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Building Permit #Exception - 575 OSGOOD STREET 5/1/2018 (12)
L � ;;4iH: � HORTk 9 BUILDING PERMIT o ZSLED ti TOWN OF NORTH ANDOVERJ0 - APPLICATION FOR PLAN EXAMINATION '�- Permit NO#: Date..ReCelNeCl'"' �gg0RAreD gyp" _ SgACHUs� Date Issued: IMPORTANT:Applicant must complete all i#ems°on_this age z . Ni PR®PERTY OWNE,Rn _IP a_ n t�c'tu - es� tPARCL.-_. _ �� ZONJNG`®IS�TRICT _ Hist ick®t tnc, V yes. nn® IM;ac r ini&ShopdU+lla tno! 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: ❑ Demolition ❑ Other _ _ ,Septic ❑;UUelh s❑ FI'oodplarn p Wetlantls'" I "wWateFsheddg 01nct1. 1,, e -#Jt�/ewr ' m - DESCRIPTION OF WORK TO BE PERFORMED: Identification- Please Type or Print Clearly,:- OWNER: learly.:-OWNER: Name: Phone: Address: - Phone; _. S;up-%,irg rr's(M.q -rtaction License _t `rE ate H© provernenfilbgpe- _ - - -- - ARCHITECT/ENGINEER Phoae:<L' Address: Reg_No: ' FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL`ESTIMATEUCOST BASED ON$125.00 PER S.F. Total Project Cost: $ FEE $� Check No.: Receipt:;No :::; NOTE: Persons contracting with unregistered contraetors,J iot have.ac'cess to the guaranty fund -1--m.- + Slgnaturel�o , giTiw' wne_r .�_ _a�m gn`ature'o#contracto - --_ 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 o 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/Cross Section/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) i o 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 VOTE: 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:Building Permit Revised 2014 I 51 Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ T— FE 11SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ i THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ i COMMENTS CONSERVATION Reviewed on Signature COMMENTS 'HEALTH Reviewed on Signature COMMENTS r Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes J Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: 84 O [�IF IRE DEPA' ` N p -- t _ _- 9 RRTME�4 tTem €Dumpster�an Located 3 Osgood Street �. ocatediat1k24Main StreereiD�epartme_nt�gs`igna ure/d`ate-,_ -Q 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) M ❑ Notified for pickup Call Email 3 Date Time Contact Name Doc.Building Permit Revised 2014 f ' ' Location ) tf, No. ! Date 66 j . - TOWN OF NORTH ANDOVER . ,n Certificate of Occupancy $ Building/Frame Permit Fee Foundation Permit Fee $ Other Permit Fee $ — TOTAL $ Check#` 26510 Building Inspector Plans Submitted Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ElTanning/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 ❑ ❑ COMENTS CONSERVATION ❑ ❑ COMMENTS DATE REJECTED DATE APPROVED HEALTH ❑ ❑ COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes r 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 yes " ,no Al Located at 124 Main Street o Fire Department signature/date COMMENTS �- f �O-Y)v.el- - Location No. �. Date TOWN OF NORTH ANDOVER . . � ,: Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ ° rr TOTAL $ r Check# 2-02 G 9 S 25 Building inspector s NO DTH * e Y {M S J X73^C HII`''fS,O CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Permit Number 721-15 on 3/18/2015 Date: December 14, 2015 THIS CERTIFIES THAT THE BUILDING LOCATED at 575 Osgood Street MAY BE OCCUPIED AS Two Units 5302 & 5304 to one Unit 5302 IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: Edgewood Retirement Community 575 Osgood Street No-r-or -An-dover_,-MA 01845 � Buildmg Inspec or Fee: $100.00 Receipt: 29825 " Check : 2029 NORTFf own - of s E ., Andover 0 ;.. .� No. a _ I � y I z k a5 h ver, Mass o > > coc.441..cn �1' �•9 A0R�reo S U BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT ow"W.......................... .............................. lw�� , ,,,,.,, BUILDING INSPECTOR Fo 51 0 g ... � ... .............�.....has permission to erect .......................... buildin s on -g�ado to be occupied as L04".04.....9z ..................................................... c * ey provided that the person accepting this permit shall in every respect conform to the terms of the application inal on file In 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 ' PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCT109 S S Rough Service .............. ....... .. ........................................ Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to-Occupy Buildinga 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. Smoke Det. NORTH Town of t E ndover O 0 No. - � Zy g a � h ver, Mass �dCOC NIC Kl WICK y1. A04ATED S fJ BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System ��, �` BUILDING INSPECTOR • THIS CERTIFIES THAT ............. .W 1.v ...........................................................