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HomeMy WebLinkAboutBuilding Permit #352-11 - 85 FLAGSHIP DRIVE 10/26/2010 I TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION i Permit NO: �� � � Date Received Date Issued: • IMPORTANT:Applicant must complete all items on this page 1 LOCATION Print PROPERTY OWNER CMS6pWc, a ads fi !Utzcy� ra 1 Print MAP NO1076 PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no r TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family 11 Industrial Alteration No. of units: Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other Septic ,Q Well D.Floodplain ❑ Wetlands ❑ Watershed District Water/Sewer _ DESCRIPTION OF WORK TO BE PERFORMED: Pamwa La- �6-c a&d a9d /;t� 'M' /� V VV Identification Please Type or Print Clearly) OWNER: Name: lVlafC CymS Mk WitraaoCet 'P(fz6 ('a(J Phone: 50g-52 ?7Zq Address: 23 �' w% 51 h,- 5cstar w A p2 t i y CONTRACTOR Name: �sN�C7Phone: Address: RS Ce A­n� Supervisor's Construction License: ol 1-7 5- Exp. Date: �{�I /� IZ Home Improvement License: r b'� $�`j Exp. Date: 9 / i o ',&o 12 ARCHITECT/ENGINEER 6&k Nr,, IY-C'5 Phone: � 100- Address:'( f�)�- V5Wd\ MA Reg. No. 5-C) i FEE SCHEDULE:BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.P. Total Project Cost: $ I � l Sso FEE: $ Check No.:, Receipt No.: a3(a NOTE: Persons contracting h u &rere tractors do not have access to the guar , nd Si 9 n- at ent/®wne T i nafure of contractor . _ _t, r Location eA— �CfT4;2 No. SZ- Date —/d NORTH TOWN OF NORTH ANDOVER 0 s D Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ ` Other Permit Fee $ TOTAL $ Check # 23607 Building Inspector Plans Submitted Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer . Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM } DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMMENTS a CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments i Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit PW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Q i Fire Department signature/date ~ COMMENTS 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 I Notified for pickup - Date — - -- — Doc:.Building Permit Revised 2008 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 Rehabi itation Permits ❑ Building Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or S.L. icenses Copy of Contract Floor Plan Or Proposed Interior Work ❑ 'lgyAffidavits for Engineered products { NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks s . s ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses a ❑ 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 j ❑ 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 I Hydraulic Calculations (If Applicable) o 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 rnust be submitted with the building application Doc: Doc-Building Permit Revised 2008mi J A ra C4 a-r�lro Statement at Completion of Project Project: FITZGERALD HEALTH EDUCATION ASSOCIATES Project Number: 00720 Interior Improvements and Alterations 85 Flagship Drive, North Andover MA Date: January 31, 2011 Permit Number: 352-1011 In accordance with 780 CMR (Commonwealth of Massachusetts Building Code) Section 116.0 Construction Control, and specifically Sections 116.2.2 Architect's/Engineer's Responsibilities during Construction, I, ..........Rainer..Koch....NCARB.................................. Architectural Registration No. ........MA..5056............. being a registered architect, have monitored the construction and provided the following tasks and documents during this construction process: 1. Reviewed for conformance to the design concept:shop drawings, samples and other mat W Is which were submitted by the contractor in accordance with the requirements of the construction documents. 2. Reviewed and approved the quality control procedures for all code-required controlled materials. 3. Was present at intervals appropriate to the stages of construction, generally familiar with the progress and quality of the work and determined, in general, that the work was being performed in a manner consistent with the construction documents. 