,��.�"�n•'.,,.�,"�"Fs. �'1`1s �._ .� .s a.��4;.�•Qn,.Siic_5 7�� ', p� ,1..,��. .xFh_ �mom`,-Y`�•' .....�d5.. �ay.^ry�'a .Ey 7r u.�e'�� T rg � ri� e ,� '�y1w 'ti;,"-'r;.' ,.z�,*.[i R d..[�.ir �3`'!1^ �. _ .••J.'3"n�3:i:���, ' ��"Sl`r;[p�'�c,5_.`.�,_-r�'I�;k •��t�.fil-ie»':[,,�,?nv�L >a rr�-�-4'-� �'45 la rrfh,��y_,�y"z!t`=el���4"'_'•d�°�•7.�"�'�•k'� "�4t• ,a . 15 ..�[.c,.l.,,ls�. ,_... ,3., .!�,.�et'w-• �.' �1:;4.:•:; _L�.-k''�. �{Nom, �t �`� [�i4�.a E ter• � �. .[�•k"!r;Ev��r,��[[. I3 �,���}?T��/ �'9��IIZ��311.''.u'��,��'•:��"t;,"� ;-+'k•,;r- i.-'•n:_' .F i '��'�F,ti ��- ."_,., t, ..� �.,•[�„,r3�;'--���-�s,V,.--.;��'r�"�;���_.` .}.c>,L. taa"k•."11 .�:,f �n� �2 - p T .;` -rR '�' ��•zr #., �4+k -� i ARCHITECT/ENG INEERY + Phone: b ) 7 " Ll Address:_ y� 1'S® 6 . � Reg. No. / (I D, S O FEE SCHEDULE.BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ s O FEE: $ G Check No.: Receipt No.: a 3 S"'� NOTE: Persons contracting with unregistered contractors do not have access to tAeguarantyfund S i}�fure fryA nt/O mer natu e-of co d G.T: x �` Plans Submitted Plans Waived Certified Plot:Plan Stamped Plans � TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/Massage/Body Art Swimming Pools Well Tobacco Sales Food Packaging/Sales Private(septic tank,etc. Permanent Dumpster on Site f L f THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM 4 DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT 1 COMMENTS f CONSERVATION Reviewed on Signature C0MMEN T S 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 Drivewav Permit DPW Town Engineer: Signature: mr:.:.:........ ...:.:..,.._..,.__ Located Osgood treet E .: ... .,, N�' �f�e.>x� 'L-ocated ` F�re��e}sar Meg6ldate`;Y 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 t DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— (For department use) � ❑ Notified for pickup - Date i Doc.Building Permit Revised 2010 Building Department r The following isa 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 i ❑ Building Permit Application ❑ Certified Surveyed Plot Plan I ❑ 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) ❑ "'ass 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 Pian [IPhoto 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) j ❑ Copy of Contract { ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit I 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 IDoc:Building Permit Revised 2008 I A r Se4 Location < ' No. Date MORTIy TOWN OF NORTH ANDOVER f S # # Certificate of Occupancy $ Building/Frame Permit Fee $ J�CHU Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check #� 233ob r Tiding Inspector Date........ .`.. ............................ i OF tkORTH,�O TOWN OF NORTH ANDOVER p PERMIT FOR WIRING SS,CHU5E This certifies that ..........Yay.��.. .......f.���'li �t ........�../............... ..?,711..x..................... has permission to perform .� /� , ............................................... ...... . .................... wid1Dhgin the building of........ ................. .......................................................................... at .. ...!4il/.. ........r........................................ . ...........North Andover,Mass. Fee .-�' �..Lic.No. �.3�4�7 ... �........................... ... ................. ELECTRICAL IN E Check# � T:r Id Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. 