HomeMy WebLinkAboutBuilding Permit #813 - 43 HIGH STREET 6/16/2010BUILDING PERMIT
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: Date Received
Date Issued: /,0
IMPORTANT: AnDlicant must complete all items on this nage
LOCATION
O' tLao
0
Print "
PROPERTY OWNER � e--&- %A<'A ryD \3 i_r_ k�� \`, Ls• .
Print
MAP NO: PARCEL: ZONING DISTRICT: Historic Districtes no
Machine Shop Villaqe 9F no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
New Building
One family
Addition
Two or more family
Industrial
Iteration
No. of units:
Commercial
Repair, replacement
Assessory Bldg
Others:
Demolition
Other
Septic Well
Floodplain Wetlands
Watershed District
Water/Sewer
DESCRIPTION OF WORK TO BE PREFORMED:
1(L l I,? V �-zJ `1 A S Q 3 �(- Sy Q H t, `T"
Identification Please Type or Print Clearly)
OWNER: Name: "ZtN\kvD ST\5\t-1 C,%g '2.(Z,tA Phone: kz
Address: 0 1 a ���O i Z o i-�vut �u� ,✓^� �_�'g l� ��
CONTRACTOR Name: Phone:
Address: % '�. c.+� �� �t .q� 3"� �� `r —\ Nk, �kv;� OZ
Supervisor's Construction License: S V `a 3 3 Exp. Date: `� 'L-
Home Improvement License: � a %3
Date: 6 4R l \ q k.v-) \
ARCHITECT/ENGINEER QkYVt — ���� Phone: -
Address: -10-4 QJG-N (p -Q45" !2F,- ASVA-ter �''''�® Reg. No.
FEE SCHEDULE: BOLDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $ 4--0 1 13 FEE: $ q- Z A'k
Check No.: 61�1 Z t Receipt No.: 6q z—
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Signature of Agent/Owner Signature of contractor
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
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
COMMENTS
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Comments
Conservation Decision: Comments
Water & Sewer Connection/Signature & Date Wiv6ay Permit `
DPW Town Engineer: Signature:
LO ateo 164
FIRE DEPARTMENT - Temp Dumpster on site yes no
Located at 124 Main Street � n
Fire Department signature/date J* J.�l�X� -�
COMMENTS S �6t i t1
,jtreet
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
NU 1 t5 and UAI A - (For department use
❑ Notified for pickup - Date
Doc.Building Permit Revised 2008
Building Department
The following is a list of the required forms to be filled out for the appropriate permit to be obtained.
Roofing, Siding, Interior Rehabilitation Permits
❑ Building Permit Application
❑ Workers Comp Affidavit
❑ 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)
❑ 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)
r �
❑ 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
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals
that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording
must be submitted with the building application
Doc: INSPECTIONAL SERVICES DEPARTMENT:BPFORM07
Revised 2.2008
5eNlry A�
Location -> � A SF 44-
No. : I A Date�v
NORTN TOWN OF NORTH ANDOVER
AL
Certificate of Occupancy $
Eta' Building/Frame Permit Fee $ i
.7 CHUS
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check # %
232b
Building Inspector
Location /-� j"f �'�r X
No.%.3 Date
N� TOWN OF NORTH ANDOVER
D
Certificate of Occupancy $ /0
�+s
cMus f<Building/Frame Permit Fee $
J�
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #007S1 Y
Building Inspector
B U R T, H I L L
August 26, 2010
Mr. Gerald Brown
Inspector of Buildings
Town of North Andover
1600 Osgood Street
North Andover, MA 01845
Re: Serenity Tenant Fit -out
East Mills, North Andover
Burt Hill Project 07804.02
Dear Mr. Brown:
The tenant improvements for Serenity on the first floor of Building 44, at East Mills in 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 June 16, 2010, Permit # 813 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 S. Smiley, AIA
Senior Associate
Phone: 617.654.6003
cc: Kieran Whelan
Architecture Engineering Interior Design Landscape Master Planning
303 Congress Street 6'h Floor Boston MA 02210-1012
tel: 617.423.4252 fax: 617 423 4333 www.burthill.com
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Building Permit Number
CERTIFICATE OF USE & OCCUPANCY
TOWN OF NORTH ANDOVER
813 Date: August 27, 2010
THIS CERTIFIES THAT
THE BUILDING LOCATED ON 43 High Street, building 44, 1St floor, North
Andover, MA
MAY BE OCCUPIED AS Serenity Massage IN ACCORDANCE
WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH
OTHER REGULATIONS AS MAY APPLY.