4. Was present at the construction site on a regular basis or as outlined in the initial inspection schedule, and/or I have sent other appropriately qualified design professionals, to determine that the work was proceeding in accordance with the documents submitted with the building permit application and the applicable provisions of the Commonwealth of Massachusetts Building Code. 5. Provided the building inspector with an original, stamped report for each site visit scheduled or otherwise. Please accept this statement in consideration for the issue of a CERTIFICATE OF OCCUPANCY for the above referenced project/work. =R Signed and Sealed: y No.5056 9� . Attachments: Distribution: Building Department Client Architect Contractor/Field 38 Essex Road, Ipswich, Massachusetts 01938-2532 electronic: kocharchitects@verizon.net telephone: 1.978.356.5065 facsimile: 1.978.356.6056 I Construction Control Affidavit Project: Fitzgerald Health Education Associates Project Number: 00720 INTERIOR IMPROVEMENTS/ALTERATIONS Units A & B, 85 Flagship Drive, North Andover MA Date: 'October 04, 2010 In accordance with 780 CMR (Commonwealth of Massachusetts Building Code) Section 116.0 Construction Control, and specifically Sections 116.2.2 Architect's/Engineer's Responsibilities during Construction and 116.4 On Site Project Representation, I, ...........RainerKoch.. IVCARB..,,•„• Architectural Registration No. ......MA....�4. 6............... being a registered architect, have prepared or directly supervised the preparation of all design plans, computations and specifications for the above named project and I state, that such plans, computations and specifications meet the applicable provisions of the Commonwealth of Massachusetts Building Code, all acceptable engineering practices and applicable laws and ordinances for the proposed use and occupancy. As it may be required and applicable for the project, I will monitor the construction process and provide the following tasks: 1. Review for conformance to the design concept:shop drawings, samples and other materials which are submitted by the contractor in accordance with the requirements of the construction documents. 2. Review and approve the quality control procedures for all code-required controlled materials. 3. Be present at intervals appropriate to the stages of construction, generally familiar with the progress and quality of the work and to determine, in general, if the work is being performed in a manner consistent with the construction documents. 4. Be present at the construction site on a regular basis or as proposed in the attached inspection schedule, and/or I will send other appropriately qualified design professionals, to determine that the work is proceeding in accordance with the documents submitted with the building permit application and the applicable provisions of the Commonwealth of Massachusetts Building Code. 5. Provide the building inspector with an original, stamped report for each site visit, scheduled or otherwise. 6. Issue a Statementf Project olect Completion at the time the construction is considered substantially complete and ready for occupancy I understand, that no CERTIFICATE OF OCCUPANCY will be issued until all reports and a statement of project completion have been submitted to the satisfaction of the building inspector/code enforcement official. Signed and Sealed: w W b ` tit Qo. no. � n OF Distribution: Building Department Client Architect Contractor/Field 38 Essex Road, 1psMch, Vassachusetts 01938 2532 eiectronic kccharchitects�verizon.net tetephone: 1.978.356.5065 facsimile: 1.978.355.6056 HVAC &Plumbing: Demelo Plumbing,Heating&Air Conditioning 31 Broad St., Suite B Hudson,MA 01749 978-562-9959 Fire Supression: U.S. Fire Group 65 Bay State Drive Braintree,MA 02184 781-848-0887 Electrical: Escott Electrical Services 10 Coolidge Dr Tyngsboro, MA 01879 978-649-3783 Plaster: Duane Plastering 172 Elm Ave Quincy,MA 02170 617-376-0884 Carpenters: Paul Sweeney 14 Edgbaston St Billerica,MA 01821 Pat Cochran 58 Eutaw St Boston, MA 02128 I i OFFICE OF BUILDING INSPECTOR TOWN OF NORTH ANDOVER CONSTRUCTION CONTROL PROJECT NUMBER: 00720 f PROJECT TITLE: Fitzgerald Health Education Associates PROJECT LOCATION: Units A and B, 85 Flagship Drive � 8 NAME OF BUILDING: 5 Flagship Drive Interior Improvements and 1 NATURE OF PROJECT: expansiom at second floor IN ACCORDANCE WITH ARTICLE 116 OF THE MASSACHUSETTS STATE BUILDING CODE, I, Rainer Koch REGISTRATION NO. 50�� BEING A REGISTERED PROFESSIONAL ENGINEER/ARCHITECH HEREBY CERTIFY THAT I HAVE PREPARED OR DIRECTLY SUPERVISED THE PREPARATION OF ALL DESIGN PLANS, COMPUTATIONS AND SPECIFICATIONS CONCERNING: ' ENTIRE PROJECT 0 ARCHITECTURAL I STRUCTURAL ' MECHANICAL 0 i i I FIRE PROTECTION 0 ELECTRICAL .0 OTHER(SPECIFY) 4 FOR-THE ABOVE NAMED PROJECT AND THAT,TO THE BEST OF MY KNOWLEGE, SUCH PLANS, COMPUTATIONS AND SPECIFICATIONS MEET THE APPLICABLE PROVISION OF THE MASSACHUSETTS { STATE BUILDING CODE,ALL ACCEPTABLE ENGINEERING PRATICES. AND APPLICABLE LAWS AND ORDINANCES FOR THE PROPOSED USE AND OCCUPANCY. I FURTHER CERTIFY THAT I SHALL PERFORM THE NECESSARY PROFESSIONAL SERVICES AND B ' EPRESENT ON THE CONSTRUCTION SITE ON A REGULAR AND PERIODIC BASIS TO DETERMINE THAT THE WORK IS PROCEEEDING IN ACCORDANCE WITH THE DOCUMENTS APPROVED FOR THE BUILDING PERMIT AND SHALL BE RESPONSIBLE FOR THE FOLLOWING AS SPECIFIED IN SECTION 116.0 1. Review, for conformance to the design concept, shop drawings, samples and other submittals which are submitted by the contractor in accordance with the requirements of the construction documents. i 2. Review and approval of the quality control procedures for all code-required controlled materials. 