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HomeMy WebLinkAboutBuilding Permit #486 - 566 TURNPIKE STREET 1/2/2007IE® TOWN OF NORTH ANDOVER A� ®vAPPLICATION FOR PLAN EXAMINATION Permit NO: Date Received Date Issued: 1 '�% IMPORTANT: Applicant must complete all items on this page LOCATION Js �o T'Ull�lfC s %�iP-•E% Print PROPERTY OWNER /V/�iI/�f�l�•��' C �!sSs', }"S' Print MAP NO.: b�c� D PARCEL: D001 ZONING DISTRICT: Z3 'rvns A %Tn 1FTC117 nTi RrTH niNG iiiCTnRir nTgTRirT YF.q n TYPE OF IMPROVEMENT PROPOSED USE Residential � Non- Residential ❑ New Building ❑ Addition Alteration ❑ One family ❑ Two ofmore family No. of units: ❑ Indu`strial ❑ Repair, replacement ❑ Demolition ❑ Assessory Bldg XCommercial ❑ Moving relocation 0 Other ❑ Others: ❑ Foundation only DESCRIPTION OF WORK TO 1:31✓ Mt1`U MtJJ Identification Please Type or Print Clearly) OWNER: Name: /V AIV t;) Vl,,- (WSS'P—,/)a� Phone6���'����`' Address: X6 / 7-UX1lpf1e.&" 4-r,, 'u,, ak D CONTRACTOR Name: Phone: .�r Address: S h V C')Ll J C -k sD Al Gc�/� �l>�' &), P eo 1%. per' 1)a2 9'o3 , Supervisor's Construction License: 76 IV/ 2 Exp. Date: Home Improvement License: Exp. Date: ,'' ARCHITECT/ENGINEER S �SC1 4 -- Name: Phone:/� /* fa 3t>� � � Address: C -0401X,600 D/// Reg. No. FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER SF. Total Project Cost :$1-2 ,z�f FEE:$ " Check No.: Receipt No.: Page I of 4 NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund 5e,C "AP4!_Wl-&I Signature of Agent/Owner Signature of contractor Plans Submitted ❑ Plans Cived ❑ Certified Plot Plan ❑ Stamped Plans ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT ❑ COMMENTS CONSERVATION HEALTH DATE REJECTED Q DATE APPROVED DATE REJECTED DATE APPROVED ❑ ❑ DATE REJECTED r FIRE DEPARTMENT - Temp Dumpster on site yes no Fire Department signature/date .45 COMMENTS APPROVED .. V b� Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Conservation Decision: Comments Comments Water & Sewer Connection/Signature & Date Driveway Permit TYPE OF SEWERAGE DISPOSAL Tanning/Massage/Body Art ❑ Swimmin Pools ~ 0 g Public Sewer _ - Well _, ❑ Tobacco Sales ❑ Food Packaging/Sales 0 ❑ Permanent Dumpster on Site ❑ Private (septic tank, etc. Electric Meter location to project NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund 5e,C "AP4!_Wl-&I Signature of Agent/Owner Signature of contractor Plans Submitted ❑ Plans Cived ❑ Certified Plot Plan ❑ Stamped Plans ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT ❑ COMMENTS CONSERVATION HEALTH DATE REJECTED Q DATE APPROVED DATE REJECTED DATE APPROVED ❑ ❑ DATE REJECTED r FIRE DEPARTMENT - Temp Dumpster on site yes no Fire Department signature/date .45 COMMENTS APPROVED .. V b� Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Conservation Decision: Comments Comments Water & Sewer Connection/Signature & Date Driveway Permit Building Setback (ft.) Tt6ht Yard- Side Yard Rear Yaid Requirgd, Provided Required Provides Required Provided Dimension Number of Stories: Total square feet of floor"""- area, based on Exterior dimensions. Total land area, sq. ft.: NOTES and DATA - For departmeMuse) Page 3 of 4 Doc: INSPECTIONAL SERVICES DEPARTMENTMwWo Created JMC. Jan.2006 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 Addition Or Decks ❑ Building Permit Application ❑ 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) 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 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:BPFORM05 Page 4 of 4 Location5jk�- %af/��,(410!�, - No. p A Date` a —` NORTIy TOWN OF NORTH ANDOVER F + 41 9 ° Certificate of Occupancy $ � ^' ,`• + _ Imo\ Building/Frame Permit Fee $� r ,SJACMUSE Foundation Permit Fee $ Other Permit Fee $ TOTAL $ r Check # . 