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Home My WebLink AboutBuilding Permit #581-13 - Suite 209 2/28/2013 •t �� BUILDING PERMIT 3r0`,f�lD TOWN OF NORTH ANDOVER ° 0 4 j APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received �9SSAC FIUS�� Date Issued: ' IMPORTANT: Applicant must complete all items on this page LOCATION Andover Street Unit 2084 zwd 207 A Print PROPERTY OWNER RJJ Real Estate LL(" Print . MAP NO: 210-24PARCEL. 28 ZONING DISTRICT: _Historic District _ yes a Machine Shop Village ye' no, TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial EAlteration No. of units: xo Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other I"Septic 0' Well M Q'Floodplain d Wetlands ❑ Watershed DistrictaterlSewr Renovation of existing Dental Practice Suite Rework interior non-load bearing partition New floor and ceiling Identification Please Type or Print Clearly) OWNER: Name: RJJ Real Estate LLC Phone: Address: , CONTRACTOR' Name,, Phone: 978-851-9200, 'Pinn e e Construe o Cc�npan Inc. , Addres ;I„610 forum Street TewksurYiA Supervisor's Construction License: Exp. Date: / 21,14 R, Paul Morris Home Improvement License: Exp. Date: y ARCHITECT/ENGINEER Jane Estella Minias Phone: 617-472-4772 Address: 21 Fish Street Pembroke MA Reg. No. 7Rnti FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ 104, 170. 00 FEE- $ v�5^U -i- loo C' a . Check No.: Receipt No.: NOTE: Persons eontr cting with unregistered contractors do not have access to Xe guaran fund ;5EM nat�ir'e of A en#/Owne 'J�< gnature of contraettiSF'`”' �' i i TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION x. Permit NO: Date Received I Date Issued: IMPORTANT:Applicant must complete all items on this page LOCATION Print PROPERTY'OWNER Print 100 Year Old Structure yes no,. MAP NO: PARCEL: ZONING DISTRICT: Historic District yes no. Machine.Shop Village yes, no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial ❑Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well ❑ Floodplain, ❑Wetlands ❑ Watershed.Districf E!Water/Sewer DESCRIPTION OF WORK TO BE PERFORMED: Identification Please Type or Print Clearly) OWNER: Name: Phone: Address: CONTRACTOR Name: Phone: Address: - Supervisor's Construction License: _ Exp: Date: Home Improvement License: Exp. Date:- ARCH ITECT/ENG I NEER ate.ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ FEE: $ Check No.: Receipt No.: " NOTE: Persons contracting with unregistered contractors do not have access to the guarantyfund Signature of Agent/OWner r' SignatiareFof contractor y Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan 11 Stamped Plans ❑ Location A/ AIhA 4/ No. Date ® ` TOWN OF NORTH ANDOVER o y�;t=�li1�T31d�6' �' s l Certificate of Occupancy Building/Frame Permit Fee as0 r t Foundation Permit Fee $ Other Permit Fee TOTAL $ '� Check# 26181 Building Inspector { Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Phns C� TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Swimming Pools ❑ Tanning/MassageBody Art ❑ 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 m COMMENTS r Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water& Seger Connection/Signature& Date Driveway Permit DPW Tower Engineer: Signature: Located 384 Osgood Street FIRE"DEPARTMENT - Temp Dumpster on sit yes no Located at,124.Main`Street Fire Departinerit•s ignature/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, hast 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 EJ Notified for pickup - Date E f 5 Doc.Building Permit Revised 2010 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 u Building Permit Application u Workers Comp Affidavit o Photo Copy Of H.I.C. And/Or C.S.L. Licenses o Copy of Contract Li Floor Plan Or Proposed Interior Work o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks Li Building Permit Application Li Certified Surveyed Plot Plan u Workers Comp Affidavit Li Photo Copy of H.I.C. And C.S.L. Licenses u Copy Of Contract Li Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o Mass check Energy Compliance Report (If