HomeMy WebLinkAboutBuilding Permit #255 - Suite 300 9/30/2009 pORTOI
BUILDING PERMIT O�tz�eD
TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION _
Permit NO:` Date Received 7 pDAtTED °P 4`�
�SSACHUS
Date Issued:
IMPORTANT:Applicant must 'complete all items on this page
LOCATION f�L� J�1 ,F '�
Print
PROPERTY OWNER
, /70lL L
Print.
MAP NO: PARCEL: ZONING DISTRICT: Historic District yes n
Machine Shop Village yes n
TYPE OF IMPROVEMENT PROPOSED USE
Residential Non- Residential
New Building One family
Addi ion Two or more family Industrial
teratio No. of units: ommerci
replacement Assessory Bldg Others:
Demolition Other
Septic Well Floodplain Wetlands Watershed District
Water/Sewer
DESC IPTION O�RK TO BE EFORMED:
Yl �e. 6n �o
Identif ation Please Type or Print Clearly) 2�� /y
OWNER: Name:." 0 z..` C Phone:
Address: e 3151416�ZZ�;2 (��2
CONTRACTOR NameIIJ POL&t Aff 60,lAv Phone:PJ 60
Address:. so /lt°� 1 �7 l Zt
Supervisor's Construction License: ltd( Exp. Date: j Q
Home Improvement License: Exp. Date:
ARCHITECT/ENGINEER L4.6✓a�5Su 1455-oc;47ef/&cPhone: 21z- 7--f4
Address: rc Uac1,/6Z Z
® Reg. No. 71,63
FEE SCHEDULE.BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost: $ rte, y , FEE: $ l�
Check No.: r Receipt No.:�
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
Signature of Agent/Owner , Signature of contract -
Location 2;2/ �(llf1�� ��
No. Date 93�
�oRTM TOWN OF NORTH ANDOVER
3?O:�•.•o ,•1,�OO
F w
M
i Certificate of Occupancy $
s i
3C14Us<� Building/Frame Permit Fee $
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check #�0
22 . i
Building Inspector
Plans Submitted Plans Waived Certified Plot Plan Stamped Plans
TYPE OF SEWERAGE DISPOSAL
Public Sewer Tanning/Massage/Body Art Swimming Pools
Well Tobacco Sales
Food Packaging/Sales
Private(septic tank,etc. Permanent Dumpster on Site
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION Reviewed on Signature
COMMENTS
HEALTH Reviewed on Signature
COMMENTS
.s
L
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision: Comments
Conservation Decision: Comments
Water & Sewer Connection/Signature& Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
FIRE DEPARTMENT - Temp Dumpster on site ye no
Located at 124 Main Street 04
Fire Department signature/date Z.Z.
COMMENTS
Dimension
are feet of floor area, based on Exterior dimensions.
Number of Stories:______—Total squ
Total land area, sq. ft.:
Movement of Meter location, mast or service drop requires approval of
ELECTRICAL: Mo Yes No
Electrical Inspector
DANGER ZONE LITERATURE:
Yes No
MGL Chapter 166 Section 21A—F and G min.s100-$1000 fine
NOTES and DATA- (For department use
❑ Notified for pickup - Date
Doc.Building Permit Revised 2008
o�...""Y fund . - -
ignature of contract
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
❑ Copy of Contract
❑ Floor Plan Or Proposed Interior Work
❑ Engineering Affidavits for Engineered products
NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit
Addition Or Decks
❑ Building Permit Application
❑ Certified Surveyed Plot Plan
❑ Workers Comp Affidavit
❑ Photo Copy of H.I.C. And C.S.L. Licenses
❑ Copy Of Contract
❑ Floor/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 Application
Revised 2.2008
IAORTH
ONM Of 4Andover
o _�� LAKE = dover, Mass.,
COCHICHEwICK y1.