Certificate Issued to: RCG North Andover Mills, LLC
y�
Building Inspector
Fee: $100.00
Receipt: 23372
Standard Form of Agreement between Owner and
RCG LLC where the basis of payment is the Cost
of the Work Plus a Fee without a Guaranteed
Maximum Price
Date:
June 14, 2010
Owner:
RCG North Andover Mills LLC
C/o RCG LLC
17 Ivaloo Street, Suite 100
Somerville, MA 02143
Contractor:
RCG LLC
17 Ivaloo Street, Suite 100
Somerville, MA 02143
Architect:
Burt Hill
Project Name:
Serenity Massage
The Owner and Contractor agree to the terms stated by this contract. This contract
supersedes any prior agreements, representations, or negotiations, oral or written. No
liquidated damages shall apply to this agreement. This contract consists of the following
documents:
1. Obligations of the Parties
2. Contract Sum
3. Project Schedule
4. Signatures
Exhibits
Exhibit A: Estimated Cost of Work
Exhibit B: Project Schedule
Exhibit C: Drawings
Page 1 of 6
1. Obligations of the Parties
Obligations of the Contractor:
The Contractor accepts the relationship of trust and confidence established by this Agreement and
covenants with the Owner to cooperate with the Architect and exercise the Contractor's skill and
judgment in furthering the interests of the Owner; to furnish efficient business administration and
supervision; to furnish at all times an adequate supply of workers and materials; and to perform
the Work in an expeditious and economical manner consistent with the Owner's interests and in
compliance with all applicable governmental codes and regulations.
The Contractor shall keep full and detailed accounts and exercise such controls as may be
necessary for proper financial management under this Contract.
The Contractor shall keep full and detailed records of all books, records, permits, licenses,
correspondence, receipts, instructions, data, and drawings associated with the Project including all
Subcontractor contracts, invoices, vouchers, insurances, lien waivers, and other correspondence.
The Owner and Owner's Accountants shall have access to review, audit, and copy all Contractor
documentation. The Contractor shall retain these documents for a period of three years after final
payment.
The Contractor shall maintain insurance at the following levels with the Owner listed as a co-
insured:
Type of Insurance Limit of Liability
Commercial General Liability $1,000,000.00
Upon request, and at the cost of the Owner, the Contractor shall obtain a performance bond up to
the total Cost of Work. Such costs shall be added to the Construction Volume.
The Contractor understands that the Project will be financed by a construction lender and, then, by
a permanent lender. The Owner may assign any of its rights under this Contract to the construction
lender and the Contractor hereby consents to any such transfer provided no such assignment shall
relieve the Owner of any of its obligations under this Contract, unless agreed to in writing by the
Contractor. The Contractor shall execute any certificates, lien waivers, releases, receipts, and other
documents as may be reasonably required by the construction lender or permanent lender including
a subordination of its mechanic's lien rights to the construction lender's and permanent lender's
mortgage or deed of trust. The construction lender for the Project will be:
Obligations of the Owner:
The Owner agrees to furnish or approve, in a timely manner, information required by the
Contractor and to make payments to the Contractor in accordance with the requirements of this
Agreement.
Dispute Resolution:
Claims, disputes or other matters in question between the parties to this Agreement shall be
resolved by mediation or by arbitration. Prior to arbitration, the parties shall endeavor to reach
settlement by mediation.
Page 2 of 6
2. Contract Sum
Cost of Work:
The Contractor shall provide a detailed estimated Cost of Work to the Owner (see Exhibit A). The
sum of these costs, including the fee is as shown below:
$40,135.00
Change Orders:
The Contractor does not guarantee the Contract Sum in any form. In the event of changes to the
Contract Sum, the Contractor will present written changes to the owner for costs that exceed the
Contract Sum in the form of a Change Order. The Contractor will review all Subcontractor Change
Orders before submittal to the Owner and Architect and make a recommendation for payment or
non-payment. The Contractor's Fee will be calculated including any approved Change Orders.