19906 r Building Inspector `� 00 z W OD to i� ul rA 10 §w E E Cn o a cmm CO C � W a m 0 CD M C s m 0 o � 0 O U 2, O v O CD ■ 6.7 CD Z o„ O y 0 C CD CM ca CD I C C O■— ■— •E LA m m t O� CD 0 CD �3 CD O 09 LM Cc O d E: cMQ o Cc G ��CL 0 � CA Z m CL V y O C C cc CA D W cl N U) 19 W W W U) c 0 a m c a a * c N O c V ii x w C/)v � o o u 14 W o a w" w w o cG w W a ° o w c w" a rE ° cn c o cn ul rA 10 §w E E Cn o a cmm CO C � W a m 0 CD M C s m 0 o � 0 O U 2, O v O CD ■ 6.7 CD Z o„ O y 0 C CD CM ca CD I C C O■— ■— •E LA m m t O� CD 0 CD �3 CD O 09 LM Cc O d E: cMQ o Cc G ��CL 0 � CA Z m CL V y O C C cc CA D W cl N U) 19 W W W U) c 0 m c 0 0 * c N O c V ii CL C mm O c �Z O CD N �■�' m c 0 .2 0 d NJ E� c C amra c to 3 cm m .' c ye W y COD : 0 �mm "aa cm �Z 93 �a �40 :m%cc3 0. sea W C �w�t •go c •■ "5 nr CO2 .0 0 � _ to =a J2 CL= m ul rA 10 §w E E Cn o a cmm CO C � W a m 0 CD M C s m 0 o � 0 O U 2, O v O CD ■ 6.7 CD Z o„ O y 0 C CD CM ca CD I C C O■— ■— •E LA m m t O� CD 0 CD �3 CD O 09 LM Cc O d E: cMQ o Cc G ��CL 0 � CA Z m CL V y O C C cc CA D W cl N U) 19 W W W U) The Commonwealth of Massachusetts 12 Assessors Map and Parcel Number: -(// `D D %7 State Board of Building Regulations and TOWN OF NORTH ANDOVER Standards BUILDING DEPARTMENT Massachusetts State Building code Lot Area (s" Frontage(ft) 780 CMR Telephone P�72 0"J APPLICATION TO CONSTRUCT REPAIR, RENOVATE, CHANGE THE USE OF OCCUPANCY OF, OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING umber: ,,: Building Permit Number:*,,."" Date. Issued: Name (Print Address Signature Signature: Buflding Commissioner/Inspector of Buildings Date C ..r'TfnN 1- CITF. T F?nRMATinN 1.1 Property Address:C + +• J 12 Assessors Map and Parcel Number: -(// `D D %7 I Map Number C 5` o I Number 000 DD 1..3 Zoning Information: 1 A Property Dimensions: Zonin District P Use Lot Area (s" Frontage(ft) 1.6 Provides 107 Water Supply 9M.G.L.C.40.4 S 54 I S. Flood Zone Information 1.8 Sewerage Disposal System: Public O Private Zone 1..1-- Outside Flood Zone ' O Municipal Q On Site Disposal; System0 2.1 Owner of Record I {� N Address: i i ✓ /� d% 0 Si Telephone P�72 0"J 2.2 Author* ed Agent: J t e ► iI yv IL. 666 Name (Print Address Signature Telephone 5i 0 / Y' SFI .CTiON I CO S [I[TION SF.RVICFS FOR PROTECTS i.FSS THAN MUM CITRIC FF.RT OF F.NrLnQRn RPAVR 3.1 Licensed Construction Supervisor: Not Applicable 0 Licensed Construction Supervisor: k) f—O F1 License Number //�, 69 / rte/ ` Address ` 1 Expiration Date I 16 10A Signature Telephone(p 1-7' fg•3�2 3.2 Registered Home Improvemen ontractor. Not Applicable Company Name Registration Number Address Expiration Date Signature Telephone tcevlsen ryyr .Tmu Z I— The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations V ' d 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): 6 Z,L iR %9_,(/,� 3Z2_z _;a/,Zj:!�i Cd Address:— tS.C`V,e✓it/ G'i�S6 Al City/State/Zip: ;FRQ V<,P/1 (7— � , /e,7— Phone #: Are you an employer? Check the appropriate box: 1. 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. employees and have workers' [No workers' comp. insurance comp. insurance.$ required.] 5. ❑ We are a corporation and its 3. ❑ 1 am a homeowner doing all work officers have exercised their myself. [No workers' comp. right of exemption per MGL insurance required.] t c. 152, § 1(4), and we have no employees. [No workers' insurance Type of project (required):, 6. ❑ New construction 7. Xemodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12. ❑ Roof repairs 13.❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those entities have employees. If the sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: >5-66 rz)4,(%P//-ee City/State/Zip: IV, )�&V,4]D�V, 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 coverase verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. 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. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more. of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for. the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant 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 or permit 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 and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Stieet Boston, MA 02111 Tel. # 617-727-4900 ext.406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 11-22-06 wwvv.mass.gov/dia .- , DATE(MM DD YYYY) 0�10�2 A CORD,M�►� 10/10/2006 PRODUCER Risk services, Inc. of Rhode Island THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY 50 Kennedy Plaza AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS 10th Floor CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE Providence RI 02903-2393 USA COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC# PHONE.(866) 283-7122 FAX 847 953-5390 INSURED INSURERA: Liberty Mutual Fire Ins Co 23035 Glbane Building company Seven Jackson walkway Providence RI 02903 USA ! y ti INSURER B: Liberty Insurance corporation 42404 INSURER C: INSURER D: 6 d 'C INSURER E: C 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. INSR LTR ADD'L INSRD TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE(MM\DD\YY) POLICY EXPIRATION DATE(MM\DD\YY) LIMITS A GENERAL LIABILITY TB2-611-259068-026 06/30/06 06/30/07 EACH OCCURRENCE $2,000,000 DAMAGE TO RENTED $1,000,007 X COMMERCIAL GENERAL LIABILITY CLAIMS MADE © OCCUR PREMISES o a An MED EXP (Any onnee person) $10,000 & ADV INJURY $2,000,000 EJ 000 O GENERAL GENERAL AGGREGATE $4,000,000 GENT. AGGREGATE LIMIT APPLIES PER: ❑ POLICY X❑ PRO- LOC JECT O O n Ln PRODUCTS-COMP/OP AGO $4,000,000 A AUTOMOBILE LIABILITY X ANY AUTO AS2-611-259068-016 06/30/06 06/30/07 COMBINED SINGLE LIMIT (Ea accident) $1,000,000 � z ALL OWNED AUTOS SCHEDULED AUTOS R L' BODILY INJURY ( Per person) HIRED AUTOS NON OWNED AUTOS BODILY INJURY (Per accident) a L PROPERTY DAMAGE - - -(Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT ANY AUTO OTHER THAN - EA ACC 8 AUTO ONLY : AGG A EXCESS /UMBRELLA LIABILITY TH2-611-259068-056 06/30/06 06/30/07 EACH OCCURRENCE _ $10,000,000 OCCUR ❑ CLAIMS MADE AGGREGATE $10,000,000 BDEDUCTIBLE RETENTION B WORKERS COMPENSATION AND WA7-61D-25 06 - 06/30/06 )( WC STATU- 0TH - TORY LIMITS ER EMPLOYERS' LIABILITY — E.L. EACH ACCIDENT $1,000,000 ANY PROPRIETOR / PARTNER / EXECUTIVE OFFICER/MEMBER EXCLUDED? If yes, describe under SPECIAL PROVISIONS E.L. DISEASE -EA EMPLOYEE E.L. DISEASE -POLICY LIMIT - $1,000,000 $1,000,006:2 below szo 2S OTHER W..a DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Project # 11-4117-600; Project Description: Starbucks warming Program (All stores). Starbucks Coffee Company (All Stores), Jones Lang Lasalle Americas, Inc., 07374, Federal Realty Investment Trust, 07399, and 575 Worcester Road, _ LLC are included as Additional Insured with respects to General Liability where required by written contract y y Starbucks corporation SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION 58 wells Avenue DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL Newton MA 02459 USA 90 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, Or A�P;KRMUPONTHE_ PP�iiliR' ITS �. - AUTHORIZED REPRESENTATIVE °'N - CITY'OF BOSTON Lie.: NoB19395 '.' BOARD OF EXAMINERS . - _= MAYOR THOMAS M. MENINO THis P