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Building Permit #566-2011 - Suite 209 2/17/2011
BUILDING PERMIT (t�l o` N°RT 6�ti D TOWN OF NORTH ANDOVER o? bt:.'` APPLICATION FOR PLAN EXAMINATION 7D x / Permit NO: Date Received 79�DR,7e0 9SSACNUSE� Date Issued: 6q /7 `l /IMPORTANT: Applicant must complete all items on this page LOCATION .,,!/ 472dQvf►- S � c ,;g PROPERTY OWNER /Print Print MAP 210 00q �l PARCEL,!�k ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Two or more family Ind AlterationNo. of units: ommerci pair, replacement Assessory Bldg Others: Demolition Other Septic Well Floodplain Wetlands Watershed District Water/Sewer s �ESCR TIO OF ORK B E ��FOR D: U Gi/ two I^'? GG l /� G� �✓ ` o� x/c den cation fease Type dr Print Clearly) OWNER: Name: (, Phone:421. 3 Address: 1- �Inly n 37— 01le Aex/LOn n 2 q 5-1 'CONTRACTOR Namey- f(-XIS7 —,&Vi(6 Phone: 0 Address:. ! f>Le/t i 42f Supervisor's Construction License. Exp. Date: ' ,L 01 Home Improvement License: Exp. Date: r ARCHITECT/ENGINEER j03efA /J �C, 6r`- -e Phone: Address: C/ Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. // , Q6 Total Project Cost: $ l 5 �� FEE: $ 7 ;25 Check No.: / U Receipt No.: :2 3 JCA NOTE: Persons contracting with rgT�eyed contractors do not have access t Y he guaranty fund 'Signature of Agent/Ow Signature of contract L� 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 CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes i Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature & Date Driveway Permit DPW Town Engineer: Signature: Located 384 Os ood Street FIRE DEPARTMENT -Temp Dumpster on site yes o ZLocated at 124 Main Street c Fire Department signature/date COMMENTS_ R ih Location No. , 610 �2 Date HpRTITOWN OF NORTH ANDOVER Certificate of Occupancy $ v `J JACI1USEt� Building/Frame Permit Fee $ �J Foundation Permit Fee $ Other Permit Fee $ TOTAL 7 Check # ✓� n 23896 Ar Buildininspector ` NORTH '9 4 over O of . :.. %AA No. Y = lA 0 o over, Mass., / COC L KEWICK Ao PPS` 5 �qS RATED BOARD OF HEALTH Food/Kitchen Septic System .PERMIT T ` BUILDING INSPECTOR Q r���C ......................................................................................... Foundation THIS CERTIFIES THAT............��............ . ......................... ,. / S'v ���� ./�,�/ .. .OC�fi^...�f.�....................�...�..�.ff.� Rough has permission to erect........................................ buildings on ................. ` ` I �" �^, C� rao( iW-llcof(feA`rF l— Chimney to be occupied as.. . �n�ar� cJ C��=.C.,1..... ........................................................... ./�..........:. provided,that the person accepting this permit shall in every respect conform o 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 CONSTRUCT1915f STARTS Rough Service BUILDING INSPECTOR Final Occupancy Permit Required t0 Oca ipy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry (Nall To Be Done FIRE DEPARTMENT' Until Inspected and Approved by the Building Inspector. Burner. Street No. Smoke Det. SEE REVERSE SIDE==] Proposal 9433 U.S. Property Services Page 1 515 Lowell Street, Suite 3 Date 11..23.2010 Peabody, MA 01960 Devised: 12.7.2010 I. General Information Proposed by: U.S.Property Services Telephone: 978 836-1206 515 Lowell.Street,Suite 3 Peabody,MA 01.960 Submitted To: Dl LaGrasse&Associates,Inc Work Performed At: 451 Andover Street One Elm Street Suite 309 Andover MA.01810 H. Work Description: We hereby propose to furnish the materials and perform the necessary labor for the completion of the work described herein: Demo—None needed Wall construction- Construct roughly thirty-one wall to form the following offices:Kitchen/lounge, Business office,Doctors office, Accessible exam—1,X-ray,Laser exam—2, Exam-2,Exam-3,Exam—4,Laser exam—5,117ed Spa,Cleaning& Support, Toilet,Telephone/ortboties fit,Construct four(4)half walls for the control station All wall, except the four half walls, will have sound insulation batting within them No GWB soffits over the cabinets Painting: Apply one coat of primer and two coats of finish paint to all walls,GWB ceilings and door frames Apply three coats of polyurethane to the doors Apply one coat of primer and two coat of finish paint to the millwork panels above the cabinets installed by the other Blocking— r Install wood blocking as requires for all wall equipment, shelving and millwork as noted on plans marked"Progress Print-11-10-2010" Doors— Entry: Install One(1)new door with glass in the main entrance(Door type B Add mail slot,and receiver to the right of the door Borrowed Iiglit panel on right,side of interior entry will be changed to framed white opaque lexav panel Interior' Exam rooms(5),x- ay(1), bathroom(1),support✓eleaning room(1),Med Spa(1), -Install solid core doors in metal frame. Continued on page two..... Continued from page one..... Kitchen(1)and Doctor's office(1)—Install pocket door Doctors office(I)and Business office(I)—Install door with glass(door type B)in metal frame Windows— Remove existing window trim and repair G.W.B to provide gypsum return at all exterior window heads, and jam There will be an additional cost to install'b"mdf sill with al"overhang,once there are plans detailing this change the cost of the work will he given Transoms— Transoms removed between all exam rooms but will be left on the curved walls in the corridor(4 transoms)and in Doctor's Office The materials of the transoms will be Plexiglas and not double paned glass as noted on the plans. The Plexiglas will secured in place with aluminum tracks The transom design to change to 4"header instead of 1"transom height