The Owner, Architect and Contractor will negotiate disputed Change Orders in good faith.
Contractor's Fee:
15% of total construction volume up to $1 million, and 10% of construction volume over $1
million. This includes pre -construction and project management services, and field personnel and
associated management overhead. The fee is based on actual costs incurred, with final true up,
and is booked monthly in arrears. Specifically,
1. The cost of pre -construction and construction management services provided by RCG
personnel is booked monthly in arrears based on the hours reported by each employee.
2. Hours are billed at the standard hourly billing rate established from time -to -time for each
employee. The hourly billing rates effective 1/1/2007 are shown below.
3. The cost of pre -construction and construction management services provided by
independent contractors is booked when invoiced and carried within the fee.
4. RCG Builders personnel functioning as tradesmen outside their management duties will
be charged according to their hourly billing rate.
5. If a project is terminated or suspended by the Owner prior to completion, RCG Builders
LLC is compensated for the actual cost of services provided prior to receipt of notice of
termination or suspension from the Owner.
6. Total Construction Volume includes all construction trades, general requirements,
insurance, bonds and miscellaneous costs deemed necessary to perform the
construction of the project, but excludes permits and fees. Permits and Fees shall be
paid directly by the Owner.
7. Construction management labor, standard tools and equipment, and labor -related
overhead are covered "within the fee". Specialty tools or equipment, trade labor supplied
by Builders personnel and approved transportation and meals costs shall be charged
directly to the Owner without a fee.
Employee
Rate
David Steinber h
$125/hr
Kieran Whelan
$125/hr
Jason Downing
$50/hr
Subcontractors:
The Contractor plans to hire Subcontractors to perform the majority of construction associated with
this project. The Contractor shall provide the Owner and Architect information on all of the bids
Page 3 of 6
received by Subcontractors and the names of the Subcontractors selected. Owner shall have the
right to reject a proposed Subcontractor; however, in the event that this leads to a higher Cost of
Work, the Owner shall pay for the difference. The Contractor reserves the right to reject any
Subcontractor, even if it is the lowest bid, and to dismiss Subcontractors from the job that have
been previously approved by the Owner.
Payments:
The Owner shall make progress payments on the Contract Sum according to the Requisition
process described below.
The Contractor shall, at the conclusion of each calendar month on the project, present to the
Owner an application for payment (Requisition) for costs incurred during that month. The
Requisition shall include all invoices, vouchers, partial releases of liens, expense reports, and any
other evidence to support the validity of the Requisition amount. The Contractor may requisition
for completed, but unpaid work based on an expectation of payment upon receipt of funds. The
Owner, the Architect, or their representatives shall be afforded five (5) business days to review
such application and question the Contractor about its contents. In the event there are no
disputes, the Owner shall pay the Contractor within 10 business days of receipt of the Requisition.
Payment by the Owner does not represent that the Owner or Architect have made a detailed
examination of the documentation, inspection of the work, or verification of the accounting.
At the completion of the project, the Owner shall make a final payment to the Contractor based on
a final Cost of Work with a truing up of fees. If further corrections to work are required that are not
covered under warranties with Subcontractors, or that are not the outcome of negligence or poor
workmanship by the Contractor, the Owner shall pay the Contractor for any work associated with
performing the corrections based on the hourly rate agreed to in this contract.
Retainage:
The Owner shall not hold back any fees to the Contractor to ensure completion of the work. The
Contractor will be expected to hold back fees from Subcontractors to ensure their performance
based on the terms below:
10% of billed costs, unless otherwise approved by the Owner
Termination of Contract:
The Owner shall reserve the right to terminate or suspend the Contract at its sole discretion.
Within 15 days of termination or suspension, the Contractor shall present an accounting of all its
costs incurred for reimbursement by the Owner. If the Owner elects to proceed with the project
without the Contractor, the Owner shall have the right to assume the Subcontracts and
agreements related to the Project.
Working Capital:
RCG Builders shall not bear the costs of Working Capital for the project. If the Owner would like
the Contractor to gain beneficial pricing on its behalf by paying subcontractors ahead of the
Requisition schedule, the Owner shall either (1) put on deposit with the Contractor a sufficient
amount of Working Capital for the Contractor to pay these Subcontractors, or (2) make immediate
payment upon request from the Contractor outside of the normal Requisition process. Provision of
Working Capital shall entitle the provider to all discounts and savings associated with that capital.
