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HomeMy WebLinkAboutBuilding Permit #263 - 575 OSGOOD STREET 10/2/2009 BUILDING PERMIT o`NORTH q TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION �no ea � 1� Permit NO: Date Received .T.o' `�5 �SSACHU5�� Date Issued: �� 2 IMPORTANT: Applicant must complete all items on this page LOCATION C" zJ f-,.� Print PROPERTY OWNER t' f�'1 = '�'-+ ' '",�I` i LT� Print . MAP NO: PARCEL: _ ZONING DISTRICT41!:;fzc 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 Repair, replacement Assessory Bldg Others:fi-qao,Lo%L_ *rA, Demolition Other e_LL 1 rA i C, Gcr� ,jlim6i_';' ir. Septic Well Floodplain Wetlands Watershed District WaterlSew�r- < � rc DESCRIPTION OF WORK TO BE PREFORMED: �t.1��//�`�i t��5 �� �X i��t iy� `� —'i'E-�•�.._. �'.���CUI,%`j '.'(�►c:�L. e—L4 d% Identification Please Type or Print Clearly) OWNER: Name: Phone:97b 1Zc:7 41 Address:r7:;>_7rJ 0'_�C `%i'_> �—T "11--s. •¢ CONTRACTOR Name: 1,t-�, Phone: b I 4 Address: _ Supervisor't Construction License; Exp. ,Date:. 101 Home Improvement License: Exp. Date, ARCH ITECT/ENGINEERM = QL.AES eR?W7_Z= Phone: CA-7 3'-Z3-Z Address: l�R - � -5T or,51oiA M+b Re No. �� � FEE SCHEDULE:BULDING PERMIT.$12.00 PER -$$1000.000OO1F THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ �d®� f �v FEE: $ �5<S4 - C�) (f--> Check No.: ( i ✓ Receipt No.: �22_9 7/ NOTE: Persons contracting with unre ere o tractors do not have access to the guaranty fund ignature of Agent/Owner :' nature of contractor 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) ❑ 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:INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2008 /Y/ I 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 I DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT COMMENTS CONSERVATION Reviewed on Signature COMMENTS 5 'i HEALTH Reviewed on Signature b COMMENTS s 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 Departmentsignature/date COMMENTS r _ l 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 NOTES and DATA— For department use i ❑ Notified for pickup - Date Doc.Building Permit Revised 2008 Locations No. a? Date NaRTM TOWN OF NORTH ANDOVER .. 9 Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 22C/9 wilding Inspector e woo �*ya'a.ns� • CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Permit Number 263 10/2/2009,) Date: January 7. 2010 THIS CERTIFIES THAT THE BUILDING LOCATED ON 575 Osgood Street MAY BE OCCUPIED AS Occupational Therapy Clinic IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: Ed ewood Retirement Community Y 575 Osgood Street North Andover Ma 01845 Building Inspector tAORTF-� Town of '� t g L over 0 No. a2 63 * C, __ =_: dower, Mass.,--- y" .. : 0 AE I� COCKI'A KEWICK 7� Cl ADRATED f"P�\ � `S BOARD OF HEALTH PERMIT T Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT......... e cis� ''..... ... ........ ................. Foun�i on o'%'1t1 r ';l has permission to erect... buildings on .. v�`� "... ,S"t� ...... ...... .... ,Rough''C-1 .................... �.............. ey to be occupied as........ .............. -��.............................. ... ?....... ...................:.................................................., 1............. provided that the person accepting this permit shall in every respect•"conform to the terms of the,application on file in Pin � this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. 