starting at 6 ft instead of 64" Ceiling— Install suspended ceiling tile system throughout except in areas noted below Construct a GWB soffit over front of reception desk and sitting area. Install a GWB ceiling in the waiting area Electrical— 6 Quad outlets tivill be changed to 6 duplex outlets(5 are which are in the business office and one in the Xray room) 10 Duplex outlets will be removed from the floor plan Install minimal outlets as required per code,Install phone lines in the reception area,nurses station and doctors office Plumbing— Install as per plans marked"Progress Print 1.1-10-2010 Issued for Pricing" Fire Alarm— Install as per State and Local code Material Allowances:(If allowance is exceed additional cost he applied however if the allowance is not met a credit will be applied to the contract.) fees•- Light Fixtures—$15,000 Flooring&Base-$12,000 Hardware-$1,500 Signage-$500 Five Sinks and faucets-$1,500 Breakdown of Pricing: New walls, insulation where noted and GWB @6 831,500.0(1 GWB ceiling$ 84,175.00 Drop Ceiling$ 510,250.00(2.0 Dune ceiling tiles,9116"track) New doors and frames$405600,00 S 81>850.00 Glass$4R,;90.49$2,750.00 Paint$6,900.00 Plumbing- 518,500.00 Blocking-$4,900$2,200.00 Electric(not including fixture allowance)-$99,680,00 531,900.00 Con tin nod on page three.... * Con tin ued from page two.... Flooring installation only-$4,715.00 Hardware Installation only-$250.00 Signage Installation only-$100.00 Fire Alarm - $6,200.00 Permit Fee - $2,900.00 III. Exclusions HVAC Structural issues IV. Terms All material is guaranteed to be as specified, and the above work to be performed in accordance with the drawings and specifications submitted for above work, and completed in a substantial workmanlike manner for the sum of " Oit� Ilund��d TGirfr-1�'ircThorahau�( nc�e Il«ndi<r1, Ai�1chDoltUrs<�u�f OQ%00 Cer�t.5(S/3�190.00) Payments to be made as follows: 1f3 Deposit, 1/3 Progress Payment and Final payment upon completion *Any alteration or deviation from the above specifications involving extra costs will be executed only upon written. order, and will become an extra charge over and above the estimate. All agreements contingent upon strikes, accidents or delays beyond our control.. **Note—This proposal may be withdrawn by us if not accepted within 30 days Respectfully submitted on behalf of Frank Gomes,US Property Services By signing below you-wc 2 t all terms and cond it4o�s of s contract f ---�/ --� DATE - 95 - /! -- --- -------------- ignato �- -/ The Commonwealth of Massachusetts ^; Department of Industrial Accidents Il. 1` Office of Investigations _ 600 Washington Street U Boston, MA 02111 i- www.mass.gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information / Please Print Le ibi Name (Business/Organization/individual):Ij i0 Q Address: <0 /1 City/State/Zip: Gt 4 Q b G Phone #: f� Are ou an employer?Check the appropriate box: Type of project(required): � l. I am a employer with 3 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. F-1 New construction 2.El am a sole proprietor or partner- listed on the attached sheet. x EJ Remodeling ship and.have no employees These subcontractors have 8. ❑Demolition. working for me in any capacity, workers' comp. insurance. g, ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 1 I.[] Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.]t .employees. [No workers' 13.❑Other comp. insurance required.] 'Any applicant that checks boz#l 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 their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. /� Insurance Company Name: Gt Y?/ 4 7e Policy#or Self-ins. Lic.#:_4;23 q V Expiration Date: - — =0 ��i Job Site Address: `f, A21,uj! :/t/ e, s r, i(P 20 City/State/Zip " 4 rdo L/C/ 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 certify and t ep inus andpena/ties ofperjury that the information provided above is true and correct. Si nate Date: " r 15 ct ?O// Phone#: — ✓U 1061 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 i Contact Person: Phone#: 11/09/1010 TUE 14:06 FAX 978 683 0018 FRAVEL 1INSUMINCE AGENCY 0002/002 A CORD DATE pIM/DDlYYf1� ,,, CERTIFICATE OF LIABILITY INSURANCE 1u9/10 _ ODAHI I MD -- TIJC/.RIT7 M'irre N eP£I=n.•1.w to!tT?rw..-m-melts .._.p. ....�..�•� - 1ma{.%;mnr_Air.to1.5-Sur.&J45A m m i inn wrIIr1UmmA11R m - Fravel Insurance Agency ONLYAND CONFERS NO RIGHTS UPONTHECERTFICATE 231 .Button Street HOLDER.THIS CEIMFICATEDOES NOT"AMEND,EXTEND OR ALTHRTHECOVERAGEAFfORDEDBYTHEPOLICIIB OLOW. - suite IB North Andover, ISL 01845 _ INSURERS AFFORDING COVERAGE MAIC 4 IN3lIR® - INSURER/_ Zurich Insurance Co va rroper�y aesysces INSIRERE.C,ranite State Ins Co - Lisa M. Gomes "DBA INSURER C: { 515 Lowell St. Suite 3 ---�-- Peabody, MA '01960 INSJRaao: INSURERS COVERAGES THR POLICIES OF INSURANCE U==20-OW HOVE BE_6_J 19SUEO TO VWC�etG�wGn www.cra wan_v._.nw-...._o....n..oo:nn_......n....,. ............�..........� ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WNICM THIS CERMFICATE MAYBE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECTTO ALL TME TE-RMS,EXCLUSIONS AND CONOMONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDucm BY PAID CLAIMS_ INSRADD• TYPEOFiNSURANCIF- - POLJCYNUMBER PO POLICY N LIMITS GT5NIMALLIA HAY EACHOCCURRENCE 3 1,000 000 A X_ COMM6RCWLGEmE RALUATNUTY BCP 004505964 10/27/10 10/27/11 11000,000 CLAIASMAOE {X�OCCUR M®Wme Sm S 5 000 ._ - - •_ __ PS=NALSADViNJURY S 1,000,000 GENERALAGGREGATE S 2.000.000 GEN'LA T-EUMn'�ES ( PRODUCTS-CONPAL Is 2.000.000 POLICY {JJEECT U]C i�KI A gOMOBILEUABIUTY wmansy anvet timet $ ANYAUTO (Eamd _-.