7,9 ADRATED APS\ ��
`s E BOARD OF HEALTH
PERMIT T D Food/Kitchen
Septic System
J� �1 � ``� BUILDING INSPECTOR
THISCERTIFIES THAT................................................................................................................................................................ Foundation
y.. .. I...... .�has permission to erect............................... buildings on .... . 0 ......................... ............... Rough
to be occupied as.... 0 ....... �
Chimney
Provided that the person accepting this permit shall in every respect conform to the. to thear-�kf6
ofile 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
r PERMIT EXPIRES IN 6 MONTHS
ELECTRICAL INSPECTOR
UNLESS CONSTRUG7 ON STARTS Rough
--- — Service
BUILDING SPECTOR
Final
Occupancy Permit Required to Occupy Building GAS INSPECTOR
Rough
Display in a Conspicuous Place on the Premises — Do Not Remove Final
No Lathing or Dry Wall To Be Done FIRE DEPARTMENT
Until Inspected and Approved by the Building Inspector. Burner
Street No.
SEE REVERSE SIDE Smoke Det.
From: 09/28/2009 14:41 #189 P.0021002
September 28,2009
Town of North Andover
1600 Osgood Street
North Andover,MA 01845
Attn: Gerry Brown B. I.
Jim Diozzi,P. 1.
Re: Building 451 Andover Street Public and Tenant Toilets
Dear Gerry and Jim,
I have assisted the owner"First General Realty Corp."in the re-classification of the
four story office building from a rental building to an office condominium building.
Approximately a year ago,the tenants were given an opportunity to transform their leases into
ownership. Many have and some wanted to remodel their suites. Over the last several
months we assisted several suite owners develop newer and more efficient interior plans. One
of these tenants is Dr.Watchell who is moving from one suite to the larger suite on the third
floor of Building 451 Andover Street. Suite 300-1 is a 1670 square foot interior tenant
development that may trigger ADA construction improvements to the common area toilets.
As agreed with Jim Diozzi,Plumbing Inspector,I am presently reviewing all four floors for
compliance to the applicable common area Plumbing and Building Codes. Jim was also
going to review and send me the applicable Plumbing Code sections requiring the additions of
Barrier Free toilets on each floor of the existing building and in conjunction with requiring
janitor's closets with a sink on each floor.
First General Development will revise the third floor two public men's and women's
room to comply with the barrier free design or petition the state to allow the single unisex
toilet remodeling as per the plan given to the Building Inspector.
Prior to any construction or variance requests,and after any total building analysis
incorporating occupancy loading plus review of the existing common area toilets(two rooms
per floor)and the existing additional private toilet rooms internal to many suites,my office
will submit plans to the Plumbing Inspector for review and direction.
First General will comply with any required improvements. This analysis will take
approximately one week for me to do and as discussed will allow the occupancy of Dr.
Watchell into his upgraded location.
Submitted by,
(�Iel w-
Offices Joseph D. LaGrasse,AIA
One film Square T 978.470.3675
Andover,MA 01810 F 978.470.3670
1420 Celebration Blvd. www.lagrassearchiteas.com
Celebration,FL 34747
AA26001333
248 CMR: BOARD OF STATE EXAMINERS
OF PLUMBERS AND GAS FITTERS
10.10: continued
3. The number of toilets and lavatories shall be provided within reasonable access(as
defined in 248 CMR 10.10(18)0)4.) and in accordance with 248 CMR
10.10(18): Table 1 for industrial facilities.
4. Distance of direct access for industrial establishments requires that in no case may
a toilet facility be located more than 300 feet in developed direct distance away from the
regular place of daily work activity of any persons for whose use it was designed. Except
where service elevators,accessible to the employees,are provided.
5. Each 20 linear-inches,or 18-inch circumference-inches of usable sink access will be
considered the equivalent of one lavatory.
6. In industries and manufacturing facilities with departments where there is excessive
exposure to substances or liquids or where the work performed may create dust and grit
conditions,one lavatory sinkmay be required for every five persons and in all cases,a
potable water supply of hot and cold water shall be provided.
(k) Medical and Health Care Building Toilet Facilities.
1. In all medical and health care buildings there shall be separate designated toilet
facilities on each floor for male and female patients and visitors.
2. The toilet facilities may be located in a.common or core area on each floor so long
as the toilet facilities are within 300 feet of all offices.
3. Accessibility to the toilet facilities shall be direct;it shall not require going from one
medical office through another for access to the toilet facilities.
4. Handicap toilet facilities are required on each floor.
5, A minimum of one drinking fountain shall be installed for each set of toilet facilities.
