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Building Permit #853-12 - 50 MAIN STREET 5/1/2012
.r BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: d Date Received Date Issued: f /2 IMPORTANT: Applicant must complete all items oA this page LOCATION 1 J 0 1/► n 4 a VN C2 -r Print ' ' PROPERTY OWNER ril w1 I Pn' % 10,01 WC4 &I Pro i2e,4 Print MAP NO: lPARCEL:1_ ZONING DISTRICT: Historic District Machine Shop Vil T. CS+ -#-- yes yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition O�Two or more family ❑ Industrial Iteration No. of units: '1- 19Commercial - 2 ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑ Well ❑ Floodplain ❑ Wetlands ❑ Watershed District ❑ Water/Sewer DESCRIPTION OF WORK TO LBE PREFORMED: �e ert t P. -At", C[1 • �vr stidun-s) ex Ce P py'. 014 c f C,aD V-"Cio U (� �{ Li a t d i K o r e Vito Jel to +y kq� Identification Please Type or Print Clearly)'T OWNER: Name: firtVAler Oomw►`elrm,k� ry er �g W-4hone: 0 17`�o� •�32,� P Z---14 1. _ i n- A J- , „ _ . A A ^ 1 RZ . s-, Address: CONTRACTOR Name: 4GO faurn-4 Phone: 2,s(,7 Address:Sh iw'► 454iqy lr `G `z1,d� IIA 0' 181,0 Supervisor's Construction License: 5 t' Exp. Date: I �! Home Improvement License: 160-162, Exp. Date: ARCHITECT/ENGINEER T©Se h D• LAQra e— Phone: q-78 • q70. Address: ©ne V i"Av,-Ioe. �l-rt.�r, Nl . 4 oiblcReg. No. 3 i FEE SCHEDULE. BOLDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ S , 0 FEE: $ 1,76 Check No.: Receipt No.:� Q 4 2[x7 NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund 51 I f Location ff --sw ft"q No. A Date Zv Check 41-i 1-4 25347 TOWN OF NORTH ANDOVER Certificate of Occupancy $- Building/Frame Permit Fee $ Foundation Permit Fee Other Permit Fee TOTAL $ Building Inspector 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 P ANNING & DEVELOPMENT % �,� u), re� C MENTS CONSERVATION COMMENTS HEALTH COMMENTS Reviewed on Signature Reviewed on Signature Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comm Conservation Decision: Com Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street ,FIRE .DEPARTMENT Temp Dumpster on site , eyes no Located •at 124 MainStreet . F,i�e Departrn " &' dn' tWre/date d. COMMENTS Dimension Number of Stories: °L Total square feet of floor area, based on Exterior dimensions.. Total land area, sq. ft.: 2 ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No, MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA — (For department use ❑ 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/Crc ssection/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 Y OTE: 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 DOTE: 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 CO) m m m CO) m mm CO) C � S. d O z. n C O CD y A G 7 :*® CO '�0., � CrJ E o -0. N d C • =r'p O Ot Cr7 ^�al a6 r- c .0-► �. '77 C x g D. O y y �mmlcm IE CD -;; O --1 a Z � O CD � VJ b "ted PL Z C O CD CD CD O { c CL v CosO y z C� C° � ►� cn = CO) v O Cn 1 CD Oq a%: O CD � C CD � G O O O O 0 R cc O c n um CE ik O N C CL 0 N H M caa N = N � z. n C O o y G 7 :*® CO '�0., � pSO. c, M N d C • =r'p O Ot N N ^�al .0-► �. '77 C x g N 0 0 0 y �mmlcm IE CD -;; O --1 a Z � . o O N•C9 -to m a =rH 10 0 CL r+ I CD CD O H ' •' 0 CD CDCD N O N CLW Q .W a CD CD N H Co CD O m mom: ..C*3 o O CD CD CO) ate: N 1 -, 7 CD .O�w A� O� • . m d O o o = � ocm '� y 09 0 c 1 ww. pSO. M C x g rn b "ted { y 09 0 c GENERAL BUILDING NOTES/CHECKLIST- NOT LIMITED TO ITEMS BELOW POST ALL LOT NUMBERS, ADDRESS, . AND PERMIT (COPY 0K)..or no inspections INSPECTIONS: (Minimum) Excavation, Footing, Foundation, Frame, Insulation, Final. i FOOTINGS: Continuous Full 2x4 Keyway ' Continuous strip footings for interior columns FOUNDATION: Rebar as required 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 partitions. Size ridge to provide full bearing at rafter cuts. Hip and Valley rafters - watch bearing at walls. Ridge & Hip - Provide proper connections. Cathedral roof rafters provide proper connections and use "Hurricane Clips" tie to plate. Stair stringers - watch cuts and heal support. Joist hangers - fully nailed w/ hanger nails. Sill plates 2-2X6 (1 PT) w/sill seal. Girls - solid brick or steel plate bearing at foundations r' • '/Y " air space at sides in foundation pockets. Lateral bracing at ends. Certified calculations. required for Beams/LVL's Trusses. Solid bearing support for Headers/Beams etc. Check headroom clearances - stairways, under beams Attic Access. (min. 22x30 w/3' headroom above). Crawl space access. (min. 18)(24). � Bath exhaust fans to have metal duct to exterior (not in soffit). N Firecode S/R wood frame of "0" clearance fireplaces & stoves ndow Schedule or Every Habitable Room Must Have: Natural light equal to 8% of floor area. of required glazing shall be openable. J 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 `J FIREPLACES: Separate permit required. oa FINISH: Handrails returned to wall/newall post �- 1- 3 -� N Inspections at Footing - Smoke Chamber - Finish 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 w/lateral bracing. Lag all posts and rails. Pier footings down 48", Conc. pad at stair base. Guardrails required alongside open cellar stairs. Exterior grading complete. Certificate or occupancy required prior to occupying structure. Temporary Stairs required for inspection. Re -inspection fee - $30.00 (Be Ready). Certificate of occupancy required prior to occupying structure. CA m m m CO) CO) F) v, y � O CA CD a Z y CDO CL C O CL = y � o � CD CD O cr d CD CD CD CD CA 00 CD CZ O y O I CO CD S- CO) O CD � Z O CD O CCD C_ O O O O O U2 O C n to CD O 0 H CD C ?$ O O = EL N N CO) m Cl) 0 CAmao 2• m N _ U- N m N T �i m O O 0 Mn D7 O y ® m CD-;; -CD a �o m n g 4t C'. - ► C2 � _s CD W N 0 0 ,. CL N ��• d N . cr CL G co .� m . co N ,� � CD m� CD CCDI 4 o� CD � 3 N : y CD` 1 H m C o Wo .. mCO m c o CDCD _ = n (n W 'd O z n O G Cn O 'r 1 O rL C7 0Crl n .� r"CD r d cp n 0 C `c_' 0 I� GO GO � Cn Cy i C_ O O O O O U2 O C n to CD O 0 H CD C ?$ O O = EL N N CO) m Cl) 0 CAmao 2• m N _ U- N m N T �i m O O 0 Mn D7 O y ® m CD-;; -CD a �o m n g 4t C'. - ► C2 � _s CD W N 0 0 ,. 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Prepared for con su I to n is $ GOOD""" PREMIER COMERCIAL oNO.48133 PROPERTIES REALTY TRUST 1 inc. �y9�a_SS �@ Oy SCALE:1 "=40' June 2, 2011 1 East River Place, Methuen, Mass. suRN1 R.R.SPK.(SEn ' NOTEFACADE O„W OF BUILDING r r S79r IS 0.15 TO 0.20 54•0, INTO RIGHT OF WAY 0.6' 1 OF MAIN STREET. 00 �N 1 CERTIFY THAT THE S I LOCATION OF THE BUILDING SHOWN ON THIS PLAN WAS 0 DETERMINED BY A FIELD lF'fth -- r N m SUR Y 62.75' N85 -39'09"W �— z4' � '%-� PETER D. GOODWIN P.L.S. PIN(SEn S.B.(FND.) P: \11 \11-13\DWG\11-13.DWG 0 PLOT PLAN 44-50 MAIN STREET �., '�"OFA{, NORTH ANDOVER, MASS.andover PHTERD. 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N O O p ja oin- 11J¢ I-- E 0 :6 0 °a te D Nan ¢� to to LU a NH 6mp*-i '-lonsis1Lona-Ls1aaa.4s q/alN 05 - 090Z41sloa(oid Z10ZIs1o3!'oad1-,M :L9!