3. Be present at intervals appropriate to the stage of construction to become, generally familiar with6the progress and quality of the work and to determine, in general, if the work is being performed in a manner consistent with the construction documents. i PURSUANT TO SECTION 116.2 .2 1 SHALL SUBMIT WEEKLY , A PROGRESS REPORT TOGETHER WITH PERTINENT COMMENTS TO.THE NORTH ANDOVER BUILDING INSPECT ` UPON COMPLETION OF THE WORK, 1 SHALL SUBMIT A FINAL REPORTA TO THE SA'T'ISFACTORY COMPLETION AND READINESS OF THE PROJECT FOR O CUPANCY. S T BSC E AN S O TO EF ME THISZ G UE_DAY OF NOTAMITFOBLIC MY COMMISSION EXPIRES r�OL3 r '` til:►,�:tchusetts- Delhulment of Yul►iic Safm Board (if Building* Rr'ulatiuns and standard Construction Supervisor Pe or License :. License: CS 99275 Restricted to: 00 RUSSELL PASCOE 28 CENTER STREET ANDOVER, MA 01810 y I Expiration: 4(1/2012 t igl!ai.ciyrt•r Tr#: 992.75 NOMWAMMW ✓c�o �orrr� ea ,,� a � Office ot`Consumer'�airsdsiness egaad� HOME IMPROVEMENT CONTRACTOR Registration:;.160893 Type: Expiration: 9f10I2012 DBA CYP"ESS CONSTRIGOP1=_', 7 RUSSELL PASC& 28 CENTER ST ANDOVER,MA 01lllk� Undersecretary 1� C f Cypress Construction Your Green Remodeler October 25, 2010 Estimate Russell Pascoe, President Estimate for: Fitzgerald Health 25 Center St. Education Associates, Inc. Andover, MA Job Site: Units A &B 978-886-9746 85 Flagship Dr Ma License: 99275, Hic 274544 N. Andover, MA This agreement is between the parties Cypress Construction and Russell Pascoe ("Cypress") and Fitzgerald Health Education Associates, Inc. ("FHEA") Scope of work to be done: Remodeling offices at above address to follow plans dated 10/4/2010. Subcontractors will be used in the following areas: electric, plumbing, fire suppression, HVAC, and plaster. Their estimates and brief description follow: Electric: includes permit, labor and material to include wiring outlets, switches, light fixtures and emergency lights. This estimate does not include wiring for alarms, computers, ac/heating equipment or other electrical devices not supplied by subcontractor. .......:.............................................................................................................................$8,500 Plumbing: includes permit, labor and material to include 2 kitchen sinks,janitors mop sink, handicap toilet and sink, 4 toilets, 2 drinking fountains. All drains are no hub black iron and type K copper. Water lines are type L copper. This estimate does not include faucets or bathroom partitions. ...................................................................................................................................$2000 Fire,Supression: includes permit, labor and material to include new chrome recessed sprinkler heads, upright sprinkler heads to cover below mezzanine, existing main and branch lines remain untouched. This estimate does not include wiring of electrical devices, alterations to existing base building system riser assembly, fire alarm/sprinkler shut down or activation fees, fire watch and/or fees, fees for new hydrant flow test, or cutting open or patching walls or ceilings. .....................................................................................................................................$7,650 1IPage i Cypress Estimate Plaster: includes labor and material to include stocking blue board, hanging blue board, finishing blue board with plaster ready for painter,patching of walls as needed with same. .....................................................................................................................................$8,000 HVAC: 1. Installation of 1 Bryant Gas Fired 5 Ton Rooftop unit with heating and air conditioning to replace existing First Floor unit. .......................................................................................................................................7,950 2. Installation of 1 Bryant Gas Fired 3 Ton Rooftop unit with heating and air conditioning to replace existing Second Floor unit. .....................................................................................................................................$6,500 3. Install new supply trunk and supply vents for new mezzanine area off of existing 5 Ton rooftop that services second floor space. .....................................................................................................................................