� ....� ............. has ermission to erect . Fo ;rtoa-tJ......................... buildin son .. ..... ........................ .-!Rou �a J �. .wM� 1l� Arlt. C�" to be occupied as .. . . .... .... ... .. .... ... .. ..... ......................................... c � ev provided that the person accepting this permit shall in every respect conform to the terms of the application inal on file in 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 *'J v,— PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTI S S Rough . Service .............. ....... .. ........................................ Final Ln BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to-Occupy Building 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. Smoke Det. 1��-- Final Construction Control Document To be submitted at completion of construction by a I Registered Design Professional for work per the 8th edition of the Ye Massachusetts State Building Code 780 CMF, Section 107.6.4 Project Title:EDGEWOOD RETIREMENT COMMUNITY Date: 11-09-15 Permit No. Property Address: 575 OSGOOD ST.—NORTH ANDOVER Project: Check(x)one or both as applicable: New construction X Existing Construction Project description:Interior Renovations to combine two units 5302 and 5304 into a single unit. I Charles Cochran MA Registration Number: 6559 Expiration date: 08-31-16,I am a registered design professional, and hereby certify that I have prepared or directly supervised the preparation of all design plans,computations and specifications concerning': X Entire Project Architectural Structural Mechanical Fire Protection Electrical Other: for the above named project. I certify that 1,or my designee,have performed the necessary professional services and was present at the construction site on a regular and periodic basis to determine that the work proceeded in accordance with the requirements of 780 CMR and the design documents prepared by me and approved as part of the building permit and that I or my designee: 1. Have reviewed,for conformance to this code and the design concept,shop drawings, samples and other submittals by the contractor in accordance with the requirements of the construction documents. 2. Have performed the duties for registered design professionals in 780 CMR Chapter 17,as applicable. 3. Have been present at intervals appropriate to the stage of construction to become generally familiar with the progress and quality of the work and to determine if the work was performed in a manner consistent with the construction documents and this code. ED ARCy�Tcc Enter in the space to the right a"wet"or electronic signature and seal: c, to- ELM , No.6559 F no ELMSFORD Phone number: 978-251-0518 Email: itects.com Building Official Use Only Building Official Name: Permit No.: Date: Trial Version 10 09 2012 Final Construction Control Document To be submitted at completion of construction by a ' Registered Design Professional for work per the 86'edition of the ve Massachusetts State Building Code, 780 CMR, Section 107.6.4 Project Title: EDGEWOOD RETIREMENT COMMUNITY Date: 11-09-15 Permit No. 7 Property Address: 575 OSGOOD ST.—NORTH ANDOVER Project: Check(x)one or both as applicable: New construction X Existing Construction Project description:Interior Renovations to combine two units 5302 and 5304 into a single unit. I Charles Cochran MA Registration Number: 6559 Expiration date: 08-31-16,I am a registered design professional, and hereby certify that I have prepared or directly supervised the preparation of all design plans,computations and specifications concerning': X Entire Project Architectural Structural Mechanical Fire Protection Electrical Other: for the above named project. I certify that 1,or my designee,have performed the necessary professional services and was present at the construction site on a regular and periodic basis to determine that the work proceeded in accordance with the requirements of 780 CMR and the design documents prepared by me and approved as part of the building permit and that I or my designee: 1. Have reviewed,for conformance to this code and the design concept,shop drawings, samples and other submittals by the contractor in accordance with the requirements of the construction documents. 2. Have performed the duties for registered design professionals in 780 CMR Chapter 17,as applicable. 