- ALLOWNEDAUTOS I! EMILYMJURY S SCHEDULED AUTOS (I-Aar] j Hla®Autos NON-OWNEDAUTOS i (P�RYezit}RY i s PROPERTYDAMAGE S (PIBf ACLIHT� GIIRIYGELJA8ILITY I AUTO ONLY-EAACCIDENT S ANYAUTO tAACC i APUTO ONL A.GG 5 E]CCt�SSSIUMBRELLAUABILTTY EACH OCCURR6d_CE_ S OCCUR CLAIMSMAOE AGGF'-0ATE S DWUCTmLE S RETENTION S $ WORKERS COMPFNSATIDNAND WCSTATU- OST+ ITS ER B EAPLOVIOWUASILITY FIC 8266712 11/3/10 11/3111 X ANYPROIRMTOWARTNEROXECUTNE MLeAGNAGO10F.NT y 100,000 DFFT IuaszExawomi Et_DLsgnSE-EA PWvM s 100.000 ELOISEASE-PoucYuMIT Is 5001000 S�aALPROTAsausec� OTTER 11MCRIPTI01109ORRATION31LOCAM0gB IV@icLtEBIMM-LUSIONS ADDED BYENDQLMENIEHP/WECWL PROVISIONS 10-0p, LLC is listed as adcli tional insured. CERTIFICATEHOLDEt CANCELLATION r - SHG=ANYOFTHEABOVEDFSCRIBMPOUCMSBECANCFII BEFORETMEMMATIOW i DATETXLWORTHeISSUING INSURERWILL ENDFAVORTOMAIL 30 DANSWRTTTEN I.T ops TT.C_, NOTTCETOTMECMCMCATEHOLDERNAMFATOTNELM.aUTFAIWRETODOSOSMt. A_; Andovge •r`�Eagt IMPOSENOOBLIGATION ORUABIL_rtYOFANY KINDUPONAEINSURER,MAOL4T3OR North _4ndover, m 01.845 REPRESENTRI140. AUTHORIZED RIEPRFSENTATM ACORD 25(2009108) LOALCORD CORPORATION 1988 Massachusetts - Department of Public Safety Board of Building Regrulations and Standards Construction Supervisor License License: CS 104350 LISA GOMES 40 HIGHLAND ST PEABODY, MA 01960 c Expiration: 9/1/2013 ('onunissio°cr Tr#: 104350 cfxh ' Pu9�- �ry eek Ca.0 Ca ING 0z),-1,(/"q A011 Architects LaGrasse & Associates, Inc. Joseph D.LaGrasse,AIA . J_"D Thomas A Galvin,AIA Architects, Engineers & Land Pianners Jutianna E.Hoch,RA CONSTRUCTION CONTROL AFFIDAVIT PROJECT NUMBER: 2270 PROJECT TITLE: North Andover Office Park PROJECT LOCATION: 451 Andover Street Unit 209 NAME OF BUILDING: Building 1 SCOPE OF PROJECT: Construction of Interior Office In accordance with Section 1 l 6.0 of the Massachusetts State Building Code, 1; Joseph D.LaGrasse,AIA MA.Reg.# 4153 being a registered professional engineer/architect hereby certify that I have prepared or,directly supervised the preparation of all design plans,computations as specifications concerning: Entire Project X Architectural Structural Mechanical Fire Protection Electrical Other For the above named project and that, to the best of my knowledge, such plans, computations and specifications meet the applicable provisions of the Massachusetts State Building Code, all acceptable engineering practices and all applicable laws for the proposed project. I further certify that I 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 iri accordance with the documents approved for the building permit and shall be responsible for the following as specified in Section 116.2.2: 1. Review of shop drawings, samples, and other submittals of the contractor as required by the construction contract documents as submitted for building permit,and approval for conformance to the design concept. 2. Review and approval of the quality control procedures for all code-required controlled materials. 3. Special architectural or engineering professional inspection of critical construction components requiring controlled materials or construction specified in the accepted engineering practice standards listed in Appendix 1. Pursuant to Section 116.4,I shall submit periodically,a progress report together with pertinent comments to the Building Inspector. Upon completion of the work,I shall submit a final report as to the satisfactory completion and readiness of the project for occupancy. Joseph D.LaGrasse,AIA j D t ►2 r f) FtEgl� �IU ' Signature of Arc it t/Engineer Date Offices q`' N One Elm Square ' m 4 ANDOVER. R, T 978.470.3675 Andover,MA 01810 �� MA Jy� F 978.470.3670 0 �q��c�,�ssF�� 1420 Celebration Blvd. _ ., www.lagrassearchitects.com Celebration,FL 34747 AA26001333 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 CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes ' t y Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Os ood Street FIRE DEPARTMENT -Temp Dumpster on site yes o Located at 124 Main Street � V Fire Department signature/dater COMMENTS, �h 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: 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 ❑ 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:Building Permit Revised 2008 I ' 712-d� J r 09884 / Date . � �-3 TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING This certifies that . A!�• . ��. . � ! �c�O. . 11,4,1o. . has permission to perform .O U1'`^"-... . ((�� . . . . o plumbing in the buildings of. . !!`: at . . .4-5. . . . . . . . . . . . . .North Andover, Mass. Fee .,9 . Lic. NA.54(p . . . . . . . . . . . . . . . . . . 7 PLUMBING INSPECTOR Check# I r7LK S t%O R TH Town of ndover No. ' dw f - S Z ' o416 h ver, Mass, COCKICKl WI[K y1. - S lJ BOARD OF HEALTH PERMIT T LD Food/Kitchen Septic System THIS CERTIFIES THATBUILDING INSPECTOR .......R ...... . .. Foundation - has permission to ere c .............. buildings on %1V. 04"Aw.......at....l.............,. ... .. , to be occupied as ..... ... ..�� ......�#o+00 ....0 !(�1....................... Chimney provided that the person accepting this permit shall in every respect conform to terms of the application ,nal 0 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 SPE�CTQR ((� JJU Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final PERMIT EXPIRESaINONTH ELECTRICAL INSPECTOR UNLESS CONSTRUT S .., ... Service ...... ......... ........ in 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�•� SEE REVERSE SIDE ra w r �� o`X10 eTN Iti . O ltd ACNU`'fS CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Permit Number 581-13 on 2/28/2013 Date: May 30, 2013 THIS CERTIFIES THAT THE BUILDING LOCATED ON 451 Andover Street Suite 207A and 208B MAY BE OCCUPIED AS a dentist office IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: Dr. Paolo Incampo,DMD 451 Andover Street Suite 207A and 208B North Andover,MA 01845 s Building Inspector Fee: Prepaid 1. Receipt: 26181 Check : 15624 t MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK y CITY ju Au v~c/Z MA DATE PERMIT#. JOBSITE ADDRESS OWNER'S NAME cwt e� POWNER ADDRESS _ TEL FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL Q RESIDENTIAL PRINT CLEARLY NEW: MI RENOVATION: REPLACEMENT: Q PLANS SUBMITTED: YES Eq NO©i FIXTURES 1 FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM DEDICATED GAS/OILISAND SYSTEM 6 DEDICATED GREASE SYSTEM __I _.- f I -- -i _.____JI_._1 ( _.__.--J _____J _.__.__I -___J DEDICATED GRAY WATER SYSTEM ( f { ._ I .-j= DEDICATED WATER RECYCLE SYSTEM ( F7 i _.__1 I ( _ DISHWASHER �h J ( _._._ ( _! J -_.-_-I - __I --_! ---i DRINKING FOUNTAIN FOOD DISPOSER FLOOR/AREA DRAIN --j=== _J INTERCEPTOR(INTERIOR) ( J ._-__...._I __..__.._1 ..__�J ( .._-J 1 _.._.....-_I, _...___[ ___._. __...._I 1 ---I ..._..._-_i KITCHEN SINK LAVATORY ( ___.__( ...__..__ ( ......_._.J ._-____I _____1 __.___..I ._____.1 ._.-.-( .____J -_-_J _.._-__-._1 ( 1 _ 1 • ROOF DRAIN SHOWER STALL I ......___) ( . -( _ 1 SERVICE/MOP SINK TOILET �I _._.. _( ... _J URINAL WASHING MACHINE CONNECTION 4 .WATER HEATER ALL TYPES .NATER PIPING OTHER INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES[ja'NO IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY BOND E OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT I _ SIGNATURE OF OWNER OR AGENT t'(j hereby certify that all of the details and information I have submitted or entered regarding this application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will be in compliance with all Pertinent provision of the tAassachusetts State Plumbing Code and Chapter 142 of the General Laws. 6 PLUMBER'S NAME �9L '2<< _ jy Lr Dcs2 {LICENSE# �J o� ; SIG SIGNATURE 7 mpn' JPQ CORPORATION# a c6J IPARTNERSHIP D#=LLC COMPANY NAME ADDRESS Z`3 2-4,0qsq ISI.4A _ CITY -ez-,c4 - ----- -.---..- --..._._..._JSTATE t�fF, I ZIPG /�Z( -f TEL FAX _ j CELL EMAIL ROUGH PLUMBING INSPECTION NOTES BELOW FOR OFFICE USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES t ° The Commonwealth of Massachusetts DZ Department of IndustrialAccidents Office of Investigations to 600 Washington Street Boston,MA 02111 www massgov/ilia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): i�C 14'30 0 4. Address: Z.`5 G P-- City/State/Zip: /2> i 1Q /S Z/ Phone 7 F`66 73 S S S Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with Z5 4. ❑ I am a general contractor and 1 6. ❑New construction employees(fall and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet.# modeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. g E]Building addition [No workers' comp.insurance 5. El We are a corporation and its required.] officers have exercised their 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.]r employees.[No workers' q ] 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. i 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. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. /qr-p C_I,-� Z1 Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address 66 r/ M Ao u�—� S`i= f00. City/State/Zip: 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 certto under �the pains and penalties ofperjury that the information provided above is true and correct. Signature: (,[� ��,n - Date: V Phone#: G'i'7 C{7- 3.S S;_ 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#: I Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced-acceptable evidence of compliance with the insurance coverage required" Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificates of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA.02111 Tel,#617-727-4900 ext 406 or 1-877rMASSAFE Revised 5-26-05 Fax#617-727-7749 www.mass,gov/dia r-- +{ .. A�AlAAIll4fCw1�'�'L�A1'.'..w♦. Aa.nA i.aes w+r+se7� •.._• rr COMMONWEALTH 00 MASSACHUSETTS . - CaDam =pLtIU1,EERS"ANQAS��FTEt °` 4 LICENSED A'S A MASTEi PLVNfgEiia' . ISSUES THE ABOVE LICENSE TO 'lt-N2L i7 X �PD,L I DQRD � • 7e y11 42. CHAMPA {RD ; IRT!U4L_ERICA MA 01821 91�r' $�26 05%01/14 .. At11,24 •4. f; r Date.4...&Irz�................... NORTry TOWN OF NORTH ANDOVER PERMIT FOR WIRING B,CHU 0,, UA This certifies that .U4.1 ........................................... ...... ..............t.-........I................ .. .... has permission to perform. jR. . ............... ....................................................................... wiring in the building of......C-2N............�.:f��.... ...c......................... ........ ......... .... at ...........-45)........4 &V.0-A.......... ...e........ North Andover Mass ........ .... . . Fee....151...........Lic.No .01..... ........ .......... .. LEMUCAL S�PECTOR Check# 11506 UP P VInA- At- Z- n 11 Commonwealth of Massachusetts Official Use Only � � � Department of Fire Services Permit No. f� Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev.1/07] peaveblank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK ®, All work to be performed in accordance with the Massachusetts Electrical Code(NEC),527 CMR 12.00 (PLEASE PRINT W INK OR TYPE ALL INFORMATION) Date: Y/.S z/- City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. l S� LocationStreet&Number �v � ( ) �!�/ 1.1� .