(1) Covered Malls Toilet Facilities.
1. In all covered malls there shall be separate designated public toilet facilities for male
and females. These toilet facilities shall be centrally located in the common core area on
each floor.
2. These facilities are in addition to the requirements of 248 CMR 10.10(18)(i)
regarding toilet facilities for male and female employees.
3. When the occupancy exceeds 9,000,toilets shall be installed at.the rate of one per
1,500 for women and one per 3,000 for men. Lavatories shall be installed as listed in
248 CMR 10.10(18): Table 1.
(m) Handicap Toilet Facility Requirement. Facility for the physically handicapped person:
1. Plumbing fixtures shall be installed in conformance with 521 CMR 30.0: Public
Toilets(for fixture dimension requirements only).
2. When public toilet facilities are to be installed,handicap plumbing fixtures shall
comply with the requirements of 248 CMR 10.10(18)(m).
3. Unisex handicap toilet facilities maybe allowed by the Board by the variance process
as outlined in 248 CMR 3.04(2):
a. A variance is not required if the fixtures in an existing or proposed men's and
women's toilet facility and the fixtures in a unisex handicapped toilet facility meet
the minimum fixture requirements of 248 CMR 10.10(18): Table 1. A unisex toilet
may be counted only one time toward the total minimum fixture requirements.
b. These toilet facilities shall be kept clear of obstructions at all times in accordance
with 105 CMR.
4. Wherever drinking fountains are provided,a drinking fountain shall accessible to the
physically impaired.
5. Additional sanitary facilities for the physically impaired;handicap toilet stalls placed
within a fully compliant 248 CMR. toilet facility may also provide an additional
accessible handicap lavatory within the toilet stall area. The lavatory placement shall
comply with the requirements of 521 CMR.
(n) Toilet Facilities General.
I. Toilet facilities accessible to the public which have two or more toilets or urinals,or
two or more thereof in any combination,shall provide a floor drain equipped with an
automatic trap priming device and a valved hose connection equipped with a backflow
-- preventer. The hose-connection is for the purpose of floor cleaning in the toilet facility.
2. Floor drains shall be installed in the vicinity of the urinal(s)and placed at a grade to
enable floor drainage to the floor drain from all directions.
3/11/05 248 CMR- 155
i
ol
O o
m� a °Ooo
j � o
dM
4'-511
MEN
.053 OVE WALLAND
w ;
ANDOVER, NSTRUCT N WALL u
�q[lH of
MP I I w 0
OF ;
REMOVE EXISTING FIXTURES, �.Ta
WALL NOTED BY DASHED 1,4 �
LINES, t DOOR 1--1 'tj a
0
EX I ST I NSVDE O FLOOR PLAN 1
� z
SCALE: I/4"=1'-0"
x O S
INSTALL NEW 2'X4' BUILDINGTANDARD CEILING GRID d TILE, LIGHT
FIXTURE 4 REINSTALL EXHA T REGISTER. SEE PLAN BELOW. c
PAINT NEW TOILET WALLS W/ OAT PRIMER AND 2 FINISH COATS w y
NEW BUILDING STANDARD F ORING AND BASE_ PAINT ADJACENT
TENANT WALL i CORRIDOR UALL TO MATCH IISTING
4'-2111 6'-2" Q
NEW METAL STUD AND GWB LLA L TO DEC /
MEN
W/ACOUSTICAL BATTING BET £N STUDS. _
NEW ADA COMPLIANT TOILET INK, D r
ALL TOILET ROOM APPURTE NC O
� w
Cn
NEW 3'-0"X6 0
'-8" S.C. WOOD DOOR, w
CLOSER, PRIVACY LOCKSET W/LEVER
HANDLES OSS
U) O
W Z
REY I SEP, FLOOR PLANS Z
SCALE:1/4"=1'-0" Al
AREA OF WORK o s
: 3 SEPT. 2009
L ole. AS NOTED
ob
lo.: 2161Z
shat-
SCALE:
eerSCALE:1/8"=i'-0" Al THIRD FLOOR KEY PLAN
SEP-22-2009 11:41 FIRST GENERAL REALTY CORP 617 527 4176 P.003
T.S. Property Serviced, Corp.