0avf N/�_ � -_. PERMIT EXPIRES IN 6 MONTHSa s ELE ICAL INSVEC16R UNLESS CONSTRUCTI N STARS Rough Service BUILDING INSPECTOR Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove Rough 44t-� Fina, No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner 6 Street N . dle 9 SEE REVERSE SIDE Smoke Det. 1 Z�3 FINAL AFFIDAVIT To the Inspector of Buildings of the TOWN of NORTH ANDOVER: In accordance with Section 116.2.2 of the Massachusetts State Building Code: I hereby certify, to the best of my knowledge and belief, that the construction located at R.OKOUS CLINIC, EDGEWOOD RETIREMENT FACILITY, 575 OSGOOD STREET, NORTH ANDOVER, MASSACHUSETTS was built in accordance with the plans,specifications and computations submitted and approved for permit# ,and is in accordance with pp the requirements of the Massachusetts State Building Code and all other pertinent laws or ordinances. ARCHITECT NAME #REGISTRATION NO. �(E Cyi P John Pearson #4841 Margulies Perruzzi Architects, 308 Congress Street No.4841 Boston, MA 02210 eosroN. NIA Jy 617-482-3232 Date: December 31, 2009 Of�gSgP° stamp FINAL INSPECTION AFFIDAVIT In accordance with Section 116.2.2 of the Seventh Edition of the Massachusetts State Building Code: I hereby certify that the structure/renovation was constructed under my or my agent's bservation as per Section 116.2.2 of the Massachusetts State Building Code. Jo n Pearson #4841 Ma gulies Perruzzi Architects, 308 Congress Street B ton, MA 02210 617-482-3232 Date: December 31, 2009 Then personally ppearedthe above named O O IDFAeSO AI has made an oath that the above statement by him/her is true. Before me, MARIE E. CALDER NOTARY PUBLIC Oommonwealth of Massachusetts Date My Commission Expires 8eptemher 28, 2012 My commission expires J:\Edgewood Retirement Community\L. ConAdmin\L.13 Affidavits\Phase 3 Clinics\Final Affidavit- Architect Clinics.doc eZADE ZADE PARTNERS,LLC Consulting Engineers Mevlut S.Koymen P.E. 140 Beach St.,Boston,MA 02111 Muzaffer Muctehitzade M.Sc.,P.E. Phone: (617)338-4406 Fax: (617)451-2540 Email: ZadeCo@AOL.com HVAC FINAL AFFIDAVIT To the Inspector of Buildings of the Town of North Andover: Re: EDGEWOOD RETIREMENT FACILITY ROKOUS CLINIC 575 OSGOOD STREET,NORTH ANDOVER,MASSACHUSETTS (Address) I certify that I, or a design professional under my supervision,have observed the work associated with the referenced project having visited the site on various times. To the best of my knowledge,information and belief, the work generally conforms to the permit and plans approved by the Inspection Services Department and with the provisions of the Massachusetts State Building Code and other pertinent laws and ordinances. Engineer Name: Mevlut S. Koymen 3,�p�,SN OFA, �o� MEVLUT �y Company Name Zade Partners, LLC S. c Massachusetts KOYMEri w Registration Number: 30554 ##30554 Telephone aTb � Telephone Number: (617) 338-4406 Engineer Um Date: 4 January, 2010 Then personally appeared the above named Mevlut S. Koymen proved to me through satisfactory evidence of identification, which was personally known , to be the person whose name is signed on the preceding or attached documents, and made t y goath.that the above statement b him/her is truthful and accurate to the best of his/her knowledge lO1'ief. enie®``` t;Ae:o.: 21 Before me: r `Vo ' / LL Notary PublicMA&t4 e A 2l . 2014 My commission expires: o®�9SE Ha Notary Public Stamp *ZADE ZADE PARTNERS,LLC Consulting Engineers Mevlut S.Koymen P.E. 140 Beach St.,Boston,MA 02111 Muzaffer Muctehitzade M.Sc.,P.E. Phone: (617)338-4406 Fax: (617)451-2540 Email: ZadeCo@AOL.com PLUMBING FINAL AFFIDAVIT To the Inspector of Buildings of the Town of North Andover: Re: EDGEWOOD RETIREMENT FACILITY ROKOUS CLINIC 575 OSGOOD STREET,NORTH ANDOVER, MASSACHUSETTS (Address) I certify that I, or a design professional under my supervision,have observed the work associated with the referenced project having visited the site on various times. To the best'of my knowledge, information and belief, the work generally conforms to the permit and plans approved by the Inspection Services Department and with the provisions of the Massachusetts State Building