��{,e sem' vim: Z— .2 0 7 Owner or Tenant Ae ix P o Telephone No. Owner's Address s1f.st Is this permit in conjunction with a building permit? Yes Q No ❑ (Check Appropriate Box) Purpose of Building ,L e,4,4!4Z �6�'F c Utility Authorization No. y� 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: Completion of thefollowing table may be waived by the Inspector of Wires. No.of Recessed Luminaires (o No.of Ceil:Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires swimming Pool Above ❑ In- ❑ o.o mergency ig ting �/ s g rnd. rnd. Battery Units / No.of Receptacle Outlets o No.of Oil Burners FIRE ALARMS I No. of Zones No.of Detection and No.of Switches No.of Gas Burners :Z U initiating Devices No.of Ranges No.of Air Cond. Q Tons S TotNo.of Alerting Devices t� No.of Waste Disposers Heat Pump Number Tons KW No.of Self-Contained P Totals: I Detection/Alerting Devices No.;of Dishwashers g S ace/Area Heating KW Local❑ Municipal El Other P Connection No.of Dryers Heating Appliances KW Security Systems:* Y No.of Devices or Equivalent No. of Water KW No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or E uivalent /o No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent " OTHER: Attach additional detail if desired,or as regtdred by the Inspector of Wires. Estimated Value of Electrical Work: �y. 60 a, (When required by municipal policy.) A Work to Start: 4// l/3 Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless t the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE 0 BOND ❑ OTHER ❑ (Specify:) �\ I certify, tinder thepains and penalties of perjury,that the information on this application is true and complete. FIRM NAME: (!,,e e el- LIC.NO.:�/7/0 7,d Licensee: Signature LIC.NO.: (If applicable,enter"exemp'in the license number line) Bus.Tel.No.: � Address: Alt.Tel.No.: *Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lic.No. 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. 1 am the(check one)❑owner ❑owner's agent. Owner/Agent PERMIT FEE. $ Signature _ _ Telephone No. yy1{ p, ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00§Rule 8: In accordance with the provisions of M.G.L.c. 143,§3L,the X permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth,and applications shall be filed on the prescribed form.After a permit application has been accepted by an Inspector of Wires appointed pursuant to M.G.L c. 166,§32,an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the notification of completion of the work as required in M.G.L.c.143,§3L. Permits shall be limited as to the time of ongoing construction activity,and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12-month period.Upon written application,an extension of time for completion of work shall be permitted for reasonable cause.A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012.The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property.With limited exceptions,the Act automatically extends,for four years beyond its otherwise applicable expiration date,any permit or approval that was "in effect or existence"during the qualifying period beginning on August 15,2008 and extending through August 15,2012. ❑ Rule 8—Permit/Date Closed: ***Note:Reapply for new permit❑ ❑Permit Extension Act—Permit/Date Closed: Trench Inspection Pass M Failed 0 Re-Inspection Required($.)❑ Inspectors Comments: r Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed 0 Re-Inspection Required($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass IN Failed Re-Inspection Required($.) ❑ b Inspectors Comments: Inspectors Signature: Date: ROUGH INP FCTION: Pass Failed IN Re-Inspection Required($.) ❑ Inspectors omments: Inspectors Signature: v Date: FINAL IN CTION: Pass Failed Re-Inspection Required($.)❑ Inspectors Comments: Inspectors Signature: �� j, l Date: APR-08-2013 12:22 East Corp Electrical 1 978 250 0109 P.001 The Commonwealth of Massachusetts Department of Industrial Accidents Office Of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): East Corp. Electrical Services Address: PO Box 146/6 Third Street City/State/Zip: Chelmsford,MA 01824 Phone#: o(978)250 1156 Are you an employer?Check the appropriate box: Type of project(required): 1.[E I am a employer with 9 4, ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2,❑ 1 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. employees and have workers9. ❑ Building addition [No workers' comp.insurance comp. insurance.*. required.] 5. ❑ We are a corporation and its 10.0 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 91 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 indiealing such, Contractors that check this box must attaehcd an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees_ If the sub-contractors hove employees,they must provide their workers'comp.policy numbcr. am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Peerless Insurance Co. Policy#or Scif--ins. Lic.#: WC3821564 Expiration Datc: 07/21/13 Job Site Address: Dr. Incampo,451 Turnpike Rd City/State/Gip: N.Andover, MA 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 DTA for insurance coverage verification. I do hereby certify under the pains andpenalties oLuerjury that the information provided above is true and correct. r Sian tunnate: - Phone#: 978 250 1156 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#: ;COMMONWEALTH OF MASSACHUSETTS ELECTRICIANS REGISTERED MASTER ELECTRICIAN 1 ISSUES THE ABOVE LICENSE TO r E�iST `6ORF_ ELECTRICAL DAVSERVICE ID W� :DE�, BEA000URIT ' • V P O B'0X_ 1„4 6. C4ELMSFORD ,---`I1.A 01824” 0146: 17107 A 07/31/13 8733.42 ;N ` e. 1 9 3 Date. 2.11 . . . .. .. .. A NORTM TOWN OF NORTH ANDOVER PERMIT FOR MECHANICAL INSTALLATION F p . y 'S9SSAC MUSE�t This certifies that . . . . . . . . . . . . . . . . . has permission for mechanical installation(a. . ft' . 