NO. 9328
P 10 Box 549 .,., !W:" : . 2
BMcrick MA .:Aad± :,.. 9112109
,i
(. I� Continued from the previous page)
Alii Material is guaranteed to be as specified,and the above work to be performed in accordance with the drawings and
specifications submitted for above workand completed in a substantial workmanlike manner for the sum of
i 'TMJ �,cuFt. 101- ��'00
11 �Thousand SiwHundred bliss `-* `Eight Dollars and 00/100 Dollars (S 4-6W.06' )
�I Payments to be made as follows: 1/3 Deposit 1/3 Progress Payment and 1/3 Upon Completion
"Any alteration or deviation from above specifications invohring 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 ys beyond
our control.
"Note—'Phis proposal may be withdrawn by us if not accepted within30 days.
i
Respectfully Submitted Frank Gomes
On behalf of _U.S. Prop ty„Services
i
ait� �IN.'TcSf�wCX'• aw a7�nT:t'w'wLi. ;;F'M�:���?��:.v.�.r.:x•`::i.'. :.;..;�W4Tr1', V�•'�V'�V�7�•"••'"•: "i.�,•-.'•'.«.+�.:::r-�..,�.:s:+:�..::..4h:.:..''' ': �.,'..`•' '.�..�:k�l.Y.
the above prices, specifications and conditions-are satisfai toryatrd'are•-trer+etrr'accepted. You,are authorized tido tt►e work
asi�speCii9ed. Payne II be as outlined above.
17
Date . Z D Signature /
i
Date �.' Signature
i
•.I
,I
i
.I
`I
U.S.Property Servion-Tel:978587-2WO-Fmc 978-607-26M
j uap<opertyservice�hotriieil.aan
III
TOTAL P.003
SEP-22-2009 11:41 FIRST GENERAL REALTY CORP 617 527 4176 P.002
U.S. Property Serviced 9328
P; ox O B 545 FP '': 1
Billerica,MA r ._:.ti 9112/09
I
I.°General Information
Proposed by- U.S. Property Services Telephone- (978)587-2809
P.0 Box 545 Fax: (978)587-2809
Madca,MA
Submitted TO: First General Realty Corporation Work Performed At 451 Andover Street
93 Union Stmt,Suite 315 North Andover MA
Newton Centre, MA 02459
3i°floor handicapped bathroom
.I
11-'J Work Descriaeion
We hereby propose to furnish the materials and perform the labor necessary for the cmmptedon of the worts described herein
anis to commence on the date listed above:
!I • Demo one wall in the current bathroom Cost:$4,898.00
• See if additional space IS needed to gain enough space to meet ADA requiremerrts. Up to 4"may need to be taken
from abutting tenant space.
. Remove the VCT flour and file surround
• Reframe new waw
• Install GWB,tape and mud seams
• Skim coat walls
' . Install new ceramic floor file
• Install new baseboard
• Install 36"door to the bathroom
• One coat of primer and two coats of finish paint will be applied to the walls
• Permit will be obtained for this project
• Plumbing allowance Cost$4,600.00
�; • Electrical allowance Cost$1,150.00
I
WAC
.I
L�. Exce�rtions
I pe
• rpetirlg .
-,FireAlarms/Sprinkler Systems
@rl<1<]S
'As.a. All debris will be removed on a nightly basis.
I b. First General Realty wip provide the dumpsters
J (Continued on the next page. ..)
U.S.Properly Services•Tel:978-587-2809"Fwc 978.587--2809
uspmpartyserAces@hoonaA.com
�II
d>ct- �a�s'.nrasauxccd�,�i-a+ yEasxzc�r*rte
$card dBuilding Regulat'conWan..d Standards
Construction Supervisor License s
License: CS 98124
Expiration: 111412011 Tr#;98124
Restriction: 00
_77-
DAVID ROWE
D- 4-VIS ROADUNIT G7
OTON,MA 01120 Commissioner
03/11/2009 ICED 16;01 FAX 976 750 0082 FRAVEL INSURANCE AGENCY 01/001
ACORiU,N CERTIFICATE OF LIABILITY INSURANCE °A1/13/09'
PRODUCER THS CERTIFlCATE IS ISSUED ASA MATTER OF INFORMATION
Fravel Insurance Agency ONLYAND CONFERS NO RIGHTS UPONTFECERTFICATE
6 High Street IALLTTERTI ECOV�GEAFMRDFD13YTHOES N017 E�ICIO-END OW.
Danvers, MA 01923
INSURERS AFFORDING COVERAGE MAIC#
INSURED INsuRERa Ma7r Specialty Ins Co.