2�� Occupancy and Fee Checked aM BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/071 peaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),52 CMR 12.00 (PLEASE PRINT WINK OR TYPE ALL INFORMATION) Date: 7-12,t- City or Town of: NORTH ANDOVER To the Inspector Zf Wires: By this application the undersigned gives notice of his or her,intention to erform the electrical work described below. Location(Street&Number)_ L�' G+�l Owner or Tenant AM, Telephone No. Owner's Address 17 IVAX fLi ee4, W&,C- A COW OAX-1 r Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building C-0/V7 A 6 k}L 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: /W Completion of the following table may be waived by the Inspector of Wires. ' ranNo.of Recessed Luminaires No.of Ccil:Susp.(Paddle)Fans Ts Total Trsformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA l Above In- o.o mergency Lighting No.of Luminaires Swimming Pool rnd. ❑ rnd. El Battery Units No.of Receptacle OutletsNo.of Oil Burners FIRE ALARMS No.of Zones No.of Switches No.of Gas Burners No.of Detection and Initiating Devices No.of Ranges No.of Air Cond. Tons TotNo.of Alerting Devices No.of Waste Dis osers Heat Pump Number Tons KW No.of Self-Contained p Totais: ......... Detection/Alerting Devices No.of Dishwashers S ace/Area Heating KW Local❑ Municipal E] Other p g Connection No.of Dryers Heating Appliances KW KW SecN ito Deviic s or Equivalent o.of Water No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent 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: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURA-NCE X BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties ofperjury,that the i formation on this application is true and complete. FIRM NAME: LIC.NO.: 13 Licensee: AWO-1L& Signature LIC.NO.: (Ifapplicable,enter "exempt"in the license umber e.) Bus.Tel.No.• Address: _ $ h,/11— l�� Alfl 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)[]owner ❑owner's agent. Owner/Agent PERMIT FEE: $ Signature Telephone No. I The Commonwealth ofMassachusetts 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 kpi)licant Information Please Print Leyibiy Name(Business/Organization/Individual): Address: 2 3�0� f ,e� City/State/Zip: Phone#: SIJ 9 aOD� 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 1 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.El am a sole proprietor or partner- listed on the attached sheet.z �• emodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. g• ❑Building addition coin .'insurance 5. ❑ We are a corporation and its o workers' xn � p airs or additions required.] officers have exercised their 10.❑Electrical rep «.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers'comp, c.152,§ (4 1 ,and we have no ) 12.❑Roofrepairs insurance .re uiredemployees.[No workers' required.) 13.0 Other comp.insurance required.] 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. I Homeowners who submit this affidavit indicating they a're doing all work and then hire outside contractors must submit a new affidavit indicating such. TContractors 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 emptoyer that is pYoviding workerscompensation insurance for my employees. Below is fhe policy and job site information. Insurance Company Name:. Li IT Poli#or Self-ins.Lie./#: Expiration Date: Job Site Address: �11 ) /1/, City/State/Zip: Atil a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requiredunder 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 maybe forwarded to the Office of 'Investigations of the DIA for insurance coverage verification. Ido h'ereby cero under the palns penalties ofperjury that the information provided above is true and correct. � ZT Signature: Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.CitylTown Clerk d.Electrical Inspector 5.PIumbing Inspector 6.Other - - Contact Person: Phone#: ORTH. F ' ovm 0o OAndover No. O _�= LA=KE � lover, 1Vlass., COC H IC HE WICK AORA TE D PC7 `SS BOARD OF HEALTH Food/Kitchen .PERMIT. T D Septic System a BUILDING INSPECTOR THIS CERTIFIES THAT.......... .... ... i ���..