4,-. .4.4 - in the buildings of ., . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. North Andover, Mass. Fee. Lic. No.. �.2 . . Y . . . . . . . . . . . . GASINSPECTOR WHITE:Applicant CANARY: Building Dept. PINK:Treasurer 1 ` Commonwealth of Massachusetts Sheet Metal Permit Date : 2 i 3 Permit# �� Estimated Job Cost: 2_ 1 30 G Permit Fee: $ Y` Plans Submitted: YES NO Plans Reviewed: YES Business License# 7 — Applicant License# �" 7 -3- Business Information: Property Owner/Job Location Information: Name: ,Aj�qLg IC"lwl 14-/ /AJC Name: A/° IAi 0126 Street: D(e l PFT-W b o D Street: 5'/ P-/�&VW— City/Town: H , City/Town:k A-;,14 1)(f(1b'Y ( M "i f Telephone: 2-7 S' "q Telephone: - Photo I.D. required/Copy of Photo I.D. attached: YES -'NO Building Type: Residential: 1-2 family Multi-family Condo/Townhouses Commercial: Office Retail Industrial Educational Institutional Building Cubic Footage: under 35,000 cu. ft. over 35,000 cu. ft. Sheet metal work to be completed: New Work: Renovation: �- '.t HVAC Metal Roofing Kitchen-Exhaust System Chimney/Vents Provide brief description of work to be done: .y 1 i 4 INSURANCE COVERAGE: 1 have a current liability insurance policy or its equivalent which meets the requirements of M.G.L.Ch.112 Ye No❑ If you have checked Yes, indicate the type of coverage by checking the appropriate box below: A liability insurance policy ❑ Other type of indemnity ❑ Bond ❑ OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 112 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. Check One Only Owner ❑ Agent ❑ Signature of Owner or Owners Agent By checking this box❑,I hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and accurate to the best of my knowledge and that all sheet metal work and installations performed under the permit issued for this application will be in compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws. Progress Inspections Date Comments Final Inspection Date Comments Type of License: By ❑ Master Title ❑ Master-Restricted Cityrrown ❑Journeyperson Signature of Licensee Permit# ❑Journeyperson-Restricted License Number: i Fee r ❑ Check at www.mass.gov/dpl Inspector Signature of Permit Approval i Sheet Metal Commercial Guidelines/Life Safety/Critical Systems Inspection Checklist Yes No N/A, Set of stamped engineering documents and detailed description of mechanical system to be installed has been provided All workers performing sheet metal work onsite has valid Massachusetts sheet metal license V All sheet metal work being performed with proper joumeyperson-to-apprentice ratios Fire dampers with access door properly installed and checked for operation Smoke and combination fire/smoke dampers with access doors properly installed- actuator checked for proper operation(May also be verified by fire department during fire alarm testing) Duct smoke detectors with access doors properly located (May also be verified by fire department during fire alarm testing) /Smoke/atrium exhaust systems installed and operation verified (May also be verified by fire department during fire alarm testing) Stair pressurization systems installed(where required)and operation verified(May also be erified by fire department during fire alarm testing) Grease/kitchen hood exhaust system installed with all seams and connections welded airtight with properly located cleanouts. Proper clea,`ances,fire rated enclosures and pressure testing required. F : ici:ri�re t.aints installed: hbl ,e required'oin e a dib..ment and dr=_:tv.j. Duct penetrations in fire'rdtc ivaID3 and floors sealed Metal roofing systems installed watertight losing proper materials and fasteners / Flexible duct nuns installed 6'-0"maximum length Ductwork installed using proper hanger spacing,hanger stock,threaded rod and angle iron Ductwork/ l)lenum connections sealed substantially Y airtight Ductwork insulated by means of external covering or internal lining Volume dampers installed for each supply air branch duct � New/clean-properly sized filters installed(final inspection) Testing and Balancing report complete(final sign-off) y � , Sheet Metal Residential Guidelines/Inspection Checklist Yes No N/A Detailed description and sketch of sheet metal system to be installed has been provided All workers performing sheet metal work onsite has valid Massachusetts sheet metal license All sheet metal work being performed with proper joumeyperson-to- apprentice ratios Equipment sized per heating/cooling load calculations Duct work sized per manual "D"calculations Bath/shower rooms contain mechanical exhaust fan vented outdoors Electric dryer exhaust properly installed maximum total run 35'-0", maximum flexible run 8'-0" Flexible duct runs installed 14'-0"maximum length Volume dampers installed for each supply air branch duct Ductwork installed using proper gauges and hangers Ductwork/plenum connections sealed substantially airtight . Ductwork insulated by means of external covering or internal lining New/clean -properly sized filter installed(final inspection) Testing and Balancing report complete(final sign-off) COMMONWEALTH OF MASSACHUSETTS i `SH kT METAL WORKERS AS A BUSINESS ISSUES THE ABOVE LICENSE TO: R03E'12T 'M GUPTILL JR Ar1ERICA" AIR INC 35_ DR IF`TW00D DR ' TtWKSBURY MA- 01876-1361 472 09/28/13 69564 v COMMONWEALTH OF MASSACHUSETTS • SHEET METAL WORKERS + ED a R:O�BE:RT -M GUPTLL 35 :DR.IFTWOOD DR TE'WKS$URY MA 01876 4033 4 . rl 1 i I The Commonwealth of Massachusetts - Department of IndustriqlAccWnts 07 Office of Investigations 600 Washington Street Boston,MA 02111 go www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/F, Pleasepaint Le bl _Applicant Information leas >;f,� ASK INC Name(Bus ess/Organi'zation/Individual):, f t+��/�„�,�t-�� �-► Address: 35- Dial F71—Vi Pe?Q city/State/Zip:T�� K S Lz_U l2 Phone#: 0 1 ? ��m g g 6 Are you an employer?Check the appropriate box: Type of project(required): I am a employer with 4. 