Code and other pertinent laws and ordinances. Engineer Name: Mevlut S. Koymen M 5E Company Name Zade Partners, LLC S.CJ KOYAREN Massachusetts .y, #30554 O ` Registration Number: 30554 �c��/STC,�°�. AL Telephone Number: (617) 338-4406 Engineer kimi Date: 4 January, 2010 Then personally appeared the above named Mevlut S. Koymen proved to me through satisfactory evidence of identification, which was personally known to be the person whose name is signed on the preceding or attached documents, and made the od�Aj iat the above statement by him/her is truthful and accurate to the best of his/her knowledge and�j ,%%%f::v., 21 Before me: o°F� �� � t • s LL o 9 N` Notary Public a ° 0 i s � My commission expires: to 21, Q,p 14.. `'�,,e2,�, �AY P�6,� Clio 000 Notary Public Stamp `ZADE ZADE PARTNERS,LLC Consulting Engineers Mevlut S.Koymen P.E. 140 Beach St.,Boston,MA 02111 Muzaffer Muctehitzade M.Sc.,P.E. Phone: (617)338-4406 Fax: (617)451-2540 Email: ZadeCo@AOL.com AOL.com FIRE PROTECTION FINAL AFFIDAVIT To the Inspector of Buildings of the Town of North Andover: Re: EDGEWOOD RETIREMENT.FACILITY ROKOUS CLINIC 575 OSGOOD STREET,NORTH ANDOVER, MASSACHUSETTS (Address) I certify that I, or a design professional under my supervision,have observed the work associated with the referenced project having visited the site on various times. To the best of my knowledge, information and belief, the work generally conforms to the permit and plans approved by the Inspection Services Department and with the provisions of the Massachusetts State Building Code and other pertinent laws and ordinances. ttt OF, � Engineer Name: Mevlut S. Koymen g�� M'EVLUTy Company Name Zade Partners, LLC c S. m KOYMEN Massachusettsti #30554 � Registration Number: 30554 �a�F6'57V,�,� T elephone Number: (617) 338-4406 "�tw Engineer to Date: 4 January, 2010 Then personally appeared the above named Mevlut S. Koymen proved to me through satisfactory evidence of identification, which was personally known , to be the person whose name is signed on the preceding or attached documents, and made the oath that the above statement by him/her is truthful and accurate to the best of his/her knowledge and be a:o,,;, , \ d Before me: @pv C),•. ,. .rc�, Notary Public =L'e • o�. (NN My commission expires: D , 9-014 e o•ter �G• de'tegHnaeoe\\e Notary Public Stamp ZADE ZADE PARTNERS,LLC Consulting Engineers Mevlut S.Koymen P.E. 140 Beach St.,Boston,MA 02111 Muzaffer Muctehitzade M.Sc.,P.E. Phone: (617)338-4406 Fax: (617)451-2540 Email: ZadeCo a,AOL.com ELECTRICAL FINAL AFFIDAVIT To the Inspector of Buildings of the Town of North Andover: Re: EDGEWOOD RETIREMENT FACILITY, ROKOUS CLINIC 575 OSGOOD STREET,NORTH ANDOVER, MASSACHUSETTS (Address) I certify that I, or a design professional under my supervision,have observed the work associated with the referenced project having visited the site on various times. To the best of my knowledge, information and belief, the work generally conforms to the permit and plans approved by the Inspection Services Department and with the provisions of the Massachusetts State Building Code and other pertinent laws and ordinances. s.�11 Engineer Name: Muzaffer Muctehitzade �rJN' OF MUZAFFER Company Name Zade Partners, LLC MUCTEHITZADE Massachusetts ELECTRICAL H No.32579 Registration Number: 32559 .o�o��cisT�aw� Telephone Number: (617) 338-4406 eer Stamp Date: 4 January, 2010 Then personally appeared the above named Muzaffer Muctehitzade proved to me through satisfactory evidence of identification, which was personally known , to be the person whose name is signed on the preceding or attached documents, and made the oath that the above statement by him/her is truthful and accurate to the best of his/her knowledge and bel oy Before me: ogi Jv O%SSIOA ?y�`� Notary Public 4-��� o My commission expires: �a �'o?