$4,680 4. Replace existing I '/z ton rooftop with new 3 Ton Bryant rooftop. Install new curb and plenum and add additional duct to feed 3 existing offices on the eastern side of the building on the second floor. .....................................................................................................................................$8,250 Prices include labor and material, crane and disposal of unit affected. These prices do not include the electrical wiring of the units and city permits. Carpentry: includes permit, labor and material to include, demo, scheduling and coordinating with sub contractors, framing as specified, ceiling as needed, TJI floor joist and subfloor, bathroom stalls, dumpster fees. This estimate does not include doors (material), cabinets (material), carpet/vct(labor and material), cubicles (labor and material), appliances (labor and material), bathroom vanities/mirrors (material), faucets(labor and material), grab bars (labor and material). This estimate also does not include a structural engineer ...................................................................................................................................$44,000 Other estimates: 1st floor B side: includes labor and material to include changes made per plan. This estimate does not include the vct or carpet tiles. .....................................................................................................................................$1,050 21Page r Cypress Estimate SPECIAL CONDITIONS General: This bid expires 6 months from date above. Billing: Percentage of total contract price billed at specific intervals as follows- 10%at time of contract signing, 25%the day work starts, 25% after frame, 25% after rough inspections and 15%after final inspections. Changes: Any changes to the above outline will result in a change order. A change order will be priced and approved before the change can be enacted. This amount will amend the billing amount and schedule. Some conditions that will require correcting are not apparent at time of initial inspection and will be treated as a change order. The change order must be paid before the change can be enacted. Stock: This bid is for labor and miscellaneous material. Material will be subject to a handling fee of 30% above cost and is reflected in the total amount due. Schedule: A mutually acceptable time will be established. Permits: The general contractor is responsible for overseeing permits. Work required by town inspectors is not included in this estimate and will be treated as a change order. � 3 � Page Cypress Estimate ADDENDUM 1. Payment Schedule Start Rough Finish Phase �n of Work Work Puch List Signing Phase Completed Completed Completed I 10% 25% 7.5% 7.5% 50% II 40% 50% 10% Where phase 1 is Unit A first floor; phase 2 is Unit A& B second floor; phase 3 is Unit B first floor. 2. FHEA is relying on Cypress Construction's expertise as a general contractor. a. All personnel on this project will be engaged through Cypress construction and Cypress will be responsible for insuring that all its own workers and subcontractor's workers are duly licensed, when required by law or regulation and competent to perform the tasks assigned. b. Cypress is responsible to see that all personnel on this project are fully insured for general liability and workmen's compensation insurance. c. Cypress is responsible for determining the scope of work to meet all regulatory and performance and quality criteria of FHEA. Cypress is not responsible for area outside the scope of work as described above. 3. Cypress Construction will perform the renovations in accordance with the architectural plans for the project prepared by Koch Architects dated 10/4/2010. Notwithstanding, Cypress Construction will review and concur with the plans and FHEA's projected schedule of work before performing any work. 4. Cypress is not responsible for delays in construction dut to delays not with the control of Cypress or it's subcontractors. 5. Cypress Construction is responsible for all permitting, compliance with state and local, laws, regulations and building codes. Any corrective work needed in order to comply with such laws, regulations and building codes will be performed at no cost to FHEA except additional work required by tow inspectors outside the scope of work. Any such work will be treated as a change order and billed to FHEA. 6. All disruptions of electrical service will be planned in advance with FHEA knowledge and approval so as to minimize the disruption of FHEA normal business operations. 7. Cypress acknowledges that FHEA must continue to conduct business in and around the contracted work. Adjustments to work schedules will be made by Cypress to minimize disruptions including scheduling sub-contractors to perform work in a non-contiguous 'time frame. . _._ .. _............