Applicable) L3 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) Li Building Permit Application o Certified Proposed Plot Plan u Photo of H.I.C. And C.S.L. Licenses + ' u Workers Comp Affidavit Li Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And . Hydraulic Calculations (if Applicable) o Copy of Contract o Mass check Energy Compliance Report o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit j 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 subm;tted with the building application Doc: Doc.Building permit Revised 2012 I 'I Pinnacle Construction Company, Inc. General Building Contractors 16o LORUM STREET • TEwKSBURY,MASSACHUSETTS 01876 • TELEPHONE:978-851-9200 FAx 978-851-5342 www.pinnco.com • e-mail: info@pinnco.com May 28,2013 Town of North Andover 1600 Osgood Street—Bldg.20 North Andover,MA 01845 Attn: Brian Leathe Re: Permit#581-13 451 Andover Street—Suite 208 Dear Mr.Leathe: In accordance with section 107.6 of the Massachusetts State Building Code,I certify to the best of knowledge and belief the work at451 Andover Street—Permit No.581-13 has been completed in substantial accordance with the permit drawings.Items#1 and#2 of 780 CMR Section 107.6 have been met. If you have any questions,please feel free to call. Very truly yours, PINNACLE CONSTRUCTION COMPANY,INC. P u Morris—CLS 044300 President Cc: Artios Architects 0710060I A rrIOS ARCHITECTS 21 Fish Street PembrokgtJM023S9 Tele: (781)985-8592 ARTIOS CONSTRUCTION CONTROL AFFIDAVIT - CLOSING REPORT " Project Location: , 'Ire, . ie{'' S Project Name: wcA ink �� aLl �,� Job Number: Nature of Project: Rr3,• 4 — u" I hereby certify that I have reviewed design pians,computations and specifications concerning: Entire Project Architectural Structural Mechanical Fire Protection Electrical For the above named project and that to my knowledge,such plans,computations and specifications meet the applicable provisions specified in Section 780 CMR 116.0 of the Massachusetts State Building Code. I further certify that I,or my authorized agent have performed the necessary professional services for the above referenced project.In addition we have provided the following services. Reviewed shop drawings,samples,and other submittals of the contractor as required by the construction contract documents as submitted for the building permit and approval for conformance to the design concept. Was present on the construction site on a regular and periodic basis to determine that the work has proceeded in accordance with the documents. This affidavit serves as a final report that the above referenced project is satisfactorily complete in accordance with the submitted permit documents and is ready for its intended use and occupancy. Original Signalwe ,, �' Date ARTIOS ARCHITECTS 21 Fish Street Pembroke, - k-92359 Tele: (781)985-8592 ARTIOS __ CONSTRUCTION CONTROL AFFIDAVIT - CLOSING REPORT Project Location: 46 1 &J,y,r S1 2t,� 0 Project Name: r. 4 a �a►C�1np, -n G� Job Number: / Nature of Project: m v" I hereby certify that I have reviewed design plans,computations and specifications concerning: Entire Project Architectural Structural Mechanical Fire Protection Electrical For the above named project and that to my knowledge,such plans,computations and specifications meet the applicable provisions specified in Section 780 CMR 116.0 of the Massachusetts State Building Code. I further certify that I,or my authorized agent have performed the necessary professional services for the above referenced project.In addition we have provided the following services. Reviewed shop drawings,samples,and other submittals of the contractor as required by the construction contract documents as submitted for the building permit and approval for conformance to the design concept. Was present on the construction site on a regular and periodic basis to determine that the work has proceeded in accordance with the documents. This affidavit serves as a final report that the above referenced project is satisfactorily complete in accordance