3. Have been present at intervals appropriate to the stage of construction to become generally familiar with the progress and quality of the work and to determ' a work was performed in a manner consistent with the construction documents and this code. Ep ARCMjrFc �g g COC�y r Enter in the space to the right a"wet"or ��0 6559 electronic signature and seal: so MSFpPD' tLUUJ CNE MA � l F Phone number: 978-251-0518 Em it a onearc tects.com Building Official Use Only ,Building Official Name: Permit No.: Date: Trial Version 10 09 2012 FNORTH Town of : �_E n over No. a C h ver, Massa �. o� , 1 cocHic»ewick 1 RATED U BOARD OF HEALTH Food/Kitchen PERMIT T t� Septic System Q THIS CERTIFIES THAT . �!...�..... �R� .11M1�1N� BUILDING INSPECTOR has permission to erect ..........................buildings on .5-1 .. , ............. Foundation r � , . -1 Rough to be occupied as .C1 lmx.*A qz...%&m.1 1 Chimney . provided that the person accepting this permit shall in every respect conform to the terms of the application on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and Final >. Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCT I S S ' ' Rough -- Service .............. ....... .. Final BUILDING INSPECTOR � GAS INSPECTOR ' Occupancy Permit Required to Occupy Building 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 Y: Street No. Smoke Det. Date... ............ TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING CHU v . tP Ck" I40A Thiscertifies that ............................. .............. .................... ....................................... . u,'NJWJL— s , , +0 has permission to perform ....C)...................................................................................... Y2�'tk A, wiringin the building of ................................................................................................... at ')...................... North Andover,Mass. Fee Lic.No.00 . . . ......... .............................. ................. ............................ �l ELECTRICAL INSPE�CTO -7 24 Check# �61-6 Commonwea§th Of massach useefcs Official Use Only Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.9/05] leave blank APPUCATION FOR PERNT TO PERFORM ELECTR8CAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: /Z // EGD/ City or Town of. AAv. A-1 q 4y&11.L/2 To the I ect of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street&Number) ,6-75- 0'S ®moi 6-'70-- U hd o- Ir �3�r-Z•��7 ®caner or Tenant CGS W B D/-7� G7A G' Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building � T1 hl��G'K Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd❑ No.of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: 7V14"-, 7—u"e Completion of thefollowing table may be waived by the Inspector of Wires. No.of Total No.of Recessed Luminaires No.of CeiL-Susp.(Paddle)Fans Transformers INA No.of Luminaire Outlets No.of Rot Tubs Generators K-VA Above n- o.o Emergency Lighting No.of Luminaires. Swimming Pool rnd. ❑ nd. ❑ Batte Units No,of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones No.of Detection and No.of Switches No.of Gas Burners Initiating Devices No.of Ranges No.of Air Cond. Tons No.of Alerting Devices 1Hleat Pump ]Vumber ions _ _._.._._ o.of Self-Contained No.of Waste Disposers / Totals; Detection/Alertin Devices Municipal No.of Dishwashers f Space/Area Heating IOW Local❑ Connection F1 Other Heating Appliances �r Security Systems:k No.of Dryers ( No.of Devices or Equivalent 47 No.offater , No.of No.of Data Waring: Heaters Signs Ballasts No.of Devices or Equivalent Telecommunications Wiring: No.Hydromassage Bathtubs No.of Motors Total IIP No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. . Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: nspections to be requested in accordance with MEC Rule 10,and upon completion. NP INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The ed certifies that such covers a is in force,and has exhibited proof of same to the permit issuing office. undersign ._ CHECK ONE: INSURANCE OND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of perjury,that the information on this application is true and complete._ N FIRM NAME: Perin & Campbell Pr•i-r; t- r, t_ P,4;-,qLIC-NO.: 17a-�1A _ Licensee: (/fb�G�d/ !��l26h' Signature LIC.NO - I a licable enter "exempt"in the license number line.) Bus.Tel.No.: 781 -245-0921 (f PP P Address:l22- �„R�s�e Wakefield, MA 01880 Alt.Tel.No.: t le enter the license number here: required for this work;if applicable,Security System Contractor License r q pp , OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. i am the(check one)❑owner ❑owner's,agent. .Owner/Agent �� ��� r Signature Telephone No. 5-ctfl ( , 3 _ I r r f �C�����I-�1 =� I !