�...................................................................... .'••"••'•P•••'•....... Foundation has permission to erect........................................ buildings on ....... .........�'1 �'1.... .. .........................:.................... Rough to be occupied as.... . . . . G' ,a.V� tom• ....... .. .. - Chimney provided that the person accepting this permit all in every rdspect conform to th erms 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 3:3- PERMIT EXPIRES MONTHS ELECTRICAL INSPECTOR UNLESS CONS CTIO AR . .>��_� .. Rough ..........................................:.......................... 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 Lathingor D Wall To Be Done � FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner. Street No. SEE REVERSE SIDE Smoke Det. t 1 ORTFi. � F ,� s T0 0 oAndover 0 No. 403 ___ C% LAKE .0 dover, Mass-, -7_--"p ' COCHICHEWICK ADRATED SS BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System i oriZI.-i � BUILDING INSPECTOR THIS CERTIFIES THAT.......... ' . .. ... fid:�.s..................... Foundation has permission to erect........................................ buildings on ......�.. ......... . . ` . ..... ..-..........................:................... Rou ' \ to be occupied as.......... '1�. �.�' ��d....... . . ... . ��.'1';e ....... �`. provided that the person accepting this permit all ins very rifspect conform &-tih/- tio--f- 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 - PERMIT EXPIRES MONTHS UNLESS CONS CTIO ELECTRICAL INSPE OR Service � BUILDING INSPECTOR Fin 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 (NORE DEPARTMENT Until Inspected and: Approved by the Building Inspector. Bur er Street No. SEE REVERSE SIDE Smoke Det. n t.t ICS Location �� � No. -� Date 8 NORT1y TOWN OF NORTH ANDOVER F • ; Certificate of Occupancy $ CMBuilding/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # ��" �J/ •, 2366& Building Inspector r,, •r I ��'rS�cNu5E4 CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Permit Number 143-2011 Date: October 12, 2010 THIS CERTIFIES THAT THE BUILDING LOCATED ON One -High Street, Building 6, North Andover, MA Schneider Electric MAY BE OCCUPIED AS business office IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: Schneider Electric Building Inspector Fee: $100.00 Receipt I 1 I Location No. Date rcj'a d NORTry TOWN OF NORTH ANDOVER O�t.�♦e .♦,7• Certificate of Occupancy $ s+CIN S t� Building/Frame Permit Fee Foundation Permit Fee $ Other Permit Fee $ _ TOTAL Check # 23668 NO. 493405 - Building Inspector i (FORMERLY Knlvww �: 11-09-10 INVOICE/ INVOICE DESCRIPTION DOCUMENT GROSS AMOUNT DISCOUNT AMT. NET AMOUNT CONTRACT DATE 110910 ENC 11-09-10 110910 ENC P02 0065921 100.00 0.00 100.00 THE ATTACHED CHECK IS IN FULL SETTLEMENT OF TOTA 100.00 0.00 100. MS LISTED-DETACH BEFORE DEPOSITING THE ORIGINAL DOCUMENT HAS A WHITE REFLECTIVE WATERMARK ON THE BACK.HOLD AT AN ANGLE TO VIEW.DO NOT CASH IF NOT PRESENT. Schneider SCHNB�D R 1=Lf=CTRIC BLfILDINGS, L C aPMtirgan Chase Bank NA NO 493405 :Chrcago,.IL P.O. BOX 2940 LOV PARK;IL 61132-294t? 70-2322 .e 79 . • •. DATE ". 