#ew7 aa!d 0, J J I � C M C O � C a LWN V c _1 Z ;. °' 76 LL � J J Q CL~ W Vl� U XQ O ZZ =U O01:1: F— LAJ W Q V) W Z W N — cn jW� =C�p WQ C7 Z O—i N ci ZW pc~i�® =0 W M p O � L W N a Z W Z Q W Z J J I � C M C O � C a LWN V c _1 Z ;. °' 76 LL � J J Q W p �- 0 CL = m W O W LU z � cn V a ui 5 W LU Z D p Z CL W M � Q pN W p �- 0 CL = m W O W Q U Q:E I Z W N N W ui 5 W LU e �ii�ii■� z c�z J C, OL UO O� m= Q Q U W CL W W pQ �� W Z I- ZWor c) z N Q W O Z z N ♦_ LU %C W z O O Z J Q w U) U) .c CV O 'O L / 901 m 3 6mp*i-l'-ionylsllon&-Lsliaaiis L!aW 09 - o9oetisioa(oid Z6oZIS1o3!'oNdI.,M :ooA?-,*Q-Iav-4 The Commonwealth of Massachusetts , - .Department oflndustrk[Accidents O, face 0 nvestigations 600 Washington Street Boston, MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractor8fFIectricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): ` J e et!VeS')Jx5 L C Address: aw-t City/State/Zip: 34V -P-1 (4_ �,� Phone #: `Any applicant that checks box #I must also fill out the section bel6w showingtheir workers' compensation policy information. 7 Homeowners who submit this affidavit indicating they tie 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. lam an employer that is providing woAkers' compensation insurance for my employees Below is thepolicy and job site information. i Insurance Company Name% ` e c o -hS 1 h,S ua-p.,iM 45,506, d y M Policy # or Self ins. Lic. #: t" C' y 00 q .-1 301 Expiration Job Site Addresses L,_l '50 Mah e3l City/Sta&2 Attach 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 civilpenalties in the forn of a STOP WORK ORDER and a fine I f up to $250.00 a day against the violator. De advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA. for insurance coverage verification. I do Hereby cerO under the pains andpenalties q fperjury that the information provided abovq, is tfue ant!correct. ,. 0'1,j Official use only. Do not write in this area, to he completed by city or town offrcial. City or Town:. Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Pudding Department 3. CitylTown Clerk 4. Electrical Inspector S. Plumbing Inspector 6. Other - - Contact Person: Phone Are you an employer? Check the appropriate b x- Type ofproject (required): 1. El am a employer with 4. am a general contractor and I 6• New construction ' employees (full and/orpart time) have Hired the sub -contractors 2. El employees am a sole proprietor or partner- listed on the attached sheet. t 7• Remodeling ship andno employees These sub -contractors have 8. Demolition El working for me in any capacity. workers' comp. insurance. g• ❑ Building addition [No workers' comp. insurance 5. ❑ We area corporation and its ME] Electrical repairs or additions required.] officers have exercised their 3, ❑ I 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 wehave no 12.❑ Roof repairs insurance required.] t employees. [No workers' 13.❑ Other comp, insurance required.] `Any applicant that checks box #I must also fill out the section bel6w showingtheir workers' compensation policy information. 7 Homeowners who submit this affidavit indicating they tie 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. lam an employer that is providing woAkers' compensation insurance for my employees Below is thepolicy and job site information. i Insurance Company Name% ` e c o -hS 1 h,S ua-p.,iM 45,506, d y M Policy # or Self ins. Lic. #: t" C' y 00 q .-1 301 Expiration Job Site Addresses L,_l '50 Mah e3l City/Sta&2 Attach 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 civilpenalties in the forn of a STOP WORK ORDER and a fine I f up to $250.00 a day against the violator. De advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA. for insurance coverage verification. I do Hereby cerO under the pains andpenalties q fperjury that the information provided abovq, is tfue ant!correct. ,. 0'1,j Official use only. Do not write in this area, to he completed by city or town offrcial. City or Town:. Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Pudding Department 3. CitylTown Clerk 4. Electrical Inspector S. Plumbing Inspector 6. Other - - Contact Person: Phone ACOORVDATE®CERTIFICATE OF LIABILITY INSURANCE 5/30/20112 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER MTM Insurance Associates 1320 Osgood Street North Andover MA 01845 CONTACT Linda Murray PHONE (978) 681-5700 FAX No), (978)681-5777 EAI -ML .lindam@mtminsure.com INSURERS AFFORDING COVERAGE NAIC # INSURERADecotis Insurance Assoc of MA INSURED Verdeco Designs One Elm Square Andover MA 01810 INSURER B Atlantic Charter Ins Group INSURER C: INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:12-13 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF MM/DD/YYYY POLICY EXP MMIDD LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE Fx_] OCCUR CIP127898 /17/2012 /17/2013 DAMAGE S ( RENTED PREMISES $ 100,000 Ea occurrence MED EXP (Any one person) $ 5,000 PERSONAL 8 ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,000 }i POLICY PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident BODILY INJURY (Per person) $ ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY (Per accident) $ HIRED AUTOS NON -OWNED AUTOS PROPERTY DAMAGE $ Per accident UMBRELLA LIABOCCUR HCLAIMS-MADE EACH OCCURRENCE $ AGGREGATE $ EXCESS LIAB DED I I RETENTION$ $ B WORKERS COMPENSATION I WC STATU- OTH- AND EMPLOYERS' LIABILITY y / N EACH ACCIDENT $ 500,000 ANY PROPRIETOR/PARTNER/EXECUTIVEE.L. OFFICER/MEMBER EXCLUDED? F-1 (Mandatory in NH) NIA WCV00951301 /4/2012 /4/2013 E.L. DISEASE- EA EMPLOYE $ 500,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Certificate holder as listed below CERTIFICATE HOLDER CANCEu_ATIAN ACUKU Z5 (2U1U/U5) INS095 r,minnsi m ©1988-2010 ACORD CORPORATION. All rights reserved. Th. Artr%Pn . -4 1n — m.,Irc of ArnOn SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of North Andover ACCORDANCE WITH THE POLICY PROVISIONS. Building Department AUTHORIZED REPRESENTATIVE 1600 Osgood Street North Andover, MA 01845 M Laorenza/LINDAs' — ACUKU Z5 (2U1U/U5) INS095 r,minnsi m ©1988-2010 ACORD CORPORATION. All rights reserved. Th. Artr%Pn . -4 1n — m.,Irc of ArnOn Information and Instruction's Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...everyperson in the service of another under any contract ofhire,- 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 shallnot 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 ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapterhave beenpresented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) andphonenumber(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. Han LLCorLLP does have employees, a policy is required. B e advised that this affidavit may be submitted to the, Depart . ment of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and priated legibly. The Departmenthas 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 permithicensa number which will be used as a reference number. In addition, an applicant that must submit multiple permithicense applications in any given year, need only submit one affidavit indicating current policy information (ifnecessary) and under "Job Site Address" the applicant should write "all locations in (city or town)" A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. 'Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license orpermit to burn leaves etc) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone anal fax number: Tho Com mon oaf t of Mossavhuset�s Dapadment ofTactdustdal.A,coldauts Me of Xu'iFestigatiom 60 Wa$hiWoa Street Boston}MA,02111 TO, # 617-7.2.7-.4900 W406 or 1-577:MASSA B Revised 5-26-05 a 617"727-7 749 Oftic,e�orQ� e-'rs iness egu aho [NiPROVEME' NT CON irZ z;TOR ;J - Registration: .4- 1..8762 Type: y . Expiration: :4/5%2013 LLC V CO DESIGNS LLCM i MA2K YANOWITZ.� 20 WILD ROSE DP. ANDOVER, MA 01810 Underse&,-tary ' 'icense or registration valid for individul use only before the expiration date. If Bund return to: Office of Consumer Affairs and Business Re ulation lop ark Plaza - Suite 5170 Boston, i<TA :02116 1Vot Nal d without signature Massachusetts - Dcpartment of Public Safct' ,. Board of Buildin�2 Regulations and Standards Construction Supervisor License Licf nse: CS 105187 J MARK YANOWITZ ' 20 WILD ROSE DR ANDOVER, MA 01810 Expiration: 7/11/2013 ('ununissinncr Tr#: 105187 r i I r� J/ PROJECT NUMBER' 2 3 4 `1 OFFiCB OF BUILDING INSPECTOR TOWN OF NORTH ANDOVER CONSTRUCTION CONTROL PROJECT TM-E-A7R fA" :5r, 9U ! t0 f1'jq �n [ C2�v 2 FlG'vCfoP� R6 J o LrA PROJECT LOCATION_ 5-6 /n tA ,^i NAMEOF BUILDIING: /ft7CE� U56 VC- 4(EA-Jrs, IN ACCORDANCE vv1TH ARTICLE 116 0—F THE MASSACHUSETTS STATE BUILDI G CODE. 1. c.l ce s — H �,� C SS k LA REGISTRATION NO. BEING A REGISTERED PROFESSIONAL ENGINEERJARCHITECH HEREBY CERTIFY THAT I HAVE PREPARED OR DIRECTLY SUPERVISED THE PREPARATION OF ALL DESIGN PLANS, COMPUTATIONS AND SPECIFICATIONS CONCERNING: ENTIRE PROJECT ❑ ARCHITECTURAL R STRUCTURAL ❑ MECHANICAL ❑ FIRE PROTECTION ❑ ELECT RICAL ❑ OTHER (SPECIFY) FOR THE A80VE NAMED PROJECT AND THAT, TO THE BEST OF MY KNOWL EGE_ SUCH PIANS. COMPUTATIONS AND SPECIFICATIONS MEET THE APPLICABLE PROV15ION OF THE MASSACHUSETTS STATE BUILDING CODE, ALL ACd'EPTABLE ENGINEERING PRATICES. AND APPLICABLE LAWS AND ORDINANCES FOR THE PROPOSED USE AND OCCUPANCY. 1' FURTHER CERTIFY THAT 1 SHALL PERFORM THE NECESSARY PROFESSIONAL SERVICES AND BE PRESENT ON THE CONSTRUCTION tSITE ON A REGUI AR ANU PERIODIC BASIS TO DETERMINE THAT THE WORK IS PROCEEDING INACCORCANCE WITH THE DOCUMENTS APPROVED FOR THE BUILDING PERMIT AND S14ALL 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 co6tractor in accordance with Me requirements of the construction documents. _ 2. Review and approval of the quality control procedures for all code -required controlled materia 3. Be present at intervals appropriate to the -stage of construction to become, generally famili with the 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 1162 2 I SHALL SUBMIT WEEKLY. A PROGRESS REPORT � TOGETHER WITH PERIINENT COMMENTS TO THE NORTH ANCOVER BUILDING -INSPECT 2ir1,e P"v"P. a No. 4153 ANDOVER. NIA UPON COMPLETION OF THE WORK. 1 SHALL SUBMIT A FINAL REPORT AS TO THE SATISFACTORY COMPLETION AND READINESS OF THE PROJECT FOR OCCUPANCY. Q . .1 j�� S+ SSIGNATURE SIGATURE SUBSCRIBED ANDSWORN TO BEFORE ME THIS�OAY OF C 61 le' X NOTARY PUBLIC MY COMMISSION EXPIRES�� 3, 16?� 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 PLANNING & DEVELOPMENT COMMENTS CONSERVATION COMMENTS HEALTH COMMENTS DATE REJECTED 11 DATE APPROVED DATE REJECTED DATE APPROVED ❑ ❑ 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 Located at 124 Main Street Fire Department signature/date COMMENTS no