% e C ozEzrrzoczr��ealt�z of lrssaclzusctts Printorrn l .17'W. ,.T Depart, oqMM�fY �w ®ffice of Investigations 1 Congress,Street, Suite 100 Boston, MA 02114-2017 wwiv.nzass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Piumbers AoDlicant Information Please Print Le ibl Name (Business/Organization/Individual):_BLg � Address:,/ �L�r vJcl�?Qzr-�S.T City/State/Zip:__ GwgPhone #: Are you a employer? Check the appropriate box: 1. am a employer with_ jam_ 4. ❑ I am a general contractor and I Type of project(requiled employees (full and/or part-time).* have hired the sub-contractors 6. ❑New constructio 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have working for me in any capacity. employees and have workers' g' ❑ Demolition [No workers' comp. insurance comp. insurance.1 9. ❑ Building addition required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs 3.❑ Iamaho homeowner loin all officers � g work have exercised their. 11 m self. ❑Plum re airs y [No workers comp. right of exemption per MGLg p insurance required.] t c. 152, §1(4), and we have no 12•❑Roof repairs . employees. [No workers' 13.❑ Other comp. insurance required.] *Apy applicant that checks box#1 must also fill out the showing their workers' t 1i omeowners who submit this affidavit indicating they are doingeall vwork and then hire outside contractors mulst icy s b�minsation t a new davit indicating such. com-,Contractors that check this box must attached an additional sheet showing the name of the sub-contra ctors 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 arz employer t/zat isprOVldll workers'co,npensa�ion ZItSura�zce for irzy employees. Below i�tlzepo�licyan��djob site iazfornzatton. Insurance Company Name: Policy#or Self-ins. Lic. #:. We q Expiration Date: ,S� �O/ Job Site Address:. f-:7r D S. GrQ/ �� . City/State/Zip: �Oy�� yr�p�lj Attach a copy of the workers' coinensatio p n policy declaration a Failure to secure coverage as required under Section 25A of MGL . 5 2(can lead tohthe impositiolicy nof crer itminal penalties of a fine�ip 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 co of this PY s statement may e,tigzhons of the DIA for insurance coverage verification. Y be forwarded to the Office of Ido hereby certFfy'under the pains es and enaltio P fperjury that the information provided above is true and correct Si nature: ' 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): I.Board of health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6. dther p Contact Person: Phone#: Division of Professional Licensure: License Search Page 1 of 1 The Official Website of the Office of Consumer Affairs and Business Regulation(OCABR) Division of Professional Licensure Mass.Gov Mass.Gov Home State Agencies A-Z Topics Home>Division of Professional Licensure> ONLINE SERVICES .....................................-................................................................................................................................................................................................................ Check a License Check A Professional License Locate a Licensed Professional By the Division of Professional Licensure Online Address Change Contact the Agency More... LICENSEE Name:VICTOR J. PERIN REFERENCES& Business: PERIN£t CAMPBELL ELECTRICAL CONT INC RELATED INFO WAKEFIELD,MA Disclaimer Regarding NEW SEARCH I Website License Searches ""This Licensee has additional Licenses, click here to view them."" Glossary of License Status Codes Licensing Board: ELECTRICIANS More... i MASTER ELECTRICIAN License Type: TYPE CLASS:A License Number: 17031 Status: CURRENT Expiration Date: 7/31/2016 Issue Date: 8/28/2000 Exam Date: 6/2/1981 School: This web site displays disciplinary actions dating back to 1993. This license has had no disciplinary actions taken during this time. y The page above has been generated by the Division of Professional Licensure web server on Friday,December 12,2014 at 9:44:51 AM. ©2007-2011 Commonwealth of Massachusetts Site Policies Contact Us http://license.reg.state.ma.us/public/pubLicenseQ.asp?board_code=EL&type_class=_A&1... 12/12/2014 Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost 42„©i0 ).,00 m $ - $ 504.00 Plumbing Fee $ 63.00 Gas Fee 100 comm. $, 1!0;©1.001 Electrical Fee $ 63.00 Total fees collected $ 730.00 575 Osgood Street - Edgewood 721-15 on 3/18/15 Convert two units into one large unit i i I s I Massachusetts -Department of Public Safety I Board of Building Regulations and Standards Construction Supervisor License: CS-092345 -1;,r MATT PBHNTEj�- 27 Boutwell Rd Andover MA 01830 Y_ t. t cls Jf14`�` Expiration Commissioner 05/04/2015 J' Initial Construction Control Document To be submitted with the building permit application by a d Registered Design Professional for work per the 8th edition of the Massachusetts State Building Code, 780 CMR, Section 107.6.2 Project Title: EDGEWOO.D RETIREMENT COMMUNITY Date: 02-11-15 Property Address: 575 OSGOOD ST.