�T ��c:'`` •` Rl' P� o , IIA�fin7���� Notary Public Stamp SITE PROGRESS REPORT October 2009 To: Gerald Brown, Inspector of Buildings Town Of North Andover Building Department 1600 Osgood Street North Andover, MA 01845 From: John Pearson, AIA, LEED AP, Massachusetts Registration No. 4841 Sr. Associate Margulies Perruzzi Architects Project: Edgewood Retirement Community Continuum of Care & Bistro 575 Osgood Street, North Andover MA 01845 Report date: November 2, 2009. 1 . Visited the site on October 2, 6, 7, 8, 9, 13, 19, 20, 27 2009. 2. Attendees: Danny Bolduc, Eckman Construction 3. Work underway for this period: SITE: Water main relocation, storm-tech install, memory garden fence footings, granite curbs, slab on grade. CIU: gypsum wallboard, window trim, ceramic tile, rough mechanical, millwork install, ceiling grid, boiler room equipment install, light fixtures. Clinic, PT/OT: Select demolition, partition framing, rough install MEP. 4. Comments: Work proceeding in compliance with Construction Documents In accordance with Section 116 of the Massachusetts State Building Code (Seventh Edition), I certify that, to the best of my knowledge, information and belief, the work on the subject project is being performed in accordance with the construction drawings and specifications and in accordance with the requirements of the Massachusetts State Building Code and all other pertinent laws and ordinances. Respectfully submitted, ED eH Margulies Perruzzi Architects ` �ti p,Pfq��rA�� John Pearson, AIA LEED AP Sr. Associate ETON. r~ Massachusetts Registration No. 4841 MA PC: Kevin Tremblay, EC David Mermelstein, Trident �jt� Of Eric Hastings, EC SITE PROGRESS REPORT November 2009 To: Gerald Brown, Inspector of Buildings Town Of North Andover Building Department 1600 Osgood Street North Andover, MA 01845 From: John Pearson, AIA, LEED AP, Massachusetts Registration No. 4841 Sr. Associate Margulies Perruzzi Architects Project: Edgewood Retirement Community Continuum of Care & Bistro 575 Osgood Street, North Andover MA 01845 Report date: November 30, 2009. 1 . Visited the site on November 3, 6-10, 17, 24, 2009. 2. Attendees: Danny Bolduc, Eckman Construction 3. Work underway for this period: SITE: Ambulance entrance slab, gravel base for bituminous areas, generator pad poured, binder course paving, finish loam and mulch. CIU: Finish painting, Ceramic tile, Ceiling tile, permanent heat and power completed, wood doors, cubicle track, toilet room accessories, carpet installation, finish mechanical-electrical-plumbing, handrail, final millwork install, column enclosures, power shades. Clinic, PT/OT Wall framing and drywall installation, painting and finishes. 4. Comments: Work proceeding in compliance with Construction Documents In accordance with Section 116 of the Massachusetts State Building Code (Seventh Edition), I certify that, to the best of my knowledge, information and belief, the work on the subject project is being performed in accordance with the construction drawings and specifications and in accordance with the requirements of the Massachusetts State Building Code and all other pertinent laws and ordinances. Respectfully submitted, ED 4,g�i�� Cr Ca Margulies Perruzzi Architects > ° o.4434 John Pearson, AIA LEED AP OSTON4 Sr. Associate PAA Massachusetts Registration No. 4841 ���Pg� PC: Kevin Tremblay, EC David Mermelstein, Trident Eric Hastings, EC SITE PROGRESS REPORT December 2009 To: Gerald Brown, Inspector of Buildings Town Of North Andover Building Department 1600 Osgood Street North Andover, MA 01845 From: John Pearson, AIA, LEED AP, Massachusetts Registration No. 4841 Sr. Associate Margulies Perruzzi Architects Project: Edgewood Retirement Community Continuum of Care & Bistro 575 Osgood Street, North Andover MA 01845 Report date: November 30, 2009. 