4• El am a general contractor and I g_ E]New construction have hired the sub-contractors 7.�-Remodeling employees(full and/or part- listed on the attached sheet.� 2.❑ I am a sole proprietor or partner- ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. g, 0 Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions required.] officers have exercised their 11. Plumbing repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL ❑ c. 152,§1(4),and we have no 12.[]Roof repairs myself. [No workers comp. employees. o workers insurance required.]i ' 13.❑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 Lire doing ail 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. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. t S Insurance Company Name: L5.S 0 C f Af � � \ Policy#or Self-ins.Lic. -7/P /D la-d / ��— Expiration Date: Ci /State/Zip: /ll l�do U Job Site Address: �S/ �M IU l/�YZ S 7_ t3' 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 certify under the pains and penalties of perjury that the information provided above is true and correct. 2 � nate: Z G z 3 Signnature � � a Phone#: 72' s tl/ 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.CitylTown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#' Informati®n and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract ofhire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)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 Comm=M—alth.of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA,02111 Tel.#617-727-4900 ext.406 or 1-877,7"SA.FE Revised 5-26-05 Fax#617-727-7749 vvww.m ass,gov/dia rxarrrcrskmComponent Constructions Job: Date: Apr 01,2013 wAteO . ••. C�WO*C4*16 Entire House By: Christopher Bergeron S.G. Torrice Co. 801r='rar-a Nay,Wilmington,MA 01887 Phone:(800)888-8359 Fax:(978)657-4255 Email:cbergeron@sgtorrice.com Project Information For: American Air, Dr. Paulo Incampo 400 Research Drive,Wilmington, MA 01887 Design Conditions Htg Clg Htg Clg Outside db(TF) -1 89 Inside db(°F) 70 75 Outside RH (%) 80 50 Inside RH (%) 27 50 Outsidewb(°F) 20 75 Inside wb(°F) 52 63 Dailyrange(TF) - 18 Design TD(°F) 71 14 Moisture diff. (gr/Ib) 50.8 40.8 Cats#` Or Area U-value UA Loss Gain tion descriptions ft' (atuh"-'F) (8tuh'F) (Btuh) (Btuh) Walls Blk wall,2"x6"metal int frm,4"thk,r-21 cav ins,5/8"gypsum board int n 479 0.07 31.9 2255 281 fnsh Partitions Firm wall,stucco ext,r-13 cav ins,2"x4"wood frm 1356 0.10 139 9783 2002 Windows htg clg htg cig 2 glazing,clr outr,air gas,insulated vinyl frm mat,clr low-e innr,1/4" n 48 0.32 / 0.32 15.4 / 15.4 1084 778 gap,1/8"thk Doors Door,wd he type in 53 0.46 23.9 1689 307 Ceilings C part ceiling,carpet fir fnsh,r-13 ins,80 Ib/ft'concrete fir,6"thkns, 1872 0.04 82.4 5746 2727 dead air pinm,suspended,foam board int fnsh Floors Partcarpet fir fnsh,r-13 ins,80 Ib/ft'concrete fir,6"thkns,dead 1872 0.04 82.4 5746 1176 air pinm;s'gspended,foam board int fnsh wiri-IhitF.sOft' 2013Apr-01 11:24:04 Right-Suite®Universal 2012 12.1.05 RSU17410 Page 1 rican Standar&American Air-400 Research Drive,Wimington.rup Calc=CLTD Front Door faces: Ri ht-Suite@ Universal 2012 Short Form Job: Date: Apr 01,2013 • rr.++ta +. .. cako• aa+.c Entire House By: Christopher Bergeron S.G. Torrice Co. 80 Industrial Way,Wilmington,MA 01887 Phone:(800)888-8359 Fax:(978)657-4255 Email:cbergeron@sgtorrice.com Project • • For: American Air, Dr. Paulo Incampo 400 Research Drive,Wilmington, MA 01887 Htg Clg Htg Clg Outside db (*F) -1 89 Inside db (aF) 70 75 Outside RH N - 50 Inside RH N - 50 Outside wb ('F) - 75 Inside wb (°F) - 63 Daily range (*F) - 18 Design TD (aF) 71 14 Moisture diff. (gr/Ib) - 41 Heating Equipment Cooling Equipment Make Make Model Model Type Gas furnace Type Split AC Efficiency 80 AFUE COP/EER/SEER 0 Heating Input 0 MBtuh Sensible Cooling 0 MBtuh Heating Output 0 MBtuh Latent Cooling 0 MBtuh Humidifier 18.4 gpd Total Cooling 0 MBtuh Leaving Air Temp 70.0 aF Leaving Air Temp 55.0 aF Actual Heating Fan 915 cfm Actual Cooling Fan 915 cfm Equipment Location Entire House System Type PEAKCV Fan Motor Heat Type PACKAGE Fan&Motor Combined Efficiency 0 % Static Pressure Across Fan 0 in H2O NAME Area I Heat I Sensible I Latent I Htg I Clg I Time ft2 Loss Gain Gain cfm cfm SEATING AREA 195 6302 2465 858 91 95 Jul 1700 LDT BUISNESS OFFICE 155 4235 1798 680 53 68 Jul 1700 LDT AUX-BUISNESS 102 3344 1459 449 55 57 Jul 1700 LDT OP. 1 162 4211 2011 711 61 77 Jul 1700 LDT OP.2 105 2801 1367 460 42 53 Jul 1700 LDT PRIVATE OFFICE 60 1665 676 262 21 26 Jul 1700 LDT OP. 3 109 3535 1547 481 58 61 Jul 1700 LDT LAB 84 5353 1344 645 93 54 Jul 1700 LDT VAC. PUMP 9 0 0 0 0 0 Jul 1700 LDT STG. 8 0 0 0 0 0 Jul 1700 LDT LAV. 28 1347 441 121 24 18 Jul 1700 LDT CL. 8 0 0 0 0 0 Jul 1700 LDT MILL. 10 490 160 44 9 6 Jul 1700 LDT OP.4 114 4018 1509 502 61 58 Jul 1700 LDT BLK STG. 43 1302 523 187 18 20 Jul 1700 LDT STAFF LOUNGE 123 3776 1515 543 52 58 Jul 1700 LDT HYGIENE 1 126 3839 1545 555 53 59 Jul 1700 LDT HYGIENE 2 95 2173 1014 416 22 38 Jul 1700 LDT TREATMENT COORD. I 44 1 1012 1 472 I 194 1 101 18 I Jul 1700 LDT W�1 ht$Oft' 2013-Apr-01 11:24:04 Right-Suite®Universal 2012 12.1.05 RSU17410 Page 1 rican Standard\Amedcan Air-400 Research Drive,Wilmington.rup Calc=CLTD Front Door faces: i STERIL. I 64 i 1466 i 684 I 281 i 15 i 26 i Jul 1700 LDT i HALL 1 103 2369 1105 453 24 41 Jul 1700 LDT