- - -- _ ....... .- - 4Page i Cypress Estimate I I 8. Any labor, work or deliveries of materials outside normal business hours, M-F 9 AM—5 PM must be arranged with FHEA in advance. In no case will activity outside normal business hours cause overtime labor charges to FHEA despite the need for the work to be done in order for Cypress to meet its commitment to the attached schedule and milestones. a. Milestone 1: completion of all contracted work on Unit A, first floor including but not limited to reconfiguration of all doors and walls,new bathrooms, new front stairs,removal of closet and unused stairs in production room. b. Milestone 2: completion of all contracted work on Unit A and B second floor, including but not limited to construction of the mezzanine over the Unit A warehouse, demolition of the wall between the new mezzanine and the existing Unit A second floor as well as the passage through to Unit B second floor, new ceiling and lighting in the new and joined Unit A second floor. c. Milestone 3: completion of all contracted work on Unit B first floor, including but not limited to moving entrance to employee break room, demolition of existing wall separating the break room from the kitchen and partial demo of demising wall at the sink. Owner: Contractor: Marc W. Comstock, CEO Russell Pascoe, President Fitzgerald Health Education Associates, Inc. Cypress Construction 85 Flagship Drive 28 Center St North Andover, MA 01845 Andover, MA 01810 Ddfe Z6 Zo/ 0 Date 5 Page Cypress Estimate LEGAL NOTICE: 1. Notice: a. That all contractors and subcontractors shall be registered and that any inquiries about a contractor or subcontractor relating to a registration should be directed to: Registration Division,Program Coordinator One Ashburton Place Room 1301 Boston,MA 02108 Tel:(617)727-3200 ext 25239 b.The contractor's registration number must be on the first page of the contract c.the owner's three day cancellation rights under MGL c 93 s 48;MGL c 140D s 10 or MGL c 255D s 14 as may be applicable. d.All warranties on the owners rights under the provisions of 780 CMR R6 and MGL c 142A e. Whether any lien or security interest is on the residence as a consequence of the contract. N/A 2. An enumeration of such other matters upon which the owner and contractor may lawfully agree. 3.Any other provisions otherwise required by the applicable laws of the Commonwealth.N/A 4.Permit Notice:Every contract shall contain a clause informing the owner of the following: a. any and all necessary construction-related permits b.that it shall be the obligation of the contractor to obtain such permits as the owner's agent c.that owners who secure their own construction-related permits or deal with unregistered contractors shall be excluded from access to the Guarantee Fund. 5.Acceleration of payment:No contract shall contain an acceleration clause under which any part or all of the balance not yet due may be declared due and payable because the holder deems himself to be insecure.However, where the contractor deems himself to be insecure he may require as a prerequisite to continuing said work that the balance of the funds due under the contract,which are in the possession of the owner,shall be placed in a joint escrow account requiring the signatures of the home improvement contractor and the owner for withdrawl. 6.No work shall begin prior to the signing of the contract and transmittal to the owner of a copy of such contract. By signing,you agree to the terms of the contract. 7.Arbitration: "The contractor and the homeowner hereby mutually agree in advance that in the event that the contractor has a dispute concerning this contract,the contractor may submit such dispute to a private arbitration service which has been approved by the Office of Consumer Affairs and Business Regulation and the consumer shall be required to submit to such arbitration as provided in MGL c 142A." DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. Owner: Contractor: Marc W.Comstock,CEO Russell Pascoe,President Fitzgerald Health Education Associates,Inc. Cypress Construction 85 Flagship Drive 28 Center St North Andover,MA 01845 Andover,MA 01810 n ' Date !� Date NO E:The signatures of the parties above apply only to the agreement of the parties to alternate dispute reso tion initiated by the contractor.The owner may initiate alternative dispute resolution even where this section is not signed separately by the parties. 6Page i �r r r' .__`deposit start completion \ hvac/plumbing 47380', 15793.33 15793.33 15793.33333 - - - - - contract signing start 1 rough 1 final rough 2 final punch electrician 8500 2125 2125 2125 2125 plaster 8000 4000 4000 sprinkler 7650 1650 3000 3000 cypress 69200 6920 17300 5190 . 