with the submitted permit documents and is ready for its intended use and occupancy. LAI �1 Original Signature .,, 3 1!J,� Date Pinnacle Construction Company, Inc. General Building Contractors 160 LORUM STREET • TEWKSBURY,MASSACHUSETTS 01876 • TELEPHONE:978-85 1-9200 • FAx 978-851-5342 www.pinnco.com e-mail: info@pinnco.com May 28,2013 Town of North Andover 1600 Osgood Street—Bldg. 20 North Andover, MA 01845 Attn: Brian Leathe Re: Permit#581-13 451 Andover Street—Suite 208 Dear Mr. Leathe: In accordance with section 107.6 of the Massachusetts State Building Code,I certify to the best of knowledge and belief the work at451 Andover Street—Permit No. 581-13 has been completed in substantial accordance with the permit drawings. Items#1 and#2 of 780 CMR Section 107.6 have been met. If you have any questions, please feel free to call. Very truly yours, PINNACLE CONSTRUCTION COMPANY, INC. u Morris—CLS 044300 President Cc: Artios Architects 07100601 w I ;h0 r r 3SACNUSE 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 Buil ing Inspector Fee: PrePaid Receipt: 26181 Check : 15624 NORTH Town of 2 ? _E ndover Zlot % � h ver, Mass, + coc.41c..ewick �1 �'9S R�reo �PP��S U BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System THIS CERTIFIES THAT R ............... BUILDING INSPECTOR r Foundation has permission to ere c ........... buildings on y .�. ! .� ......a. ....l....... ......,. ..... .. , to be occupied as ......Dvo+jr........ ri`�....................... Chimney provided that the person accepting this permit shall in every respect conform to terms of the application mal d '/O�� 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 1[11�4ECT�,R �/ ' VIOLATION of the ZoningBuildin Regulations Voids this Pit. Rough or g g ons Permit. Finalj PERMIT EXPIRESIN 2ONTH ELECTRICAL INSPECTOR � • '�� UNLESS CONSTRU 10 ST S .................... .......... 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 � -_�� 4 %A RTH i , Town of : _ 6Andover p y' 0 No. O •T - C' qAK, h ver, Mass, A- COCHIC"IWIC« y�• 7d q�RATED r'Pp,`�C`� S U BOARD OF HEALTH PER Food/Kitchen Septic System THIS CERTIFIES THAT .. MIT T LD BUILDING INSPECTOR 1• A044WAVFoundation has permission to erec ........,............... buildings on ...... .t. .... ......�. ••••!••••••• Rough to be occupied as ... som 0.......D.#o '� � •• •••••• Chimney ... ......... ............... provided that the person accepting this permit shall in every respect conform toq terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final IdPERMIT EXPIRES IN ONTH ELECTRICAL INSPECTOR UNLESS CONSTRU 10 ST S Rough Service ......... .... ......... ...........,.... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final . No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. SEE REVERSE SIDE t NIRTI� 4 E Town. of _ �� 6Andover Q `•• to No. —1 �y Y f Zblot 4 o . LAK* h ver, Mass, COC NIC.IWICM y�. RATE D S U BOARD OF HEALTH PERMI� T T LD Food/Kitchen Septic System CERTIFIES THAT .. BUILDING INSPECTOR .THIS CER .....�... ..�� .......��i.�.� �... .. .................................. �• Ad" �• Foundation has permission to erec ........................ buildings on ...q.t. .... ... ........ ....l....... Rough to be occupied as / .. •t� �' ��•• ••• Chimney ... ... ....... .................. provided that the person accepting this permit shall in every respect conform tog terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR Rough VIOLATION of the Zoning or Building Regulations Voids this Permit. Final 1 � PERMIT EXPIRESa1N0NTHJ ELECTRICAL INSPECTOR UNLESS CONSTRUT SRough Service ......... ..........�..... Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises - Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. SEE REVERSE SIDE Enter construction cost'for fee cal - North Andover Fee Calculation Construction Cost $ 104,170.00 m $ - $ 1,250.04 Plumbing Fee $ 156.26 Gas Fee 100 comm. $ 100.00 Electrical Fee $ 156.26 Total fees collected $ 1,662.55 451 Andover Street Unit 208A and 207A 581-13 on 2/28/2013 Renovation of exisiting dental practice w Pinnacle Construction Company, Inc. General Building Contractors 16o L,ORUM STREET • TEWKSBURY,MASSACHUSETTS 01876 • TELEPHONE:978-851-9200 • FAx 978-851-5342 www.pinnco.com • e-mail: info@pinnco.com February 7, 2013 Dr. Paolo Incampo One West Water Street Wakefield, MA 01880 Re: Proposal for 451 Andover Street Dear Paolo, This letter is written to serve as a quotation. Please consider the following scope of work. -Apply and pay for Building Permit -Demo interior finishes as needed -Includes entire ceiling and all flooring, partitions as needed and all doors -Salvage and set aside and or recycle components as much as possible -Demo work performed on Saturday daytime Demolish and remove all designated interior non-masonry partition walls Demolish and remove all designated doors and frames Demolish and remove all designated ACT ceilings Demolish and remove all designated flooring Demolish and remove all designated millwork -Construct new metal stud and drywall partition -Construct drywall soffit as per plan -Provide and install 25 gauge framing, 16"on center, with R-11 unfaced, fiberglass insulation and one layer of 5/8"Type X each side with a Level 4. Partitions extend to 9'-0"A.F.F. -Deck height included at 11'- 0"A.F.F. Ceiling heights assumed at 9'-0"A.F.F. -Provide and install drywall soffit and ceiling in Reception area and new soffit in room with arched doorways -Furnish and install glass block to infill exiting door opening -Furnish and install glass block to create walls generally as per plan -Sheetrock valance at top of glass block -No steel lintel for glass block -Furnish and install commercial doors, frames and hardware; includes 1 3/4"solid ore commercial door with pressed metal frame -Doors are as follows: Wood Doors Clear Finished Birch 7—Single 3 —Single Full Light Vision 1 —Set BiPass Full Light Vision I —Pocket Door Full Light Vision 3 —BiFold Sets - Included Clear Glass 15 —Hardware Sets -Excludes new door to hallway -Paint all new drywall three coats -Prep and paint walls to remain -Paint entire Suite GWB walls to receive on coat of primer and two coats late eggshell finish Frames to receive semi-gloss enamel finish Soffits to receive primer and finish Doors to be pre-finished -Furnish and install new ceiling grid and tile Furnish and install 1,800 square feet of Armstrong Supra Fine Ceiling Grid System with Armstrong 2x2 Ultima Health Zone tiles#1936 Furnish and install Armstrong 9/16 g Supra Fine ceilingridsystem with Armstrong infusion 2x2 tiles Indigo Surf Color -Furnish and install Millwork as follows: Reception: Reception Desk with built ins; P-lam (20) solid surface tops Practice Management: Base Cabinets P-lam 22' Counter Top P-lam 22' Upper Cabinets P-lam 22' Desk P-lam 8' with end panel Doctors Office: Base Cabinets P-lam 11' Counter Top P-lam 11' Upper Cabinets P-lam 11' Desk P-lam 5' with end panel Patient Coordination: Base Cabinets P-lam 19' Counter Top P-lam 19' Upper Cabinets P-lam 8'with end panel -Window treatments by others -Furnish and install flooring as follows: Supply and install Mannington Modular Sylvan Structures I and II color Rustic for both Supply and install Shaw Tempt Tile color Flirt Supply and install Shaw Crete 18x18 color Vivirdian Supply and install Shaw Jedgori in color Jute and Fiber Supply and install Mannington Premium Edge 4"rubber base in three colors Supply and install Vinyl transitions -Modify Plumbing as follows: Demolition plumbing for(1) water closet, (1) lavatory sink and(1)shower unit _ Furnish and install all of the necessary underfloor rough and finish plumbing for(1) lab room sink Furnish and install all of the necessary compressed air, water, vacuum/suction,and drainage for(2)new operatory chairs Relocate all of the necessary plumbing for the relocation of(2) exiting dental, operatory, chairs as well as install all of the necessary lines for(1) future dental chair w (3) Sterling "Southhaven"#11403-NA, stainless steel, 3 hole, drop in kitchen sinks (3) Chicago #201-AGN8AE3-317-CP, polished