11-09-10 AMOUNT al 100.00 *OlVIt HUNDRED AND 00/100' TOWN OF NORTH ANDOVER 0 1600 OSGOOD LANDING 0 NORTH ANDOVER MA 01845 AUTHORIZED sIGNAT E 'VOID OVER "'IM00 11' 49340511' 1:07L9232261: 777L4089811' BL.TRT , HILL October 7, 2010 Mr. Gerald Brown Inspector of Buildings Town of North Andover 1600 Osgood Street North Andover, MA 01845 Re: Schneider Electric (tac) Building 6, Third Floor One High Street Burt Hill Project 10805.00 Dear Mr. Brown: The tenant improvements for Schneider Electric on the third floor of Building 6, at One High Street, North Andover, MA, were to the best of my knowledge, belief, and understanding, constructed in conformance with the construction documents issued for building permit dated August 20, 2010, Permit# 143-2011 in accordance with 780 CMR Commonwealth of Massachusetts building code. During the course of construction, representatives of our office made periodic visits to the site to observe the progress of the work. Sincerely, BURT HILL Linda Smiley, R.A. Senior Associate Direct Dial: 617.654.6003 Architecture Engineering Interior Design Landscape Master Planning 303 Congress Street 6th Floor Boston MA 02210- 1012 tel: 617.423.4252 fax: 617.423.4333 www.burthill.com ' � f B U R -IF I L 1- 303 303 Congress Street-6th floor tel: 617-423-4252 Boston,MA 02210 fax: 617-423-4333 www.burthill.com FIELD REPORT From: Linda Smiley October 7,2010 Subject/Project Number: TAC/Schneider Electric - 3rd Floor Renovation Burt Hill Project 10805.00 Report Number: Date of Visit: Weather: TWO 10-05-10 Reason for Visit: Construction Observation Comments: The following work was noted: 1. Electrical work is completed. 2. Telecom work is scheduled to be completed on 10-06-10. 3. Workstations are currently being installed—are scheduled to be completed on 10-06-10. 4. Carpeting installation is complete,VCT is scheduled to be completed on 10-07-10. 5. Rework of HVAC systems is complete. 6. HVAC sensors are being installed. 7. Emergency lighting is complete. I 8. Exit signs are installed. 9. Notation was made of some doors with knob type handles. Tenant will replace with lever type handles. f:\1080500\2 corr\regulatory\field report two 10-05-10.doc Page 1 of 1 Project: building 6-3 floor renovation Schneider Electric Vendor Task ' osts—'s Schedule Burt Hill Drawings Stamp-drawings $5,500 HVAC plans Stamp-drawings 1,500 Drywall Services INC Demo $4,050 Drywall Services INC Build walls, doors $14,220 Bride-Grimes Inc Sprinklers $1,800 Merrimack Valley Corp HVAC ducts $1,980 Pro united carpet Carpet $12,045 Electrical $9,000 millwork $3,000 Total $53,095 Town of North Andover Building permit fee 0637 OFFICE OF BUILDING INSPECTOR 3? TOWN OF NORTH ANDOVER CONSTRUCTION CONTROL by'^.. o✓4.�i I SRCMYt PROJECT NUMBER: 10805.00 PROJECT TITLE: SCHNEIDER ELECTRIC - 3RD FLR, BLD 6 PROJECT LOCATION: HIGH STREET, NORTH ANDOVER NAME OF BUILDING: BLDG 6 NATURE OF PROJECT: TENANT RENOVATION IN ACCORDANCE WITH ARTICLE 116 OF THE MASSACHUSETTS STATE BUILDING CODE, I, LINDA SMILEY REGISTRATION NO.10080 BEING A REGISTERED PROFESSIONAL ENGINEER/ARCHITECH HEREBY CERTIFY THAT I HAVE PREPARED OR DIRECTLY SUPERVISED THE PREPARATION OF ALL DESIGN PLANS, COMPUTATIONS AND SPECIFICATIONS CONCERNING: ENTIRE PROJECT ❑ ARCHITECTURAL STRUCTURAL ❑ MECHANICAL ❑ FIRE PROTECTION ❑ ELECTRICAL ❑ OTHER(SPECIFY) FOR THE ABOVE NAMED PROJECT AND THAT,TO THE BEST OF MY KNOWLEGE, SUCH PLANS, COMPUTATIONS AND SPECIFICATIONS MEET THE APPLICABLE PROVISION OF THE MASSACHUSETTS STATE BUILDING CODE,ALL ACCEPTABLE ENGINEERING PRATICES. AND APPLICABLE LAWS AND ORDINANCES FOR THE PROPOSED USE AND OCCUPANCY. I FURTHER CERTIFY THAT I SHALL PERFORM THE NECESSARY PROFESSIONAL SERVICES AND B EPRESENT ON THE CONSTRUCTION SITE ON A REGULAR AND PERIODIC BASIS TO DETERMINE THAT THE WORK IS PROCEEEDING IN ACCORDANCE WITH THE DOCUMENTS APPROVED FOR THE BUILDING PERMIT AND SHALL BE RESPONSIBLE FOR THE FOLLOWING AS SPECIFIED IN SECTION 116.0 1. Review, for Conformance to the design concept, shop drawings, samples and other submittals which are submitted by the Contractor in accordance with the requirements of the construction documents. 