1 . Visited the site on December 1, 2-81 9, 15, 18, 22, 30 and 31, 2009. 2. Attendees: Danny Bolduc, Eckman Construction 3. Work underway for this period: SITE: Curbs and edging at drives, Loam placed, site lighting CIU: Millwork installation, painting, handrail installation Clinic, PT/OT: Painting, Ceiling Grid install, ceramic tile install, millwork install. Ceiling tile installation. Finish flooring installation.. 4. Comments: Work proceeding in compliance with Construction Documents In accordance with Section 116 of the Massachusetts State Building Code (Seventh Edition), I certify that, to the best of my knowledge, information and belief, the work on the subject project is being performed in accordance with the construction drawings and specifications and in accordance with the requirements of the Massachusetts State Building Code and all other pertinent laws and ordinances. Respectfully submitted, �loft, �, e•P � Margulies Perruzzi Architects John Pearson, AIA LEED AP 4 Sr. Associate STONO MA Massachusetts Registration No. 4841 PC: Kevin Tremblay, EC ;, NOPE David Mermelstein, Trident Eric Hastings, EC NORTH TO" of tAndover . 0 NO. ol 63 p y� * 0 �' LAKE dover, Mass.' (� _ COCHICHEWICK ADRATED PPS\ 5 �`s E BOARD OF HEALTH PER, M IT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES THAT.......... ................ --:'' ... . . l`..: . i� � ° ••••• Foundation .. .. F s has permission to erect........................................ buildings on.......57.... ................... Rough to be occupied as....... , ` ........ ............ ?� Chimney ......... (. .. .... provided that the person accepting this permit shall in every respettl6riform to the terms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PENT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTI N STARS Rough Fh .. yth... .............i.............. ..................................... Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. r A. ACORD CERTIFR ATE OF LIABILITY INSUFI NCE DATE(MMIDDNYYY) ,M 08/30/2009 PRODUCER 603.224.2562 ` - FAX -603.224.8012 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION The Rowley Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 139 Loudon Road ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O. Box 511 Concord, NH 03302-0511 INSURERS AFFORDING COVERAGE NAIC# INSURED Eckman Construction Co., Inc. INSURER A-Fi remen's-Ins -Co--of-Wash.-DC 003-73-- - 84 Palomino Lane INSURERS: Acadia Insurance Company 31325 Bedford, NH 03110 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. INSR ADD1 TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTR NSR DATE MM/DDNYYY DATE MM/DDNYYY GENERAL LIABILITY CPA012120115 09/01/2009 09/01/2010 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY PTo REMISES EaENTED occurrence $ 250,000 CLAIMS MADE I I OCCUR MED EXP(Any one person) $ 5000 A X CG0001 PERSONAL&ADV INJURY $ 1,000,000 X CG2503/CG2504 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY X PRO- JECT X LOC AUTOMOBILE LIABILITY CAA012120315 09/01/2009 09/01/2010 COMBINED SINGLE LIMIT X ANY AUTO (Ea accident) $ 1,000,000 ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) $ A X HIRED AUTOS BODILY INJURY $ X NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY CUA012120415 09/01/2009 09/01/2010 EACH OCCURRENCE $ 10,000,000 X OCCUR ❑ CLAIMS MADE AGGREGATE $ 10,000,000 B Is DEDUCTIBLE $ X RETENTION $ 0 $ WORKERS COMPENSATION WCA012120716 09/01/2009 09/01/2010 X TORY LIMITS ER AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y4NIt STATES: NH, VT, ME, E.L.EACH ACCIDENT $ 500,000 _ A OFFICERIMEMBER EXCLUDED? !—I (Mandatory In NH) MA, CT E.L.DISEASE-FA EMPLOYEE $ 500,000 If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 OTHERCPA012120115--09/01/2009--.-09/01/2010 -_Limit.__o-f--Laab.il.ity.$200,.000-- _- - --- --- ------ _-_..__ — _ Lie - --- -- AEquipment Deductible- $1,000 ACV Applies DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT 1 SPECIAL PROVISIONS e: Edgewood Retirement Community, North Anodver, MA. Edgewood Retirement Community Inc., and Trident Building LLC, their subsidiaries, affiliates and parent companyes, and their respective fficers, directors, trustees, managers, building committee members and employees are added as additional insureds on all policies listed above except workers compensation for liability arising but of the operations of Eckman Construction Co. Inc. and its subcontractors on this project. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL Edgewood Reti rment Community Inc. IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR 575 Osgood Street REPRESENTATIVES. North Andover, MA 01845 AUTHORIZED REPRESENTATIVE Scott Dearden/SD .CJJ'I-del ACORD 25(2009/01) ©1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD r 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 This Certificate of Insurance 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. i I I ACORD 25(2009/01) Edgewood Retirment Community Inc. Certificate issued to Edgewood Retirment Community Inc. 08/30/2009 The Rowley Agency, Inc. 10/31/2008 Bank of America, N. A. is also included as -an additional insured on all liability policies except workers compensation for liability.arising out of construction operations of Eckman Construction Inc. on this project 8oarr m Con stru ,SuperVlAho /u and Standards I; Llcense: CS sor License 98240 U. Ex P, Oon 6/9/2011 r fff �r ResWctton:,0'0- 98240 '1 I DANIEL SOLDUC 282 H I MPSr p RPAb DERRY 1 , NH 03038 Commissioner r DESIGN AFFIDAVIT To the Inspector of Buildings of the TOWN of NORTH ANDOVER: In accordance with Section 116.2.1 of the Massachusetts State Building Code 7`' Edition I hereby certify that, to the best of my knowledge and belief, the Architectural plans, specifications and computations accompanying the attached application concerning EDGEWOOD RETIREMENT FACILITY, ROKOUS CLINIC RENOVATIONS 575 OSGOOD STREET, NORTH ANDOVER. MASSACHUSETTS are in accordance with the requirements of the Massachusetts State Building Code, and all other pertinent laws or ordinances, including Architectural Access Board Regulations. (CMR 52 1) ARCHITECT NAME & REGISTRATION NO. John Pearson#4841 �q itE Q Architect- Massachusetts Reg. No. Margulies Perruzzi Architects, 308 Congress Street . r, Boston, MA 02210 go s0 N, 617-482-3232 Date: September 9,2009 'C1k pci1P5�'P stamp INSPECTION AFFIDAVIT In accordance with Section 116.2.2 of the Massachusetts State Building Code[ hereby certify that the structure shall be built under my or my agent's observation and progress reports will be submitted periodically to the TOWN of NORTH ANDOVER. CHITECT NAME & REGISTRATION NO. John Pearson#4841 -Architect- Massachusetts Reg. No. Margulies Perruzzi Architects, 308 Congress Street Boston, MA 02210 617-482-3232 Date: September 9, 2009 Then personally appeared the above named � have made an oath that the above statement by him/her is true. Befor e, T My commission expires J:\Edgewood Retirement Community\L.ConAdmin\L.13 Affidavits\Design Affidavit-Rokous Clinic.doc ZADE ZADE PARTNERS,LLC Consulting Engineers Mevlut S.Koymen P.E. 140 Beach St.,Boston,MA 02111 Muzaffer Muctehitzade M.Sc.,P.E. Phone: (617)338-4406 Fax: (617)451-2540 Email: ZadeCo(jt,AOL.com HVAC DESIGN & INSPECTION AFFIDAVIT To the Inspector of Buildings of the Town of North Andover: Re: THE ROKOUS CLINIC PROPOSED NEW WELLNESS MEDICAL CENTER I certify that to the best of my knowledge, information and belief, the plans and computations accompanying the attached application concerning the locus at 575 OSGOOD STREET, NORTH ANDOVER, MASSACHUSETTS are in accordance with the requirements of the Massachusetts State Building Code and all other pertinent laws and ordinances. INSPECTION AFFIDAVIT In accordance with Section 116.2.2 of the Massachusetts State Building Code: I hereby certify that the structure shall be built under my or my agent's observation as per Section 116.2.2 of the Massachusetts State Building Code Mevlut S. Koymen - #30554 Engineer- Mass Reg. No. o� MEVIUT. Zade Partners, LLC � G v KO MEN Company .p #30554 ® ' 140 Beach Street, Boston, MA 02111 ®��C,sek; ``?A (617) 338-4406 ssrAL��� Phone Then personally appeared the above-named Mevlut S. Koymen and made oath that the above staterr>� p� him is true. Before me % zoo ZZ�s�k Atld��coF•�`• My Commission expires us Q� � �61,1 ' U14 f ZADE ZADE PARTNERS,LLC Consulting Engineers Mevlut S.Koymen P.E. 140 Beach St.,Boston,MA 02111 Muzaffer Muctehitzade M.Sc.,P.E. Phone: (617)338-4406 Fax: (617)451-2540 Email: ZadeCo(a),AOL.com PLUMBING DESIGN & INSPECTION AFFIDAVIT To the Inspector of Buildings of the Town of North Andover: Re: THE ROKOUS CLINIC PROPOSED NEW WELLNESS MEDICAL CENTER I certify that to the best of my knowledge, information and belief, the plans and computations accompanying the attached application concerning the locus at 575 OSGOOD STREET, NORTH ANDOVER, MASSACHUSETTS are in accordance with the requirements of the Massachusetts State Building Code and all other pertinent laws and ordinances. INSPECTION AFFIDAVIT In accordance with Section 116.2.2 of the Massachusetts State Building Code: I hereby certify that the structure shall be built under my or my agent's observation as per Section 116.2.2 of the Massachusetts State Building Code Mevlut S. Koymen - #30554 Engineer - Mass Reg. No. MULUT Zade Partners, LLC KOYMEN' Company 140 Beach Street, Boston, MA 02111 x'30554 p c'/STEPS 617 338-4406 RL Phone A Then personally appeared the above-named Mevlut S. Koymen and made oath that the above statement by him is true. Before me ```,v • � 21.�L� ¢Ik o0, aT .;�,o-4 My Commission expires $ 4®Np1N�y�g®, ��`�� ZADE ZADE PARTNERS,LLC Consulting Engineers Mevlut S.Koymen P.E. 140 Beach St.,Boston,MA 02111 Muzaffer Muctehitzade M.Sc.,P.E. Phone: (617)338-4406 Fax: (617)451-2540 Email: ZadeConaAOL.com FIRE PROTECTION DESIGN & INSPECTION AFFIDAVIT To the Inspector of Buildings of the Town of North Andover: Re: THE ROKOUS CLINIC PROPOSED NEW WELLNESS MEDICAL CENTER I certify that to the best of my knowledge, information and belief, the plans and computations accompanying the attached application concerning the locus at 575 OSGOOD STREET, NORTH ANDOVER, MASSACHUSETTS_ are in accordance with the requirements of the Massachusetts State Building Code and all other pertinent laws and ordinances. INSPECTION AFFIDAVIT In accordance with Section 116.2.2 of the Massachusetts State Building Code: I hereby certify that the structure shall be built under my or my agent's observation as per Section 116.2.2 of the Massachusetts State Building Code Mevlut S. Koymen - #30554 P�xt%OF , Engineer - Mass Reg. No. �'�s, Mk�ILU� Zade Partners, LLC �y , c S Company 0 KOYMEN 140 Beach Street, Boston, MA 02111 #30554�0� (617) 338-4406 IST ��`.� ' Phone To Then personal) ppeared the above-named Mevlut S. Koymen and made oath that the above statement by him is true. �►� vCjl�} J� .raJ .��`��'•° '��r Before me My Commission expires ESO T / haps►naa ► ZADE ZADE PARTNERS,LLC Consulting Engineers Mevlut S.Koymen P.E. 140 Beach St.,Boston,MA 02111 Muzaffer Muctehitzade M.Sc.,P.E. Phone: (617)338-4406 Fax: (617)451-2540 Email: ZadeCo(a�AOL.com ELECTRICAL DESIGN & INSPECTION AFFIDAVIT To the Inspector of Buildings of the Town of North Andover: Re: THE ROKOUS CLINIC PROPOSED NEW WELLNESS MEDICAL CENTER I certify that to the best of my knowledge, information and belief, the plans and computations accompanying the attached application concerning the locus at 575 OSGOOD STREET, NORTH ANDOVER, MASSACHUSETTS are in accordance with the requirements of the Massachusetts State Building Code and all other pertinent laws and ordinances. INSPECTION AFFIDAVIT In accordance with Section 116.2.2 of the Massachusetts State Building Code: I hereby certify that the structure shall be built under my or my agent's observation as per Section 116.2.2 of the Massachusetts State Building Code ®� Muzaffer Muctehitzade - #32579 �. MUZAFfER Engineer- Mass Reg. No. �: MUCTEHITZADE Zade Partners, LLC v ELECTRICAL Company Wo.32579,D 140 Beach Street, Boston, MA 02111 O90 `GIs-r- (617) 338-4406 s�0 LPhone C.� Then personally appeared the above-named Muzaffer Muctehitzade and made oath that the above statement by him is true. ;gS;o• -4.0 1% Before me OS J:�!� Lf . 41 °o•�r ��°•a'� My Commission expires l,„u�i�i5� ►����eLl The Commonwoolth Of assechus.e.ts w Ftine offiice Qf Health acrd Human Services Department ofi Pudic Health 1 Div-]sior of H afith Care Quality 1 -99 Chauncy Street, Boston; MA 021'1.1 1 DEUAL'L.PATRIPK: GOVERNOR, TIMOTHY P.MURRAY LIEUT.I NANT-GQI/FRNQR JUDYANNP 9tGBY,M..D $ECR.E'fARY JOHN AUJ RSACH ebnnMiss.►oN�R pr ,l :2:2, .2 00 9 i James X RoSenm.an Tq.x- e.qu. t ivei Director Edgewo;od Retirement Community:,: Inc j 5`7.. Osgood Streot: Na th Andover,, MA GA,A5: D1.ear I�Tr ) rlRosenman I am ;pleased to inform you that 'the' support documentation M ch you and your 40-h ect.; Margulies' & ASsoc atQ- suk?mitt.ed for the pro posed The R kous Clinic, " " SeCoricl Flao�r, Sui�eling 4000 S a New Medi: cal., Oy'sic 1 a�.d Occupataonal Therapy Clinic:,; 575, Qsgood Street, 7a°rth Andover;,. ;MA Ol$45; has been: reviewed and #J", is the -Dep°artrnent's. c.rster. a fo=r plan approval under our "self-certi: icati. proses=s.: Based on the Affidavit am tY1e ArChteet.'s Campl: ance checklists documentin..g ccmpl,ianc:e with pkysical pla=nt requixements f=or l c ensu.re,, the plans submit, �e.d to: this o f f;i ce= tin ITovember 1'1, 2=D 0 a-rd April, 07, 2'p o'9 are ;approved:. This approval is not. basQ..d o;�, ?a: cdet.a.iaed review` of the plans by th=is Department., A5'. stater in. the: Affielav t, the Department s=hall have oont,ihu rg! authority t:o revieV- `the plans submitted,. conduct on-,site ;inspe,ction , and withdraw this plan approval fo=r reasons' relsated 'to comp1 ante .or cl anger in prof eci scope: the abo.va referee sed facility shall hare;. a c.ontiriii.ng obligation to matte any changes required by the Department to comply with Li.cezisure Regulations: whether .or not construction Or a1'L.erations', have been completed Const`ructiori of the project must con=form to: the plans far, whcki written approval- has bee=n i sawed by phis off ic.e. April 22 2009 Thiq Rokous Clins.c. . -TherapyFae: li-t . A, New Meda.cal, pj ys�eal & Occu ?L,,L-i.oxna.1 . y p . Second Floor, Building 4,0.0.9 B; 'Page 3 LTCE.NSUR.E .PROCESS:. Please send a written notification indicating the anticipated date :of occu- pan cy of the facility .arcd a .copy of this letter to David ;B'ro ; LXcensure &: .. . . Cert;ifcatiori Coordinator;. at the above l'ett_erheael. address, at leas1.t two anc. of the facility.; (2): months p'raor to the anti(jlpated date. of 6cou p Y That 'no'tlficatian will initiate the -Final phase cf :the .:licensure process. for the proposed facail .ty, which may include an: on-:site licensure survey. if you hay. 'e; :any :quest.-d.ons:;,. please` :ca.l-1 at (617). '?53 8126- very truly: yours Lu y: AW ga' 't _. P E?gsriee _. cc: John Pearson, Paul DNatale: ', David Broin Sheila F`aiella ClYnic" file i