chrome 8"centerset gooseneck faucets (with wrist blade handles) (1) Watts#009M2QT, backflow preventer(for the vacuum pump system) (1) Plaster trap (for laboratory sink) -Tying into the existing hot water heater -Opratory sinks by others -Abandon and remove existing HVAC units -Infill interior of through wall sleeve with insulation and drywall -Exterior of existing HVAC sleeve to remain -Furnish and install new HVAC as follows: -Furnish and install two new Mitsubishi ducted heat pump systems to supply heat and cooling to the space -All the existing wall units will be abandoned and removed -There will be two new zones of heating and cooling -The existing seating area and existing business office will stay as is with the existing ductwork -The rest of the area will be new system -One zone will be all the outside offices -The second zone will be all the interior space except for seating and business office. They will continue to use existing ductwork -The proposed systems are as follows: Outside office zone =Mitsubishi P Series PEADA24AA ducted air handler with a PUZA24HA3heat pump condenser Interior zone= Mitsubishi P Series PEADA30AA ducted air handler with a PUXZA30HA3 heat pump condenser -The system will come with a seven(7)year warranty Furnish and install Electrical as follows: Lutron architectural devices and plates included for all patient accessed areas Patient treatment rooms to have hospital spec grade receptacles Offices and other private areas to have standard spec grade devices and plates Fire Alarm quoted for full coverage of horn/strobe units. Smokes and pulls not expected or included. Tel/data for rings and strings Emergency lighting per code All decorative pendants, Type A, B, C, D to be supplied by LAS per drawing 6A Notes -Proposal excludes tel/data, access, security, t-stat, stereo, or any other wiring not specifically noted in this proposal -If Fire Alarm panel shut down is required, it is to be by Landlord's vender and not included in this proposal -Provide full time supervision six day weeks—48 hours a week -Provide added labor for layout, clean up, etc. -Provide legal disposal off-site for this contractor and its subcontractors -Coordinate with Dental Equipment supplier -Provide final clean and waxing of floors Total Lump Sum $104,170.00 Excludes: Architectural/structural design or certification, bonds, concealed conditions, cutting or patching for other trades, disposal for other contractors, handling or disposing of hazardous waste, moving owners furniture and equipment, sprinkler, signage, temporary heat, lights, water, telephone, electricity, warrantee beyond one year and relocation or storing dental equipment. See Schedule of Values for Breakdown Any questions please feel free to call. Very truly, Pinnacl �strn Company, Inc. R. Paul Morris President i Paoi&-Mc`ampo 02071303 Massachusetts-Department of Public Safety Board of Building Regulations and Standards Construction Supen icor License: CS-044300 . PAUL R MORS 160 LORUMSt I Tewksbury*A 01876 tl . a y Expiration Commissioner 02/2212014 � , CITY OF BOSTON BOARD OF EXAMINERS LIC. I, 0 820050 i MAYOR Z:- THOMAS M.MENINO � THS C- ` f � PAtiL,.R MORRIS'' ....t IS Y LI Er.W r y WO UNDER PROVtS10N5 OF THEA AIS 04'},�,,,CH% SQMENDEIV SEEeB CKi1 �.,�. 3%14J'13 BOARD OF EXAMINERS A.EXANDER H MA.CLECD a a yt SCCi-DARUNG III I PArR!CK-RAZ:Y u- Lic. No. 0349 Class I F, IIF, I I I F, I V,V Expires 7/31/2012 Date 8/30/2011 BOARD OF EXAMINERS CITY OF CAMBRIDGE BUILDING DEPT. LICENSE FOR CONTROL OF BUILDING OPERATION This is to certify that MORRIS R PAUL is duly licensed to take personal charge of work under the provisions of the Building Ordinances of the City of Cambridge. Board of Examin C it.ddgat�-- Signature of Licensee (OVER) ✓,ze lOonz,�no�'uue2GU2- C��,��aadae�zu6e�.6 r� Office of Consumer Affairs&Bdsiness Regulation ula �\ g ton -- HOME IMPROVEMENT CONTRACTOR Registration: 112224 Type: Expiration: 3/5/2013 Private Corporatio PINNACLE CONSTRUCTION CO INC PAUL MORRIS 160 LORUM ST