rirles- ^k:CM C IS I _ _ ` GEO _ WQRK UPI) R•PROftI9NS OF THEATS, - n ad�Oros SEE; Il; . - �rasro� I v Chrisa'1$ � "•';r•, "eagsued -E7�6%G�e BOARD OF EXAMINERS ALEXANDER H. MACLEOD. AIA T.F. SCOTT DARLING III PATRICK TRACY r ------------- F i 1 , B19395 SEE BACK 11/16/07 CLASS OF LICENSE EXP DATE PAUL M. TIERNEY 40 BROOKRIDGE DR EXETER RI 02822 A -LTD B -LTD C REIVIARKS Dig Safe Call Center (888) 344-7233 464 17 I 00 - 35,000 cf enclosed space 1A - Masonry only 1G -1 2 Family Homes Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. Burnham Nationwide Simply Getting It Done! Offices in Chicago, New York and Major Markets Served Nationwide www.BumbamOnline.com To: Brian Leathe North Andover Building Dept. From: Aaron Jagiel Date: December 21, 2006 Pages: 2 Starbucks - 566 TURNPIKE STREET Per the request of Karolyn Parker, I am sending to you a copy of the approved contract cost. If you have any questions please contact me at 312.260.7088. Thank you vu-N-OV41W-o- 17,7b � 0V;�A-� 111 W. Washington St., Suite 450 Chicago, IL 60602 Phone (312) 407-7990 Fax (312) 407-7915 ITSM LANG J LA3ALca. ! Yun>tlVaq! Ait4pAiB Or �fA�O. Warming Pmgrmn - Boston Phase 1 GC Site Bio Fora! - 6tibane 90PIM U)Mfie Q86 10118=6 PR�CRAL REM* DATE STDRE3@7773 - North nodavary SITY'Ture ka St Tom O'Connor FR61f.CT AlM PpOWBFA e16TAU DATE GEi1ML CONTRACTOR GArme IN Fwn r^r Rit t V/ va ii�iiy���t'. :+j��r�+�g A".iI�MyE3.�'dyyW woura t�f�l 1. Ll. -. so GEi1ML CONTRACTOR GArme IN Fwn SECTION 6 - DESCRIPTION OF PROPOSED WORK (check all applicable) New Construction Q Existing Building ® Repairs 0 Alteration(s) Addition --F- Accessory Bldg. 0 Demolition [3 Other [3 Specify Brief Description of Proposed: I G (T) m co o --J 01crzowrVIC o vb-- o tAF k�n Go v J rg'�t P, 'r - i s EyL A —%o 2 SECTION 7 - USE GROUP AND CONSTRUCTION TYPE USE GROUP Check as applicable) Independent Structural Engineering Structural Peer Review Required Yes Q No CONSTRUCTION TYPE A Assembly A-1 A4 A-2 A-5 A-3 lA 1B Q O B Business 13 2A 2B 2C C) 0 Q E Educational [3 F Facto 0 F-1 F-2 H High Hazard 0 3A 3B Q 0 I Institutional Q I-1 I-2 I-3 M Mercantile 19 4 E3 R Residential 0 R-1 R-2 R-3 SA 5B 13 0 S Storage E3 S-1 S-2 U utility Q Specify: M Mixed Use E3 Specify: S Special 0 Specify: COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS. ADDITIONS AND/OR CHANGE IN USE Existing Use Group: N 1fh Existing Hazard Index 780 CMR 34 Proposed Use Group: Proposed Hazard Index (780 CMR 34) SECTION 8 - Building Height and Area BUILDING AREA Existing if applicable) Proposed Number of Floors or stories include basement levels ST Floor Area per Floor (s Total Area s Total Height ft SECTION 9 - STRUCTURAL PEER REVIEW (780 CMR 110.11) Independent Structural Engineering Structural Peer Review Required Yes Q No SE N 1 R AUTHORIZATION - TO BE COMPLETED WHEN PYS OR CO CTOR APPLIES F BUILDING PE vt+pl/ ��'��G G� ' , As Owner of subject property hereby authoriz r vin i 6 to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date revised bldg form/state JMC PROJECT NUMBER: PROJECT TITLE: S40,r iyj S PROJECT LOCAT NAME OF BUILDI OFFICE OF BUILDING INSPECTOR TOWN OF NORTH ANDOVER CONSTRUCTION CONTROL NATURE OF PROJECT: I h4e(t kap r"qC M4.10AS IN ACCO . DANC�Wl H A LE 116 95F/THE MASSACHUSETTS STATE BUIL NG CODE, r �5 �o REGISTRATION NO. 6-7 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: NTIRE PROJEC • 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 INSP UPON COMPLETION OF THE WORK, I SHALL SUBMIT A FINAL REPORT AS TO T SATISFACTORY COMPLETION AND READINESS OF THE PROJECT FOR OCCUP I r SIGNATURE THIS 16 DAY OF I' `0yeA be -.P 200(P MY COMMISSION EXPIRES 7 � aOa I