2. Review and approval of the quality control procedures for all code-required controlled materials. 3. Be present at intervals appropriate to the stage of construction to become,generally familiar with6the progress and quality of the work and to determine, in general, if the work is being Q `��1oA S.s 'c yid. performed in a manner consistent with the construction documents. C14 . 10080 `-� `A, 0 PURSUANT TO SECTION 116.2 .2 I SHALL SUBMIT WEEKLY, A PROGRESS REPORT ,� 5 oar y TOGETHER WITH PERTINENT COMMENTS TO THE NORTH ANDOVER BUILDING INSPEC UPON COMPLETION OF THE WORK, I SHALL SUBMIT A FINAL REPORT AS TO THE �� oFSSp,G SATISFACTORY COMPLETION AND READINESS OF THE PROJECT FOR OC9wPANCY. SIGNATURE SUBSCRIBED AND SWORN TO BEFORE ME THIS__1 DAY OF67 >_1 i NOT Y PUBLIC MY COMMISSION EXPIRES� y��01� 1 CONSTRUCTION CONTROL AFFIDAVIT Project Number: Date: 06/13/2010 Project Title: Schneider Electric Project Location: North Andover, MA Name of Building: Building 6 Scope of Project: Tenant Space Renovation IN CCORDANC,. W H SECTION 116.0 OF THE MASSACHUSETTS STATE GUIDING.-CODE, I C- Dov C�0 IB Srd_ , MASS. REGISTRATION NO. BEING A REGISTERED PROFESSIONAL ENGINEER HEREBY CERTIFY THAT I HAVE PREPARED OR DIRECTLY SUPERVISED THE PREPARATION OF ALL DESIGN PLANS, COMPUTATIONS, AND SPECIFICATIONS CONCERNING: Civil Architectural Structural Mechanical X Electrical Fire Protection Other(specify) 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 FOR THE PROPOSED PROJECT. I FURTHER CERTIFY THAT I OR MY REPRESENTATIVES 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 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 control materials. 3. Special architectural or engineering professional inspection of critical construction components requiring controlled materials or construction specified in the accepted engineering practice standards listed in Appendix I. PURSUANT TO SECTION 116.4, 1 SHALL SUBMIT PERIODICALLY, A PROG T TOGETHER WITH PERTINENT COMMENTS TO THE BUILDING INSPECTO OF THE WORK, I SHALL SUBMIT A FINAL REPORT AS TO THE SATIC% READINESS OF THE PROJECT FOR OCCUPANCY. SignatG of <� o sta�o� Subscribed and sworn before me this day of 2010 0, 04, ., Notary Public My Commission Expires •'�, ` M.E�Ai 'fir ': t �0��•9 . t r4 to to anuau`' � I i CONSTRUCTION CONTROL AFFIDAVIT Project Number: Date: 06/13/2010 Project Title: Schneider Electric Project Location: North Andover, MA Name of Building: Building 6 Scope of Project: Tenant Space Renovation INCORDAWE WITH SECTION 116.0 OF THE MASSACHUSETTS STATF BUIDING CODE, I �AA0.6 [• MASS. REGISTRATION NO. /GCx1tog BEING A REGISTERED PROFESSIONAL ENGINEER HEREBY CERTIFY THAT I HAVE PREPARED OR DIRECTLY SUPERVISED THE PREPARATION OF ALL DESIGN PLANS, COMPUTATIONS, AND SPECIFICATIONS CONCERNING: Civil Architectural Structural Mechanical Electrical X Fire Protection Other(specify) 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 FOR THE PROPOSED PROJECT. I FURTHER CERTIFY THAT I OR MY REPRESENTATIVES 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 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 control materials. 