5190 17300 10380 -6920 34600 34600 /0 CcI-e-ss , QZa- ao Z�� 3 `33 ORTiy Tovm of Andover No. axo LAK -o dover, Mass., o4o COC MIC KE WICK Ad RATED `S BOARD OF HEALTH P,ERMIT T D Food/Kitchen Septic System nn BUILDING INSPECTOR THIS CERTIFIES THAT.........I..I.I��1 - ...:.�.6.!'�►...5. .4.k : Foundation • has permission to erect. .......... buildings on .... .!...... 1P....................................... Rough to be occupied as.. `.a. ......................�14' .... -......... .....�CI.l1 ► ................................................................ Chimney h' provided that the person accepting this permit shall in every respect conform 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 PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUC STARTS Rough . ................... Service . ... ..... ..................... BUILDING PECTOR 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. AC�® DATE(MMIDDIYYYY) CERTIFICATE OF LIABILITY INSURANCE 10/26/2010 PRODUCER (781)986-4400 FAX: (781)963-4420 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Risk Strategies Company ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 15 Pacella Park Drive ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Suite 240 Randolph MA 02368 INSURERS AFFORDING COVERAGE NAIC# INSURED I INSURERA:NGM Insurance Company Russell Pascoe, DBA: Cypress Construction INSURER B:Granite State 28 Center Street INSURER C: INSURER D: Andover MA 01810 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 OFSUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD'L POLICYNUMBER POLICDATEIMEFFEECTIVE POLICY EXPIRATIONTYPE OF INSURANCE LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000 000 A'AGE ToX COMMERCIAL GENERAL LIABILITY PREM SES(E.occu RENTED nce) $ 50,000 A CLAIMS MADE ❑R OCCUR MPF1408E 11/8/2009 11/8/2010 MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY IX jECT PRO LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) $ HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (Per accident) $ PROPERTY DAMAGE $ (Per accident) GARAGELIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESSI UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR, FICLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ B WORKERS COMPENSATION Company to issue I Ty.'r.-Y'M OI, AND EMPLOYERS'LIABILITY Y I N ANY PROPRIETOR/PARTNER/EXECUTIVE❑ E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? (Mandatory in NH)I E.L.DISEASE-EA EMPLOYE $ If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ A OTHERguilderS Risk/ F1408E 01/25/2010 11/8/2010 $35,000 Special Form Installation Floater Special Form DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Issued as Evidence of Insurance. CERTIFICATE HOLDER CANCELLATION (978)423-9144 SHOULDANYOF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Fitzgerald Health Education Associates DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN 85 Flagship Drive NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL North Andover, MA 01845 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE Michael Christian/NB ACORD 25(2009101) ©1988-2009 ACORD CORPORATION. All rights reserved. INS025(200901) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations 600 Washington Street Boston,MA 02111 O4F www.mass.gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Ct'((j V`�5S C�Y1 Sir-t')Q'V\ Address: Cel1,jeX S� City/State/Zip: Xd o,, !,ec Phone#: Y-A— 9� Are you an employer?Check the appropriate. ox: Type of project(required): 1.❑ I am a employer with 4. I am a general contractor and I 6. ❑New construction employees(full and/or part-time).' have hired the sub-contractors 2.El am a sole proprietor or partner- listed on the attached sheet.# 7• Remodeling . ship and have no employees These sub-contractors have 8. Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its ' officers have exercised their 10.❑Electrical repairs or additions required.] 3.❑ I am a homeowner doing all work right of exemption per MGL I L❑Plumbing repairs or additions myself. [No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs employees. o w workers insurance required.]t � Other q , comp.insurance required.] 13.❑ l I - *Any applicant that checks box#1 must also 91 out the section below showing their workers'compensation policy information. T Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workerscompensation 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do Hereby cei'd&undert ns and penalties ofperjury that the information provided above is true and correct. Si ature: - Date: /0 Phone# Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town CIerk 4.EIectricaI Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: