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HomeMy WebLinkAboutBuilding Permit #720-13 - 790 TURNPIKE STREET 5/1/2013TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION 7zJ - / -3 Hata PprPivPri � I �b I I y` TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential El New Building 0 Addition ti 0 One family D Two or more family El Industrial ®ration No. of units: NICOmmercial El Others: ❑ Repair, replacement 0 Demolition D Assessory Bldg D Other Wetlands idiF,,,.Io'o,a*016ii=hr:���,,,ioi� btetshe 6t S W 11 , ate!/Sewer. Coo i/ C- � CA -1 t7 (�14 r)IAIKIPPP Name: )K 1)hbL;K1r I WN ur vv% S c AWfific tion Please V,2 r- � TZ3 or Print Clearly) A zd,2LWV1 I Address 777= -Q-ONTRAic T. • S 'fAiddres E S Construction "�I�!#al'� --7 0 0,�,Awt tioln-16,11rnprqvement -icensA.. N ARCH ITECT/ENGI NEER3d b��v �,d �,S Phone: OF/ 8 Ceq 3 +0 ^ Reg. No. s: Addres FEE SCHEDULE: BULDING PERMIT. $12.00 PER $1000-00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ FEE: Check No.: Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the gi aranty fund g Signature of contradto Signature of A g6nt/ Omer Plans Submitted ❑ Plans Waived F1 Certified Plot Plan ❑ amped Plans 0 0 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/SaIes ❑ Private (septic tank, etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED PLANNING & DEVELOPMENT ❑ COMMENTS DATE APPROVED El CONSERVATION Reviewed on . Signature U'�OMMENTS HEAD+ TIS 'Reviewed on Signafure COi\iMENTS C , �l Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/signature � gage Driveway Permit _ RTW Town ]Engineer: Signature: r FIRE DEPARTMENT - Temp Dumpster on site yes Located 3n4eOs cod street Located at'124 MainStreet Fire ®epaitmerit signat6fe1&te COMMENTS Dimensoon Number of Stories: Total land area, sq. ft.: Total square feet of floor area, based on Exterior dimensions. 1 ELECTRICAL: Movement ®f Meter location, mast or service drop requires approval of Electrical Inspector Yes No ®ANGER ZONE LITERATURE: Yes No MGL Chapter 966 Section 21A -F and G min.$100-$1000 fine !pc.Building Permit Revised 2010 i The folowing is a list of the required forms to be filled out for the appropriate.permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits o Building Permit Application o Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses o . Copy of Contract o Floor Plan Or Proposed Interior Work o Engineering Affidavits for Engineered products � ®TE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks o Building Permit Application o Certified Surveyed Plot Plan o Workers Comp. Affidavit o Photo Copy of H.I.C. And C.S.L. Licenses o 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) o Engineering Affidavits for Engineered products MTE: 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 o Photo of H.I.C. And C.S.L. Licenses o Workers Comp Affidavit o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) o Copy of Contract L3 Mass check Energy Compliance Report o Engineering Affidavits for Engineered products MTEe 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 app; al period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording Ynust be subm;¢ted with the building application Doc: Doc.Building Pet -mit Revised 2012 Location No. k Check #) 0 r 26342 Date TOWN OF NORTH ANDOVER° Certificate of Occupancy $ Building/Frame Permit Fee $ 9G Foundation Permit Fee $ Other Permit Fee $ TOTAL $ 7 Building Inspector .I Location No. 7—,6? e0 Date Check # P/V7�/ 26773 TOWN OF NORTH ANDOVER Certificate of Occupancy $fid-' Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ W 1 01 No •rM �Y ti v cy �SSACHU`'E� CERTIFICATE OF USE & OCCUPANCY Building Permit Number 720-13 on 5/1/2013 Date: June 27, 2013 THIS CERTIFIES THAT THE BUILDING LOCATED ON 790 Turnpike Street MAY BE OCCUPIED AS 10 offices IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: KS Partners, LLC 130 New Boston Street Lowell, MA 01851 Fee: $100.00 Receipt: &�-2 7 Check : I Building Inspe for a m m m m y m y m v a C � U) 0 O CD n Z NroolL CD 0-0 CL �O CL r— A co 0 CD � � — cr CD CD o CD CD N. vCD CQ CD I � v 0 z CD 0O CDO 0 9 m m a) 0 Cl) 0 0-0 __ CD �• (D _0 cn CD a n Q 0 m . � O =r-0 -� 7 fn „=,r FD 17 O o r+ a. 0 rn �°ID N c CD CD _ CCD �•O : ® C 0 cn, o 70 r^ Rr CD CD CD f ^ < (.0 :V O o0cnN oCD 0 0 a g �� =ra n�� Q 0 CL � < CD CD a) CD o � C, Vk, 4CD o -� �C o- :po, CC o �+ L rt O CD CD =— r CD C� O in N .+ D 'D : (O 0 2) o CL r v V7 V1 W O O rOD rD°'DOC r7f�D T �o O O O T N 7 (D °—' OCG T Z7 3 O °—' QOG n% -n j' SO °' 37 7Q K p' N T3 (D O '6, a(D n \ n S mc n C E W v 3 C � o0 D mZ _ DA ,`�+ Z z D Z 70 r^ lz . 4K 6s m 9 rl--_� -am.m. Z' (o m 1, 0 c GENERAL BUILDING NOTES/CHECKLIST- NOT LIMITED TO ITEMS BELOW POST ALL LOT NUMBERS, ADDRESS, AND PERMIT (COPY OK)..or no inspections INSPECTIONS: (Minimum) Excavation , Footing, Foundation, Frame, Insulation, Final. FOOTINGS: Continuous Full 2x4 Keyway Continuous strip footings for interior columns FOUNDATION: Rebar as required Anchor bolts or straps Damproofing Foundation drain - pipe/stone/fabric filter/cover and�outlet connection. FRAME: Fireblock - over girts/plates between floor joist Penetrations for plumbing, heat, elec, etc. Walls at stair stringers. Windbrace corners and center bearing partitions. Size ridge to provide full bearing at rafter cuts. Hip and Valley rafters watch bearing at walls. Ridge & Hip - Provide proper connections. Cathedral roof rafters provide proper connections and use "Hurricane Clips" tie to pla Stair stringers - watch cuts and heal support. Joist hangers - fully nailed w/ hanger nails. KIN Sill plates 2-2X6 (1 PT) w/sill seal. Girts - solid brick or steel plate bearing at foundations '/ " air space at sides in foundation pockets. Lateral bracing at ends. Certified calculations. required for Beams/LVL's Trusses. Solid bearing support for Headers/Beams etc. I Check headroom clearances - stairways, under beams ` �l Attic Access. (min. 22x30 w/3' headroom above). Crawl space access. (min. 18x24). Bath exhaust fans to have metal duct to exterior (not in soffit). Firecode S/R wood frame of "0" clearance fireplaces & stoves Window Schedule or Every Habitable Room Must Have: Natural light equal to 8% of floor area. '/ of required glazing shall be openable. Bedrooms required min. 20x24 egress window or r door. Vent attic spaces - "proper vent", soffit and required ridge vents. ( L Firecode under stairs if used for storage FIREPLACES: Separate permit required. Inspections at Footing - Smoke Chamber - Finish Smooth parging, clean joints, 8" solid @ combust. DECKS: Lag to house, provide flashing. � Rails min. 36 " high, Baluster max space 4" on center. C\C Over 8' above grade, use 6x6 posts w/lateral bracing. Lag all posts and rails. y (\ Pier footings down 48", Conc. pad at stair base. FINISH: Handrails returned to wall/newall post. Guardrails required alongside open cellar stairs. Exterior grading complete. Certificate or occupancy required prior to occupying structure. Temporary Stairs required for inspection. Re -inspection fee - $30.00 (Be Ready). Certificate of occupancy required prior to occupying structure. S C 91 p -r E L ®I • J: C 0 n N 'r i�o � a ti ,CiL O ,fir} �; • " 3 "= �� J 4mom N G1 rte-. k.: o c. o � 0 d : w �} _CD _ �# U) CD OEM �Eoo c N�;• CL � U ... m 0 Cc ` N 0) ' Q N as o v� Uv (D Um s w = -03- o °� rn c C ~ W 0 'E 0�_O o L 0 � ._ = � 0-0 N •�-• Q U)o "" = O UnAink 0 T Q w 0 o W,� Q W 'V W O z WWC W LL O d z ` `iJ z M LA ? U a G _ �J m i �� m J LU Q W Ui 25 Z � L +O+ ? C O 4V ���� d V W y\ `.J. to O O 4; N Y O V .O O. 0 cuLL �t10 O LLU t-.O, 7 C d.0 C LL OA O C K LL O v v �] O N LL LULU (n {% (n p -r E L ®I • J: C 0 n N 'r i�o � a ti ,CiL O ,fir} �; • " 3 "= �� J 4mom N G1 rte-. k.: o c. o � 0 d : w �} _CD _ �# U) CD OEM �Eoo c N�;• CL � U ... m 0 Cc ` N 0) ' Q N as o v� Uv (D Um s w = -03- o °� rn c C ~ W 0 'E 0�_O o L 0 � ._ = � 0-0 N •�-• Q U)o "" = O UnAink rM7 .r 0 w :a z z � m Cl) Z � to O Z U LU LULU O U LU CL z rM7 .r n GENERAL BUILDING NOTES/CHECKLIST- NOT LIMITED TO ITEMS BELOW POST ALL LOT NUMBERS, ADDRESS, AND PERMIT (COPY OK)..or no inspections INSPECTIONS: (Minimum) Excavation, Footing, Foundation, Frame, Insulation, Final. FOOTINGS: Continuous Full 2x4 Keyway Continuous strip footings for interior columns FOUNDATION: Rebar as required Anchor bolts or straps Damproofing Foundation drain - pipe/stone/fabric filter/cover and+putlet connection. FRAME: Fireblock - over girtslplates between floor joist Penetrations for plumbing, heat, elec, etc. Walls at stair stringers. Windbrace corners and center bearing partitions. Size ridge to provide full bearing at rafter cuts. Hip and Valley rafters - watch bearing at walls. Ridge & Hip - Provide proper connections. Cathedral roof rafters provide proper connections and use "Hurricane Clips" tie to pla Stair stringers - watch cuts and heal support. 1�, Joist hangers - fully nailed w/ hanger nails. Sill plates 2-2X6 (1 PT) w/sill seal. Girls - solid brick or steel plate bearing at foundations '/ " air space at sides in foundation pockets. Lateral bracing at ends. Certified calculations. required for Beam s/LVL's Trusses. Solid bearing support for Headers/Beams etc. Check headroom clearances - stairways, under beams Attic Access. (min. 22x30 w/3' headroom above). Crawl space access. (min. 18x24). Bath exhaust fans to have metal duct to exterior (not in soffit). Firecode S/R wood frame of "0" clearance fireplaces & stoves Window Schedule or Every Habitable Room Must Have: Natural light equal to 8% of floor area. '/1 of required glazing shall be openable. Bedrooms required min. 20x24 egress window or door. M Vent attic spaces - "proper vent", soffit and required ridge vents. ( �' Firecode under stairs if used for storage c� FIREPLACES: Separate permit required. Inspections at Footing - Smoke Chamber - Finish Smooth parging, clean joints, 8" solid @ combust. DECKS: Lag to house, provide flashing. Rails min. 36" high, Baluster max space 4" on center. Over 8' above grade, use 6x6 posts whateral bracing. Lag all posts and rails. �\ Pier footings down 48", Conc. pad at stair base. FINISH: Handrails returned to wall/newall post. Guardrails required alongside open cellar stairs. Exterior grading complete. Certificate or occupancy required prior to occupying structure. iiza Temporary Stairs required for inspection. { Re -inspection fee - $30.00 (Be Ready). Certificate of occupancy required prior to occupying structure ' �% O4 KORTH �* 'SSACRUSEi CERTIFICATE OF USE & OCCUPANCY Building Permit Number 720-13 on 5/1/2013 Date: June 27, 2013 THIS CERTIFIES THAT THE BUILDING LOCATED ON 790 Turnpike Street MAY BE OCCIUPIED AS 10 offices IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: KS Partners, LLC 130 New Boston Street Lowell, MA 01851 Fee: $100.00 Receipt: i Check : /937 a 3 Building Inspe for ar O : :V : ul :a C9 Z 0 a N U I— z O LLJJ M L� ii LX s i w ti NV v C.� 0 n F- Q O W ✓ Z �J O y W O d Z � Q a, Z W LL o Q z c � ? z m u �` a Z N Q q a a W LU o o m O v a, =' m N J _ n J W d: LL O Y N .Y O Q LL VI C 7 3 LL C' U 7 d' LL ai dk1 V 3 " r fA LL h0 7 C w LL Z O a) Y s0.. `1 O CO N N O : :V : ul :a C9 Z 0 a N U I— z O LLJJ M L� ii LX s i w ti NV v C.� 0 n O O c O 1. C CD d: w �oo N t E y O : :V : ul :a C9 Z 0 a N U I— z O LLJJ M L� ii LX s i w ti NV v C.� 0 n Enter construction cost for fee cal - North Andover Fee Cakulation Construction Cost $ 80,257.00 m $ - $ 963.08 Plumbing Fee $ 120.39 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 120.39 Total fees collected $ 1,303.86 790 Turnpike Street 720-13 on 5/1/2013 10 New Office and Conference Room Rework Electrical, New Kitchen Cabinets and Sink CA m m m y m . v C � N 0 'a 0 O 2) = �o CL N .a o <0 CD o CD CL Cr — CD CD o CD CD 0 CD �. C N. QQ. CCD I v 0 Z CD 00 0 CCD 0 CD 3.- z m 0 z Cl) C z cn Cl) c� Z Z Cl) 0 O m Cl) z cr) O cn 010 -PL 0 -1 0 a) --IN=�<m D V m0 -n O .Z7 O 3 in n T j' a�_ c`D,cDo rt Q- 0 � m _T O D, 0 o• -.=-a C W z to m a T 7 n 3 �' � m MD- O O ,.« Q. Ln 0 TI m Vi (D a n Et y 3 ao��v ccn c D� _ Q. Gt y O O Q -1 rt n to O N C a1 C.) CD <D CDo O 0:5. ,:fes O , _S 0, O o0�r = cr S :g v . + o o �' : L Cn �c� 0=0 �1 :(A CD W � CD O N rt O O 06. . c CD C O y O h ?� v_ CD : io D -0 ci � rt w OC3 Q , O y 0 N rpz 0 rr V1 1- Z O W c D V m0 -n O .Z7 O 3 H N n T j' a�_ N O .Z7 O s m m CA m a _T O D, Z7 O �c S C W z to m a T 7 n 3 �' � m .Z7 O � T O a- C 3 C G z � m Vi (D a n Et y 3 T O o I- 7C ' W v o m D` ti 0 c Client#- 55556 KSPARTNERS1 ACORD. CERTIFICATE OF LIABILITY INSURANCE OATE(MMIDDIYYYY) TYPE OF INSURANCE _I 4/30/2013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: HUB International New England PHONE FAX AIC No Ext): 978 657-5100 AIC No ; 866-475-7959 299 Ballardvale St a DD MAIL Ss: nee.certificates@hubinternational.com Wilmington, MA 01887 MED EXP (Any one person) $ 978 657-5100. INSURER(S) AFFORDING COVERAGE NAIC# INSURERA: EastGUARD Insurance Company 14702 PRODUCTS - COMP/OP AGG $ INSURED KS Partners LLC etal INSURER B: AUTOMOBILE LIABILITY - ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIREDAUTOS AUTOS Jefferson Equity/ Jefferson Office Park INSURER C : . - - 130 New Boston St Ste 303 INSURER D COMBINED SINGLE LIMIT Ea accident Woburn, MA 01801 INSURER E: PROPERTY DAMAGE Per accident $ $ INSURER F : UUVEKAUES CFRTIFICATF MIIMRFR• - DC\AQInk1 k1111012ro. THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT :TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF INSURANCE _I ADDL NSR SUB WVD POLICY NUMBER . POLICY EFF MMIDD POLICY EXP MMIDD LIMITS GENERAL LIABILITY COMMERciALGENERALLIABILITY CLAIMS -MADE D OCCUR EACH OCCURRENCE $ PREMISES eENTED $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: POLICY n ECT LOC PRODUCTS - COMP/OP AGG $ $ AUTOMOBILE LIABILITY - ANY AUTO ALL OWNED SCHEDULED AUTOS AUTOS NON -OWNED HIREDAUTOS AUTOS - - COMBINED SINGLE LIMIT Ea accident BODILY INJURY (Per person) $ accident BODILY INJURY Per $ ( ) PROPERTY DAMAGE Per accident $ $ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION $ $ A WORKERS COMPENSATION EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICERIMEMBER EXCLUDED? (Mandatory in NH) If yes; describe under DESCRIPTION OF OPERATIONS below N / A KSWC420995 4/11/2013 04/11/2014 X 1T&SyTLA1MU1jOTH- sAND E.L. EACH ACCIDENT $500,000 E.L. DISEASE - EA EMPLOYEE $500,000 E.L. DISEASE - POLICY LIMIT $600,000 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is required) re 790 Turnpike St, North Andover MA. VGRI IrIV/1I G rIVL1JCR IUANUhLLATION Town of North Andover SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 120 Main St ACCORDANCE WITH THE POLICY PROVISIONS. North Andover, MA 01845 AUTHORIZED REPRESENTATIVE 1p t .V C/4"11110"'111— @ 1988-2010 — ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25 (2010105) 1 of 1 The ACORD name and logo are registered marks of ACORD #S912430/M908254 EH002 CM 1'. 4-1 w •� C• 4. i t%+ a�, cn 00 ' r ►"D 'S a .s z 1, i The Commonwealth of Massachusetts Department oflndustrialAccidents Office of Investigations 600 Washington Street Boston, MA 02111 UT www.mass gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): � �� t `t l �`— Address: l�J Nt w S St City/State/Zip:LAo�A&, G lisy I Phone #: 51-7k6_00 - 6500 Are you an employer? Check the appropriate box: 1. I am a employer with -3!1,-" S 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. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp, c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. E] Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ EIectrical repairs or additions I L ❑ 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. 1 Homeowners who submit this affidavit indicating they aie doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workerscompensation insuran, cefor m employees. Below is thepolicy and job site information. i Insurance Company Name:. V1 Q rV\- 41h Policy # or Self -ins. Lie. #:`� �" �:: a�`]� �`^��� Expiration Date: Job Site Address: _�?O uroe)')Q S1 city/state/zip:, tgmde r A Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as 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 cero under the pains and penalties ofperjury that the information provided above is true and correct. /5 - 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 Ions 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 w 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 ofMgssachusP#ts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston} MA. 02111 Tel, # 617-727-4900 ext 406 or 1-877:MASSA B Revised 5-26-05 FaY, # 617-727-7749 www.m.asa,govaa DSH / DESIGN GROUP Architects m Engineers m Construction Managers CONSTRUCTION CONTROL AFFIDAVIT PROJECT TITLE: INTERIOR RENOVATION OF THIRD FLOOR -LIFE CHOICE PROJECT LOCATION: 790 TURNPIKE STREET, NORTH ANDOVER, MA SCOPE OF PROJECT: REMOVAL OF THE EXISTING AND INSTALLATION OF NEW PARTITIONS. In accordance with 780 CMR Section 107.6.2 of the Massachusetts State Building Code, I Davood Shahin, Registration # 8186 being a registered professional architect with the firm of DSH Design Group, 233 Needham Street, Newton, MA 02464, hereby certify that I have prepared or directly supervised the preparation of the renovation plan indicating addition of new offices, new fire safety and exist devices and relocation of few sprinkler heads within the existing space for the above named project and that, to the best of my knowledge, such plan meet the applicable provisions of the Massachusetts State Building Code, all acceptable architectural practices and all applicable laws and ordinances for the proposed use and occupancy. I further certify that 1, or my authorized representative shall perform the necessary professional services and be present on the construction site on a regular and periodic basis to determine that the work is proceeding in accordance with the documents approved for the building pernvt and shall be responsible for the following as specified in Section 107.6.2.2: D ASC JOOD 0 o. 8186 C� N ON o,G ASSA USETTS Jco �Fq! Ty 0 M SSPV� Subscribed an orn to me this 17TB of April 2013 My Commission Expires: otary Public 233 Needham Street, Suite 300 Newton, MA 02464 T- 611- 454-1230 F- 611- 454-1231 www.dshdesigngroup.com