Page 4 of 6
3. Project Schedule
Date of Commencement:
The Contract Time shall be measured from the date of commencement. The date of
commencement of the Work shall be the date of this Agreement, unless a different date is stated
below or provision is made for the date to be fixed in a notice to proceed issued by the Owner.
June 15, 2010, or such time that Notification to Proceed is given by Owner,... .
Contract Time:
The Contractor shall provide to the Owner a Project Schedule (see Exhibit B). This Schedule is
based on assumptions reached prior to the signing of this contract, which assumptions the
Contractor shall attempt to clarify in the Schedule. However, the Schedule always assumes the
Owner and the Architect respond promptly to requests for information and do not request any
significant changes to the construction program. In the event that the Owner or Architect find any
discrepancies with the Schedule or its Assumptions, they will promptly notify the Contractor, who
shall make adjustments to the Schedule as necessary.
According to the attached Schedule, the Contractor shall achieve Substantial Completion of the
entire Work as follows:
Date of'Substantial Completion to be,.no laterthan Se temberl', 2010
The Contractor does not guarantee the date of completion. However, the Contractor shall not be
entitled to additional fees based on delays in the project unless those delays can be shown to
incur extra costs for the Contractor and were caused by the actions or requests of the Owner or
Architect.
The Contractor shall present an updated Project Schedule to the Owner and Architect on a weekly
basis for their review.
Page 5 of 6
4. Signatures
The Owner's representative is:
David Steinbergh, Manager
RCG North Andover Mills LLC
17 Ivaloo Street, Suite 100
Somerville, MA 02143
§ 14.4 The Contractor's representative is:
Kieran Whelan.
Construction Supervisor
RCG LLC
17 Ivaloo Street, Suite 100
Somerville, MA 02143
This agreement is entered into as of the day and year first written above and is executed in at
least thre original copies, one for the Owner, one for the Contractor, and one for the Architect.
Owner C ntractor
Signature Signature
Printed Name and Titl Printed Name and Title
Page 6 of 6
Serenity Massage Estimated Cost
Schedule of Values
Demolition
$250.00
Dumpsters
$550.00
Acoustical ceiling
$8,000.00
Frame & Insulate
$2,500.00
Glass Entry Door
$500.00
Drywall and tape
$1,500.00
Prime and Paint
$2,500.00
Carpet (1100 SF)
$2,200.00
VCT (100 SF)
$400.00
Vinyl base
$150.00
Kitchen Cabinetry
$600.00
Plumbing
$1,800.00
Electrical
$5,000.00
Sprinklers
$2,800.00
HVAC
$6,000.00
Final clean
$150.00
Sub -total
$34,900.00
RCG Builders fee
$5,235.00
Total $40,135.00
Plus Building Permit $492.00
Total Construction $40,627.00
Massachusetts - Department of public Sated
Board of Building Regulations and Standards
Construction Supervisor License
License: CS 66334
Restricted to: 00
KIERAN T WHELAN
31 RICHMOND ST
WEYMOUTH, MA 02188
� i�mmisinner
Expiration: 9/26%1011
Tr#: 3612
Client#: 29552
RESOU
ACORD- CERTIFICATE OF LIABILITY INSURANCE
6/0212010
PRODUCER
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
INSURANCE MARKETING AGENCIES
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
306 MAIN STREET
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
WORCESTER, MA 01608
POLICY EXPIRATION
DATE MM/DD
508 753-7233
INSURERS AFFORDING COVERAGE NAIC #
INSURED
INSURER A: Wesco Insurance Company 25011
RCG LLC
17 Ivaloo Street, Suite 100
Somerville, MA 02143-3656
INSURER B:
INSURER C:
INSURER D:
INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
LTR
NSR
TYPE OF INSURANCE
POLICY NUMBER
POLICY EFFECTIVE
DATE MM/DD
POLICY EXPIRATION
DATE MM/DD
LIMITS
GENERAL LIABILITY
EACH OCCURRENCE $
-
COMMERCIAL GENERAL LIABILITY
DAMAGE TO RENTEDIR fEa occurrence) $
CLAIMS MADE F] OCCUR
MED EXP (Any one person) $
PERSONAL & ADV INJURY $
GENERAL AGGREGATE $
GENT AGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMP/OP AGG $
POLICY PRO-
JECT LOC
AUTOMOBILE LIABILITY
ANY AUTO
COMBINED SINGLE LIMIT $
(Ea accident)
BODILY INJURY $
(Per person)
ALL OWNED AUTOS
SCHEDULED AUTOS
BODILY INJURY $
(Per accident)
HIRED AUTOS
NED AUTOS
PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY
AUTO ONLY - EA ACCIDENT $
OTHER THAN EA ACC $
ANY AUTO
AUTO ONLY: AGG $
EXCESS/UMBRELLA LIABILITY
EACH OCCURRENCE $
AGGREGATE $
OCCUR FICLAIMS MADE
$
DEDUCTIBLE
$
RETENTION $
A
WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE
WWC3010833
05/15/10
05/15/11
�( DR LIMIT OTH-
T
E.L. EACH ACCIDENT $500 000
r
E.L. DISEASE - EA EMPLOYEE $500,000
OFFICER/MEMBER EXCLUDED?
If yes, describe under
SPECIAL PROVISIONS below
YES
E.L. DISEASE - POLICY LIMIT 1 $500,000
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS
FOR INFORMATIONAL PURPOSES
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 2_ DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
REPRESENTATIVE
/7VV - `"v IrVV/ T Or Z $,TSS839/M1atluja GCE 0 ACORD CORPORATION 1988
The -Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
u4p 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): C_ Cr- (, L-, C_
Address: C, V i 0:
City/State/Zip:.So M6)-VJ I. I L t 4 w 0-L1 4-? Phone #: 6 1"7 — 6 LS -- &' ?
Are you an employer? Check the appropriate box:
I .)Er I am a employer with 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.
[No workers' comp. insurance
required.]
3. ❑ I am a homeowner doing all work
myself. [No workers' comp.
insurance required.] T
workers' comp. insurance.
S. ❑ We are a corporation and its
officers have exercised their
right of exemption per MGL
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
10.0 Electrical repairs or additions
11.❑ Plumbing repairs or additions
12.❑ Roof repairs
13.❑ Other
/Any appucant mat cneeKs box # i must also fill out the section below showing their workers' compensation policy information.
fi 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.
1 am an employer that is providing workers' compensation insurance for my employees Below is the policy and job site
information.
Insurance Company Name:
Q
N
Policy # or Self -ins. Lic. #: tW� W C' :�? 0 i 0 9 3 3 Expiration Date:
.lob Site Address: ( 1"► t &V 4) tk4�
City/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 hereby cern y under the pains and penalties of perjury that the information provided above is true and correct.
Si nature: 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. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
OFFICE OF BUILDING INSPECTOR
�? TOWN OF NORTH ANDOVER
`• •'- CONSTRUCTION CONTROL.
PROJECT NUMBER: 07804.02
PROJECT TITLE: Serenity
PROJECT LOCATION: East Mills
NAME OF BUILDING: Building 44, 1 st Floor
NATURE OF PROJECT: Tenant Fit out
IN ACCORDANCE WITH ARTICLE 116 OF THE MASSACHUSETTS STATE BUILDING CODE,
1, Linda S. Smiley REGISTRATION NO. 10080
BEING A REGISTERED PROFESSIONAL ENGINEER/ARCHITECH HEREBY CERTIFY THAT 1
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
performed in a manner consistent with the construction documents.
PURSUANT TO SECTION 116.2.2 1 SHALL SUBMIT WEEKLY, A PROGRESS REPORT
TOGETHER WITH PERTINENT COMMENTS TO THE NORTH ANDOVER BUILDING INSPECTOR.
UPON
UPON COMPLETION OF THE WORK, I SHALL SUBMIT A FINAL REPORT AS TO THE
SATISFACTORY COMPLETION AND READINESS OF THE PROJECT FOR OC PANCpq R -WE W
Y.
IGN E
SUBSCRIBED AND SWORN TO BEFORE ME THIS_,_L_DAY OF 00?O
P�Y PUBL�_/ MY COMMISSION'
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