—NORTH ANDOVER Project: Check(x)one or both as applicable: New construction X Existing Construction Project description: Interior Renovations to combine two units 5302 and 5304 into a single unit. I Charles Cochran MA Registration Number: 6559 Expiration date: 08-31-2015,I am a registered design professional, and hereby certify that I have prepared or directly supervised the preparation of all design plans,computations and specifications concerning: X Entire Project X Architectural Structural Mechanical Fire Protection Electrical Other: for the above named project and that such plans,computations and specifications meet the applicable provisions of the Massachusetts State Building Code,(780 CMR),and accepted engineering practices for the proposed project. I understand and agree that I(or my designee) shall perform the necessary professional services and be present on the construction site on a regular and periodic basis to: 1. Review, for conformance to this code and the design concept, shop drawings,samples and other submittals by the contractor in accordance with the requirements of the construction documents. 2. Perform the duties for registered design professionals in 780 CMR Chapter 17,as applicable. 3. Be present at intervals appropriate to the stage of construction to become generally familiar with the progress and quality of the work and to determine if the work is being.performed in a manner consistent with the approved construction documents and this code. When required by the building official,I shall submit field/progress reports(see item 3.)together with pertinent comments, in a form acceptable to the building official. Upon completion of the work, I shall submit to the building official a `Final Construction Control Document'. Enter in the space to the right a"wet"or CHARLES �F�w electronic signature and seal: ® COCHRAI! 6559 a . STFO Phone number: 978-399-0240 Emai : ca earchitects.com Building Official Use Only Building Official Name: Permit No.: Date: Trial Version 10_09_2012 The Commonwealth of Massachusetts Print Form Department of Industrial Accidents Office of Investigations ' 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl a Name (Business/Organization/Individual): ffle r uo-i _ Address: d City/State/Zip:W %��'`' Phone#: Are you an employer? Check t e appropriate box: Type of project(required): 1�.Dam a employer with ' 4. ❑ I am a general contractor and 1 6. 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 g• ❑ Demolition workingfor me in an capacity. employees and have workers' Y P Y• 9. E] Building addition [No workers' comp. insurance comp. insurance.$ required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13.0 Other comp. insurance required.] *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. +Contractors 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: /��'�-�1(I Policy#or Self-ins. Lic.#: �c a2.Baa LY y?-axp ration Date: Q� / V Job Site Address: OS��_) -5)- City/State/Zip:/nH�i Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certift under the pqins and enalties o era that thein ormation provided above is true and correct Signature: _ LS —-- _J Date �6 _ _ .. Phone#: r 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#: VDAC I it .,FORD WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY TYPE AR INFORMATION PAGE WC 00 00 01 ( A) POLICY NUMBER: (6S60UB-2EG2448-0-14) NEW-1 4 INSURER: HARTFORD UNDERWRITERS INSURANCE COMPANY NCCI CO CODE: 1045G 1. INSURED: PRODUCER: PIMENTEL CONSTRUCTION CO INC EDWARD F SENNOTT INS 231 ANDOVER STREET PO BOX 457 WILMINGTON MA 01887 TOPSFIELD MA 01983 Insured is A CORPORATION n in the schedules attached. identification numbers are show schedule(s)Other work places and de 2. The policy period is from 12-20-14 to 12-20-15 12:01 A.M. at the insured's mailing address. 3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers Compensation Law of the state(s) listed here: MA B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed in �— item 3.A. The limits of our liability under Part Two are: a_ Bodily Injury by Accident: $ 1000000 Each Accident Bodily Injury by Disease: $ 1000000 Policy Limit 0 Bodily Injury by Disease: $ 1000000 Each Employee N C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here: COVERAGE REPLACED BY ENDORSEMENT WC 20 03 0GA D. This policy includes these endorsements and schedules: SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE 0 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All required information is subject to verification and change by audit to be made ANNUALLY. DATE OF ISSUE: 01 -13-15 AK ST ASSIGN: MA OFFICE: ORLANDO DA HTFD 05G PRODUCER: EDWARD F SENNOTT INS 25628 004286