TEWKSBURY,MA 01876 Undersecretary ..:" OFFICE OF BUILDING INSPECTOR TOWN OF NORTH ANDOVER CONSTRUCTION CONTROL PROJECT NUMBER: PROJECT TITLE: m Wel " of DR. P A b L-b IM PROJECT LOCATION: 451 ^14VAD � IST-11 0 7 S NAME OF BUILDING: NATURE OF PROJECT: IN ACCORDANCE WITH ARTICLE 116 OF THE MASSACHUSETTS STATE BUILDING CODE, J�*Jg Gs 9L ,7k—Ml1Vl 5 REGISTRATION NO. M �`�� AR) BEING AISTERED PROFESSIONAL ENGINEER/A CHITECH HEREBY CERTIFY THAT I HAVE PR ARED OR DIRECTLY SUPERVISED THE PREPARATION OF ALL DESIGN PLANS, COMPUTATIONS AND SPECIFICATIONS CONCERNING: ENTIRE PROJECT • ARCHITECTURAL • STRUCTURAL • MECHANICAL • FIRE PROTECTION • ELECTRICAL • OTHER(SPECIFY) 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. 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. PURSUANT TO SECTION 116.2 .2 1 SHALL SUBMIT WEEKLY , A PROGRESS REPORT TOGETHER WITH PERTINENT COMMENTS TO THE NORTH ANDOVER BUILDING INSPECTOR. UPON COMPLETION OF THE WORK, I SHALL SUBMIT A FINAL REPORT AS TO THE SATISFACTORY COMPLETION AND READINESS OF THE PROJECT FOR9�GNATURE- SU UPANCY. CRIBED AND SWORM TO BEFORE ME THIS�DAYOF20�_ JENNIFER K.TQLAN NO R PUBLIC MY COMMISSION E. Notary Public Commonwealth of assachuset"<s my Cammission Expires NOv. 17,20-19 AbL The CommOnwee" ofm"achusetts fo De arhment Industrial Accidents P T -y Office ofInvestigations a 600 Washington,Street _ Boston,MA 02111 www.m ugov/dia rs Workers' Compensation Imsuranee Affidavit: SuilderiCoadaactors/Electriciams/Plu®6 6t A 6cant Information Please Print L Name(3usiness/0rganization/Irtdividuat): ic \ ( e-1- Address: �J — City/State/Zip: Phone#: Are Yo n employer?Check the appy nate hoz: Type of project(required): 1.�a employer with _ 4. ❑ I am a general contractoramd 1 6. ❑New construction employees(full and/or part-time)- have hired the sub-contractors listed on the attached sheet �• ❑Modeling 2.❑ I am a sole proprietor or partner- These sub-contractors have 8. ❑Demolition slop and have no employees employees and have workers' working forme in any capacity. t 9. ❑Budding addition [No workers'comp.insurance comp' a corporation 10. Electrical repairs or additions required] S• ❑ We are a corporation and its ❑ P 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,§I(4),and we have 13.❑Other employees.[No workers' comp.insurance required.] *�Y applicant that chemo box d1 must also fin out the section below showing their workus'compmrdma policy bibmhaam. t Homeowners who submit this aiNdavit bdicatiug they ate doing all work and then hire outside cu a w must submit a new affidavit indicadngsuch tcontractors that check this box must attached an additional sheet showing the name of the n&cohmcros and slam whether or not those eatides km employe= tf the sub-contractors bave employees,they must provide their workers'comp.po4c oder. I W X aane� rloyer Fiat is provift workers'coorpensadon 6aswunce for MY oxployM Below is&epoft and fob site Insurance Company Name E' Policy k or Self-ins.Lic.#: Expiration Date . Jab Site Address: I ice`/ policy declaration page(showing the policy number and expiration date Attach a copy of the workers'compensation 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 be form of a STOP WOM 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 m the Once of Investigations of the DLA for insurance coverage verification. I do hereby ca*ander an p &!rtes ofPed my that the 1 fornratiaa provided above is true and correct Date: 2, -- � S' afore: Phone� G�1 -- offlcial use only. Do not write in tots areQ to be completed 6y ctty or town&ra1 City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Budding Department 3.City/Town Clerk 4.Elechical Inspector I Plumbing Inspector 6.Other Phone#; r P in a®rdance with the provisions of MOL c 40. S$4.a condition of Building P=it is that hat the debris resaking From this work Shall be disposed of in a property licensed solid waste disposalfadity as defined by MOL c ill.S 1S0A. T71e debriS will be disposed of in: r 41 1 64 `(Location of Fa Signature of Permit Applicant Da e it