3. Special architectural or engineering professional inspection of critical construction components requiring controlled materials or construction specified in the accepted engineering practice standards listed in Appendix I. PURSUANT TO SECTION 116.4, 1 SHALL SUBMIT PERIODICALLY, A PROGRESS REPORT TOGETHER WITH PERTINENT COMMENTS TO THE BUILDING IN CTOR. UP GIPLET ON OF THE WORK, I SHALL SUBMIT A FINAL REPORT AS TO THE S TI ACTORY READINESS OF THE PROJECT FOR OCCUPANCY. s9 Signatur PES STROKE N0. 20068 �. Subscribed and sworn before me this 3 day of 2010 ^'q"m ,40 14 Notary Public My Commission Expir@$ ea��'.'rA�,���'; .��'�_f�� oral: Massachusetts- Department of Public Safety Board of Building Rei-ulations and Standards Construction Supervisor License License: CS 68193 SHAWN D LITTLE 15 BURNHAM ST HAVERHILL, MA 01830 Expiration: 7/19/2012 ('ommissioner Tr#: 31158 i ' The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 t t� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legiblv Name (Business/OrganizatioMndividual): S QAr CcltlrfC' a 1 t 134(14 r4 14 C Address:_ it !�l k <; City/State/Zip: N A P�j,,VQ_f I ftkf Phone #: . Are you an employer?Check the appropriate box: Type of project(required): 1. I am a employer with 4� 4. ❑ I am a general contractor and I 0 employees(full and/or part-time).* have hired the sub-contractors 6. New construction 2. I a listed on the attached sheet 7. ❑Remodeling ❑ m a sole proprietor or partner- t. ship and have no employees These sub-contractors have 8. []Demo]iti.on. workingfor me in an capacity. workers' comp. insurance. y9. ❑ Building addition [No workers'comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.F]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' comp. insurance required.] 13,E]Other *Any applicant that checks boz#t 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 I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. � q Insurance Company Name: Oom do o k cA's Policy#or Self-ins. Lic.#: ra D Expiration Date: 1 ( 1 ��. Job Site Address: © inQ - \ GA, s\- ty/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required.under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1.,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do herebycertif under the pains and penalties of perjury that the information provided above is true and correct Si nature: Date: C, )-1olO Phone#: 91 % a'z --,I - 'tl p Official use only. Do not write in this area,to be completed by city or town official. i 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 I Contact Person: Phone#: I &\ NOTICE NOTICE T m TO 9. e EMPLOYEES - � EMPLOYEE The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston, Massachusetts 02111 617-727-4900 - http://www.mass.gov/dia As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will give you notice that I(we) have provided for payment to our injured employees under the above mentioned chapter by insuring with: New Hampshire Insurance Company % Chartis NAME OF INSURANCE COMPANY 300 South Riverside Plaza; Boston, MA 02110 ADDRESS OF INSURANCE COMPANY - 60169660 1/1/2010 to 1/1/2011 POLICY NUMBER EFFECTIVE DATES Marsh, Inc. 99 High Street; Boston, MA 02110 617-385-0566 NAME OF INSURANCE AGENT ADDRESS PHONE# Schneider Electric Buildings, LLC 1415 S. Roselle Road; Palatine, IL 60067 EMPLOYER ADDRESS EMPLOYER'S WORKERS' COMPENSATION OFFICER (IF ANY) DATE MEDICAL TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician. The reasonable cost of the ser- vices provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably connected to the work related injury. In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the NAME OF HOSPITAL ADDRESS TO BE POSTED BY EMPLOYER