HALL 2 130 I 8698 I 2041 I 1123 150 81 I Jul 1700 LDT Entire House 1872 61934 23677 8964 915 915 1 Jul 1700 LDT {J}} WPiQFr tSA'f1<' Right-Sud2013 e®Universal 2012 12.1.05 RSU17410 Apr-0111:24:04 Page 2 ...titan Standard\American Air-400 Research Drive,Wilmington.rup Calc=CLTD Front Door faces: RightSuite® Universal 2012 Load Summary Job: Date: Apr 01,2013 Entire House By: Christopher Bergeron S.G. Torrice Co. 80 Industrial Way,Wilmington,MA 01887 Phone:(800)888-8359 Fax:(978)657-4255 Email:cbergeron@sgtorrice.com Project • • For: American Air, Dr. Paulo Incampo 400 Research Drive,Wilmington, MA 01887 Zone: Entire House COOLING LOAD 1. DESIGN CONDITIONS at Jul 1700 LDT Peak load at Jul 1700 LDT Inside: 75 °F Outside: 89 T TD: 14 °F RH: 50 % MoistDiff: 40.8 gr/Ib Mult: 0 Ins.wb 63 °F Sensible Latent 2. SOLAR RADIATION THROUGH GLASS 581 - 3. TRANSMISSION GAINS Sensible 6692 - Walls: 2284 - - Glass: 197 - - Doors: 307 - - Partitions: 0 - - Floors: 1176 - - Ceilings: 2727 - - 4. INTERNAL HEAT GAIN Sensible Latent 12278 1756 Occupants: 2125 1756 - - Lights: 10153 - - - Motors: 0 - - - Appliances: 0 0 - - 5. INFILTRATION: Outside air cfm: 30 474 829 6. SUBTOTAL: Space load Sensible Latent 20025 2584 Envelope 20025 2584 - - Less external 0 - - - Redistribution 0 0 - - 7. SUPPLY DUCT 0 - 8. SUBTOTAL: Space load +supply duct 20025 - Actual cfm: 915 at supply TD: 20 9. VENTILATION: Make-up air cfm: 231 3652 6380 10. RETURN AIR LOAD: Lighting+ plenum(net) 0 - 11. RETURN DUCT 0 - 12. TOTAL LOADS ON EQUIPMENT 23677 8964 HEATING LOAD 13. DESIGN CONDITIONS Mult: 0 Inside: 70 °F Outside: -1 °F TD: 71 °F 14. TRANSMISSION LOSSES 26302 Walls: 12038 - Glass: 1084 - Doors: 1689 - Partitions: 0 - Floors: 5746 - Ceilings: 5746 - 15. INFILTRATION: Outside air cfm: 143 11057 16. SUBTOTAL: Space load 37360 Envelope 37360 - Less external 0 - Less transfer 0 - Redistribution 0 - 17. SUPPLY DUCT: 0 18. VENTILATION: Make-up air cfm: 231 17842 19. HUMIDIFICATION 6733 Piping 0 20. RETURN DUCT 0 21. TOTAL HEATING LOAD ON EQUIPMENT 61934 �' 2013-Apr-0111:24:04 Right-Suite®Universal 2012 12.1.05 RSU17410 Page 1 rican StandardWmerican Air-400 Research Drive,Wilmington.rup Calc=CLTD Front Door faces: N First Floor AUX- NESS P 1 2 PRIVAFFI E OP. 3 HA ATMENT COO D. BVI SS OFFICE HALL 1 I ST �11 i TILL. A P CL. HY6)� JATI N AR OP. 4 HTNE 1 STAF NGE 6. CONDITIONED SPACE Job#: Scale: 1 : 143 Performed by Christopher Bergeron for: S.G. Torrice Co. Page 1 American Air 80 Industrial Way Right-Suite®Universal 2012 400 Research Drive Wilmington,MA 01887 12.1.05 RSU17410 Wilmington,MA 01887 Phone: (800)888-8359 Fax:(978)657-4255 2013-Apr-01 11:24:18 cbergeron@sgtorrice.com 0 Research Drive,Wilmington.rup Date TOWN OF NORTH ANDOVER PERMIT FOR WIRING ;,SSACMUSEt This certifies that ........ ........ .............................. has permission to perform .. .........n................................ wiring in the building,of........;.?�...5—ID......... ...... at.....171,61—.1 ..... ......w-V. �.... .... � . ... .North Andover,Mass. ....... ........... ..... Fee ............. Lic. ELECTRli�AL INSP R Check # Ecro 7022 Commonwealth of Massachusetts Official Use Only Permit No. Department of Fire Services Occupancy and Fee Checked L,_�Ij BOARD OF FIRE PREVENTION REGULATIONS [Rev.9/05] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL 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: City or Town of. NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) q,5'I g1yy,1V r1Z Sr" j)yy r 4J- zo it Owner or Tenant "-5>° h/, 1q/117,4VtX- Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes RR No ❑ (Check Appropriate Box) Purpose of Building 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: WIRE `/ do 4'"'d I'd vucr cl✓'_ Fort 06AIrAL uric, Completion of the following table may be waived by the Inspector of N"ires. No.of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans No.of Total Transformers KVA No.of Luminaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires Swimming Pool Above ❑ In- E] o mergency ig ung rnd. rnd. Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones o Detection and No.of Switches No.of Gas Burners No. Initiating Devices No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons g No.of Waste Disposers Heat Pum Number Tons KW No.o elf-Contained Totals Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW #—Data ecurity Systems: No.of Devices or Equivalent No.of Water KW No.o No.o Wiring: Heaters Signs BallastsNo.of Devices or Equivalent No. Hydromassage Bathtubs No.of Motors Total HPelecommun�cat�ons Wiring: No.of Devices or E uivalent 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: /da f o6 Inspections to be requested in accordance with MEC Rule 10,and upon completion. 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 undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE M_ BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of perjury,that the information on this application is true and complete. 7 FIRM NAME: SrEVC n�lr/Nzi _ LIC. NO.: /olr/9j /9 Licensee: Signature S LIC. NO.: (Ifapplicable, enter "exempt"in the license number line.) Bus.Tel. No.: 6d1 WY?A73 Address: A10l/rr0✓ Ab /4trlKrwA6Y_ A 036SY Alt.Tel. No.: *Security System Contractor License required for this work; if applicable,enter the license number here: 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 .� Signature Telephone No. PERMIT iEE. $, � Y Location No. c Date �� �aRTM TOWN OF NORTH ANDOVER F A Certificate of Occupancy $ _• �+ �M�s Building/Frame Permit Fee $ 1 Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 19665 Building Inspector