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Home My WebLink AboutBuilding Permit #434 - 550 TURNPIKE STREET 12/7/2009 TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received IV0,4 Oct Date Issued: /.2 7 7� IMPORTANT:Applicant must complete all items on this page �a5�1 LOCATION Tvrti,,��1c.�.. rtfiY�► .t."C I a n--car -•$c .vL , otew;- Print PROPERTY OWNER hbyt--t 1i K-J&VI�J Print MAP NO: o2 01� PARCEL: Q ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Addition Two or more family Industrial Alteration No. of units: Commercial Repa , replacement Assessory Bldg Others: Demolition Other Septic Well Floodplain Wetlands Watershed District Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: ti 2 -ta�► 5 .�L�nZZ 0 S.$. F?, Identification Please Type or Print Clearly) OWNER: Name: �s�T�2_ 1,��;s�� Phone: 50$.'1.52, r,.%)bo Address: c- \k c� Tcxv .._ CONTRACTOR Name: -`;yk ,.' Phone: ;2 Address: k16-3 Supervisor's Construction License: cAs S3 3e13 Exp. Date: tZ 130(l l Home Improvement License: Exp. Date: ARCHITECT/ENGINEER K4+0 Phone: Address: Reg. No. FEE SCHEDULE:BOLDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED O $125.00 PER S.F. 1 � Total Project Cost: $ '11 1 t b. 40 FEE: �� Check No.: �y Receipt No.: NOTE: Persons contractcn iti gistered contractors do not have access to th uaran and Signature of Agent/Owner Signature of contractorV 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 Reviewed on t 2,/7 LAignature ' COMMENTS �0 I Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT -Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date COMMENTS Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. f Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— (For department use ❑ Notified for pickup - Date — -..--........_...................................................................---.._..__.—........_....-- .............................................._._.__._._......................_.........._........_.................................._.....__.._...__.................................................................. ---..._.. Doc:.Building Permit Revised 2008 I I I I 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 mlt 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) Li Building Permit Application ❑ Certified Proposed Plot Plan 'a ❑ 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: Doc.Building Permit Revised 2008 M �s-sy Location 77 No. �/3y Date �o�TM TOWN OF NORTH ANDOVER 3:0.,..•� :.�tio 0 � w D Certificate of Occupancy $ �'ss►CNusEt� Building/Frame Permit Fee $ / Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # c 22660 Building Inspector DEC-07-2009 MON 12:39 PM MIN DET FAX No, 5086792600 P- 002 Dec 04 09 04:04p NORTH RNDOVER 9786889542 p. l ��_;'•:., OFFICE OF BUILDING INSPECTOR TOWN OF NORTH ANDOVER CONSTRUCTIQN CONTROL w, •.. PROJECT NUMBER: PROJECT TITLE-.__a &j5o PROJECT LOCATION: `705*¢ NAME OF BUILDING- NATURE OF PROJECT.--Z4Q�V40 A&F,04P�iCl t IN ACCORDANCE WITH ART 116 OF THE MASSACHUSETTS STATE BUILDING COOS, %G REGISTRATION NO._3 b/�® 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: ry I. ENTIRE PROJECT U ARCHITECTURAL STRUCTURAL 0 MECHANICAL FIRE PROTECTION 0 ELECTRICAL 0 OTHER(SPECIFY) FOR THE ABOVE NAMED PROJECT AND THAT,TO THE BEST OF MY KNOWLEGE,SUCH PLANS, COMPUTATIONS AND SPECIFICATIONS MEDT THE APPLICABLE PROVISION OF THE MASSACHUSETTS STATE BUILDING CODE.ALL ACCEPTABLE ENGINEERING pRATICES. . AND APPLICABLE LAWS AND ORDINANCES POR THE PROPOSED USE AND OCCUPANCY, I FURTHER CERTIFY THAT I SHALL PERFORM THE NECESSARY PROFESSIONAL SERVICESAND B EPRESENT ON THE CONSTRUCTION SITE ON A REGULAR AND PERIODIC BASIS TO DETERMINE THAT THE WORK IS PROCE,EEDING 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 matertais. 3. Be present*1 intervals appropriate to the stage of construction to become b Akp with6the g .generally famiHa �5 fit.S. . progress and quality of the work and to determine in enenal If the work Is being Performed in a manner consistent with the construction documents, y a ;SUANT TO SECTION 116.2.2 1 SHALL SUBMIT WEEKLY, A PROGRESS REPORTNd.301zo �`� :`� 'ER WITH PERTINENT COMMENTS TO THE NORTH ANDOVER BUILpING INSPf= w4"� �.0 PLETION OF THE WORK, 01`0 im y TI RY COMPLETION AND READINESS OF THE PROJECTC FOR OAS TO THrw i' FOR OC ANY �vieI /!o°r \ `ED AND SWORN TO BEFORE ME THIS 7� DAY OF p SIGNATURE NOTA PUBLIC MY COMMISSION EXPIRES` dt�� DEC-07-2009 MON 12:39 PM WUHSIM FAX No. 5086792600 P- 001 CORNERSTONE DESIGNIBUILD SERVICES, INC. 163 GRAND ARMY HIGHWAY-SWANSEA MASSACHUSETTS 02777-(508)-679-2500 - FAX'508)-679-2600 I a V, % ...Z Date., 12107109 To: Ken Gasse Company: The Meat House Fax No. 978-688-3009 No.of Page, 4 (including this Page) From., Suzanne Mftler Re: The Meat House-North Andover Message, Attached please find our Ceffificate of Insurance and Construction Control Affidavit for above referenced project Originals of these documents will be sent UPS overnight for delivery to you by 10:30 am tomorrow(Tues.. I2/8/09). DEC-07-2009 MON 12:39 PM WIN ED FAX No, 5086792600 P. 003 ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MWdDnYVY) Iw 12/04/Z009 PRQDUOER 401.619.1660 FAX 401,619,Z609 THIS CERTIFICATE 13 ISSUE6 AS A MATTER OF INFORMATION Newport Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Admiral's Cate Tower HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED 13Y THE POLICIES 00,0W. 221 Third Street Newport, RI 02840 INSURERS AFFORDING COVERAGE NAIL N INSURED Cornerstone Dan ign/Build7Servi coo, Inc INSURERA: St. Paul/Travelers Ins. Co_. TPC001 _ 163 CAR Hwy INSURER B: Swanson, NA 02777 R7SURERC.. INSURER W. - INSURER I,; COVERACIE8 THE PO4ICIEA OF INSURANCE LI$TL)?OF-LOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED_NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER AOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE IS$USO OA MAY PERTAIN.THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGRF-OAYE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. a IL My-NR TYPI'OP INSURANCE POLICY NUMBER POLI Y MI RD DA C P�TV1 LIMITS ORNFRAL MARILITY DT-CO-978K7318-COF-09 07/19/2009 07/19/2010 EACH aOCCURRENc5 s 1 000.00 X COMMCRCIAL GFRERAL LIAKITY a 1om) a 300.00 CLAIMS MADE OCCUR MrOEXP(AMonppersoly i 10.00 APERSONAL a A0V 1NJuRY S 1,000100 OENERALAOOREGATE a 3,000,00 OEN1 AOOReGATG LIMIT APPLIES PER: PRODUCTS-COMPIQP AGO 3 3,000.00 POLICY P LOC AUTOMOBILE LIABILITY DT 0810-978K7S18-COV-08 07/19/2009 07/19/2010 COMBINED SINGLE LIMIT X ANY AUTO leP Oldanp S 1,000 00 ALL OWNED AUTOS BOOILY INJURY A scnCDyLEDAUT08 IPr!P�nvtl) - MIRCDAIROD NON-OWNCOAUTOS `ODILYWJI�Y = PlraA�danl - PROPERTY DAMAGE (ParavedaM) CARAOCLNA0.1ri AUTO ONLY,EA ACCIDENT I ANY AUTO PJL ACC 3 OTHER THAN AUTO ONLY; A00 S EXCE66IUMRR6LLAVAV)LIYY DT -CUP-4Z17L829-T1L-08 07/1412009 07/19/2010 OACHOCCURRmcr. E 5 000,00 x OCCUR n CLAIMS MADE AGGRSGnTc - E 5,000 00 A s — DCDUOTUIM S X RETENTION 4 10,000 WORKERSCOMPENSA71ON DTACR-UB-078K731-8-09 07/19/2009 '07/19/2010 AND CMPLOVEIIS'LIAeIUTY YIN TAP LIMITS e X ER ANY PROPRIETORFPARTNeR¢xrcUTIV e,t•EACH ACCIDENT >< 1 000 A OFFICER/MEMOEREXCLUDEpo ,OO MAAdrrlay In NH) E,L,DIeiABR-EA E,MPLOYe 3 1,000,_f/�� 1 yes,deea)Se qnd. 1'0 SPECIAL PROVII,IONS allow 61,DISEASE-POLICY OMIT 1 1.000.00 aTNEa 0E3CRIPTION OF QPERAnONS I LOCATIONS i VEIRCLJ 5 I EXOLY910NS RDOiD QMBNT I SPEQUIL PRQVIa1ONS RO)ECT: THE MEAT HOUSE, 554 TURNPIKE STREETaY,iNDOR NORTH ANDOVER, 14A CERTIFICATE HOLDER CANCELLATION SHOUL°AH1r OF IMF ABOVE DE=IUBEO POLICIES QF CANCELLr;D BEFORE THE ERPIRATIGN - DATE THEREOF,THE 10%J1110 INSURER WILL KIDEAVOR TO MAIL 10 DAYS WRR'TEN NOVJye TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DDSO BMALL IMPOSE NOOAUQATION OR LIA311LITY OF ANY RIND UPON THE INSURER,ITS AGENTS OR TOWN OF NORTH ANDOVER A1kPRB0ENT4kT(VE9. 1600 OSGOOD STREET AOTNDRtX6GR,IPtartisNvATW4 NO TH ANDOVER, MA 0184S Ann RywizzewicOEWAR1 `:!!L ACoan 28(zC0@tel) ® close ACSIRD CORpORATIQN. All Tights reserved, The ACORD name and logo am To9l6tarod marcs of AOORD DEC-07-2009 MON 12:40 PM WIN ISIT FAX No. 5086792600 P. 004 IMPORTANT It the Certificate holder Is an ADDITIONAL INSURED,the policy(les)must be endorsed.A Statement on this certifloate does not confer rights to the certificate holder in lieu of such endorsement(a). If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain poliolen moy require an endorsement,A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). DISCLAIMER The O010cote of Insurance on the reverse side of this form does not constitute a contract between the Issuing Insurer(s),authorized representative or producer,and the certificate holder,nor does It affirmatively or negatively amend,extend or alter the coverage afforded by the policies listed thereon. ACORD 25(2001108) ACORCERTIFICATE OF LIABILITY INSURANCE DATE(MWOMyYY) 12/04/2009 "WMuaER 41;11.541660 FAX 401.619.2689 THIS CERTIFICATE IS ISSUED AS A(NATTER OF INFORMATION Newport ln$64' ce Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR Admiral's Gate Tower ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 221 Third ttreet Newport, RI 02840 _ INSURERS AFFORDING COVERAGE MAIC# INSURED Cornerstoyn,,e� Design/Build Services, Inc INSURER A: St- Paul/Travelers Ins. Co__. TP0001 Hw 163 GAR INSURER B: Swansea, MA 02777 INSURER C: INSURER D: INSURER E; COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANOING ANY REQUIREMENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. POLICY EF POLK:Y EXPIATION .. LTR INSIR TYPE OF INSURANCE POLICY NUMBER DATE IMVJDDIYYYYI DATA MMnWY LIMITS GENERAL LIANUTY OT-CO-978K7518-COF-09 07/19/2009 07/19/2010 EACH O CLIRRENGE:R S 1 000,ON X COMMERCIAL GFNERAL LIABILITY A TO REtd —" PREMISES Ea axulrenl»&) S 300 00 CLAIMS MADE OCCUR MED EXP(Arty one person) S _ 10,0 A - PERSONALS ADV INJURY S 1,(100, GENERAL AGGREGATE S 3,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP ACG S 3,1100, POLICY JELoc - .. OW AUTOMOBILE LIABILITY DT 0-810-978K7518-COF-O$ 07/19/2009 07/19/2010 COMBINED SINGLE LIMIT X ANY AUTO (Ea aodtlenl) S 1,000,00 ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (P-Pmsvnl = A ... HIRED AUTOS BODILY INJURY s NON-OWNED AUTOS (Per LY PROPERTY DAMAGE _ (Per eoaderM) GARAGE LIABILITY AUTO ONLY-FA ACCIDENT S _ ANY AUTO . OTHER THAN EA ACC $ AUTO ONLY: Ate, t EXCESS I UMBRELLA UAVILITY DT '-CUP-42171-$29-TIL-08 07/19/2009 07/19/2010 EACH OCCURRENCE 3 5 _0W,000 X OCCUR FI CLAIMS MADE AGGREGATE i S,000,000 A a DEDUCTIBLE - S X RETENTION 5 10,0 f WORKERSC UIPENSATION OTACR-UB-978K751-8-09 07/19/2009 07/19/2010 TDRYLIMITs X UIH- SIR AND EMPLOYERS'LIABILITY YIN ANY PROPRIETOROARTNERIEXECUTIVED E.L.EACH ACCIDENT i 1,000,0N_ A OFFICERIMEMBER rXCLUDEO� - (LlunedIurp acribb NH) E.L.DISEASE- EMPLOYE i If Yee,tlee under EA EPO1,000,0% SPECIAL PROVISIONS t.91ow OTHER E.L.DISEASE-POLICY LIMIT ; 1100010M DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT 1 SPECIAL PROVISIONS R03ECT: THE MEAT HOUSE, 554 TURNPIKE STREET, NORTH ANDOVER, MA CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCaLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 GAYS 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 TOWN OF NORTH ANDOVER REPRESENTATIVES. 1600 OSGOOD STREET AUTHORIZED REPIgSENTATIVE NO TH ANDOVER, MA 01845 Ann RymszewicEaEWARI ` ACORD 25(2009101) 01988-2005 ACORD CORPORATION. All rights reserved. The ACORO name and logo are registered marks of ACORD IMPORTANT If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not Constitute a contract between the issuing insurer(s),authorized representative or producer,and the certificate holder,nor does it affirmatively or negatively amend,extend or after the coverage afforded by the policies listed thereon. ACORD 25 12004108) L CORNERSTONE DESIGN/BUILD SERVICES, INC. 163 GRAND ARMY HIGHWAY SWANSEA MASSACHUSETTS 02777-(508)-679-2500 FAX 508 -679 2600 TO: The Meat House DATE: 12/3/09 554 Turnpike Street North Andover, MA 01845 RE: The Meat House v 554 Turnpike Street IATTN: Ken Gasse North Andover, MA 01845 I ` F ,t WE ARE SENDING YOU: ■ ATTACHED ❑ UNDER SEPARATE COVER VIA THE FOLLOWING ITEMS: a ❑ SHOP DRAWINGS ■ PRINTS ❑ PLANS ra ❑ COPY OF LETTER ❑ CHANGE ORDER ❑ SAMPLES ❑ SPECIFICATIONS ■ OTHER f' COPIES DATE NO. DESCRIPTION 4 12/01/09 EX-1,A-1 Floor Plans(Stamped) Mw F 1 Preliminary Construction Budget 1 Insurance Affidavit 31 THESE ARE TRANSMITTED AS CHECKED BELOW: �x x ❑ FOR APPROVAL ❑ APPROVED AS SUBMITTED z ■ FOR YOUR USE ❑ APPROVED AS NOTED w � ❑ AS REQUESTED ❑ RETURNED FOR CORRECTIONS ❑ REVIEW&COMMENT ❑ OTHER .r. . ❑ FOR BIDS DUE ❑ PRINTS RETURNED AFTER LOAN TO US REMARKS: , 'XIM COPY TO: File SIGNED: Bob Sanford IF ENCLOSURES ARE NOT AS NOTED,KINDLY NOTIFY US AT ONCE. r i Visit Us on The Web www.cornerstonedesignbuild.com LINiiissachuse tts- Department of Public Safet, Board of'Buildin', Re-ulations and Stan(I.u•dS Construction Supervisor License License: CS 53393 Restricted to. 00 ROBERT E SANFOj3,n JR ' 100 SAWYER AVE a SWANSE, MA 02777 �- --� Expiration: 12/30/2011 ('ummissiuner Tr#: 10732 i i I The Commonwealth of Massachusetts i I Department of Industrial Accidents Office of Investigations �.! 600 Washington Street ��tt Boston, MA 02.111 i- www.mass.gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant InformationiUAW Please Print Name (Business/Organization/individual): Zoe— Address: 163 GAANO brn� #w,4 City/State/Zip:_`5Gu ft's s� l4 /�/� /� 0,2��Phone 7 D Are�y u an employer?Check the appropriate box: Type of project(required): t. [TI am a employer with 1_ 4. ❑ 1 am a general contractor and 1 b. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7• ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9, ❑ Building addition [No workers'comp. insurance 5. ❑ We are a corporation and its 10.El Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL 11.[J Plumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs Insurance required.]t employees. [No workers 13.0 Other comp. insurance required.] *Any applicant that checks boz#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 their workers'comp-policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. ��/�� Insurance Company Name: Policy#or Self-ins. Lic.#: P)—ACR-(Jw- 761-6 0 9 Expiration Date: 7//1712-010 Job Site Address: 5.5 `y I-yowp KE sT►ZEE City/State/Zip: /y 0 Ql•l-1 41Vr-VV591 In 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 Iead 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 DFA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Signature: Date.• Phone#: QfIkial 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#• CORNERSTONE DESIGN/BUILD SERVICES, INC. The Meat House @ The vineyard-North Andover,MA Preliminary Construction Budget-Phase Two Expansion Division 1: General Requirements Quantity Unit Unit Cost Total Notes Supervision 80 HOURS 55.00 4,400.00 Temporary Utilities(Electric&Heat) LOT To be Paid by Tenant Dumpster 1 ALLOW 650.00 650.00 Final Cleaning LOT - - To be Completed by Tenant Bond&Police Detail ALLOW Not Applicable Parking ALLOW Not Applicable Storage Container LOT Not Applicable Portable Restroom LOT Permit&Health Department Expediting 24 HOURS 55.00 1,320.00 Permit Fees 1 ALLOW 750.00 750.00 Architectural Fees 1 LOT 1,500.00 1,500.00 Not Including Plumbing/Elec/Mech Plans Civil Engineering&Surveying Fee LOT - - Other(Local Architect for Construction Control) LOT I - Additional-If Required Total Division 1: 1 $ 8,620.00 Division 2: Demolition Quantity Unit Unit Cost Total Notes General Demolition 16 HOURS 45.00 720.00 Floor Tile Demolition 8 HOURS 45.00 360.00 Wall Demolition 8 HOURS 45.00 360.00 Plumbing Demolition LOT Not Applicable Electrical Demolition 1 LOT 500.00 500.00 Included HVAC Demolition LOT Not Applicable Other LOT Total Division 2: $ 1,940.00 Division 6: Carpentry Quantity Unit Unit Cost Total Notes Rough Carpentry Build Temporary Wood Stud/Plastic Barricade 16 HOURS 45.00 720.00 Frame&Drywall to Adjust Soffit 8 HOURS 45.00 360.00 Frame&Drywall Window Openings 16 HOURS 45.00 720.00 Patch Walls where partitions removed 4 HOURS 45.00 180.00 Cut Down wall at work counter to 1/2 wall 4 HOURS 45.00 180.00 Rough Carpentry Materials 1 LOT 250.00 250.00 Finish Carpentry Install owner provided Shelving&Racks&Equipment 16 HOURS 45.00 720.00 Finish Carpentry Materials 1 LOT 150.00 150.00 Install Door&Hardware 3 HOURS 45.00 135.00 Total Division 6: $ 3,415.00 Cornerstone Design/Build Services,Inc. 163 Grand Army Highway-Swansea,MA 02777 9.30.09 508.679.2500 Phone 508.679.2600 Fax Page:1 Of:2 I - - - i TAORTH ToVM of 4Andover ° _ � � � No. ;m � LAKE dover, 1VMass.,- A ?, 00 -- �• COCKICKEWICK �.4SDRATED BOARD OF HEALTH Food/Kitchen PERMIT T Septic System � �� O[, THIS CERTIFIES THAT ✓y fr BUILDING INSPECTOR s. �t .. d ....... . L.. ............... has permission to erect. ................. buildings on J�' 5�.......................... Foundation . . .. ... ............. Rough to be occupied as...... k � ..s '/ L ... .�'. ...�t,l..-:�r��.`�.......... .....��/. .1.../�.�. /.�'�.f.�C!5�..... ....�,�C.�• Chimney provided that the person accepting this permit shall in every respec conform to the terms of the applica ' non file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Final Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. - Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTION STARTS ELECTRICAL INSPECTOR ........ . Rough :•• Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove Rough Final No -Lathing or Dry Wall To Be Done Until Inspected and Approved by the Building Inspector. FIRE DEPARTMENT [Burner Street No. SEE REVERSE SIDE Smoke Det.