US Property Services INSURER B. Granite State
Lisa Gomes ,Nsurmic:
200 Andover St set, Suite 312 INSURER D:
Peabody, MA 01960 INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING
ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES,AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. _ ...._
INSR D POLICVNUMBER POUGYEFf�C71VE U EXPIgdTpNi LIMITS
GENERAL LIABILITY EACH OCCURRENCE S 1,000,000
NOfriGETOTiB�TEf�—'_..__..
B X COMMERCIALGENERALumuTY MAX013902000208 1/9/09 1/9/10 PREMISES(Eseearm+x $ 50,000
CLAMS MADE QX OCCUR MED EXP ae man S 5 000
PE2SONALGADVINJURY $ 1,000,000
G040MAGW4EGATE S 2,000,000
GEN'I.AGGREGATELIMITAPPLIESMR: PRODUCTS-COARRKWAGG $ 2,000,000
PoUv Inc
ANTONOOKALIABILITY COMBINED SINGLE LIMIT S
- (EB eedoenll
ANY AUTO --•-
ALLOVOIEDAUTO.S ( BODILY INJURY 5
(Par Peroa1)
SCHEDULED AUTOS • —
HIRED AUTOS BODILY
Ry S
NON-OWNED AUTOS
PROPERTYOAMAGE S
(PeraeelaelN�
WMAGELIABILITY I ( AUTOONLY-EAACCIDENT_j i
j ANY AUTO AUT ONT LYS EA ACC S
A= $
EXCESSILIMBRELLALIABIL(lY faCHOGCURRt3JCE $ .-•_
I._. OCCUR CLAIMS MADE AGGREGATE S _-•-
hOEDUCTIBLE
, $
1 I RETENTION $ $
WC$TATU- O I
WORKERSCOMPENSATIONAND
A EMPLOVEIMILIABILITY TBA 1/13/09 1/13/10 E.LEACH A000ENT s 100,000
NAM(PROfiR IETOR*"q NER/O(CCUTRE _� 07'7 7$!0 0
FICERn F.rSZREXIxuDEln T 6.Lo1SFASE-TArdJPLovEE s 100,000
If dwal eU%wE.LDLSEASE-POUCYLIMIT s 500,000
O la PRowsCNSw4w
OTHER
i
D ESCRIPTbNOF ORERATIDNS I LOCAMONS I%"L;L M l EXCLU MONS ADDED BY END ORSEAENT I SPECIAL PROVISIONS
CER'TIRCATE HOLDet CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIESSE CANCELLED BEFORE THE EXPIRATION
DATETHEREOF,THE ISSUING INSURER WILL ENDEAVOR TO 30 DA%s W RTTIEN
NO=ETOTHE CERTIFICATE HOLDER NAMED TOTHE BU FAILURBTOOOSOSHALL
IWOSENOOBLIGATIONORUAB OFANYKINDUPO THE SURER,ITS AGENTS OR
REPRESENTATIVES YI
AUTHOgM12ED REPRESENTA
ACORD 25(2oo1108) jACdRD CORPORATION 1988
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
k1V 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):16 proad( l /
Address: SY 9-Z
City/State/Zip: O l Q��C Phone #:
Are ygu an employer?Check the appropriate bog: Type of project(required):
1.Q I am a employer with_V 4. ❑ I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their
10.❑ 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.] T employees. [No workers' 13.❑ 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 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: 4
Policy#or Self-ins.Lic. #: 1}6 Expiration Date: 0�li^c"1901Q
Job Site Address: � ,/ I��YI��/�'� City/State/Zip:i L/ _ 444ZFi
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 unde e p nd penalties of perjury that the information provided above is true and correct.
--'
Signa:: Date:
Phone
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2. Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person: Phone#:
Architects
LaGrasse & Associates, Inc. Joseph D.LaGrasse,AIA
, JD Architects, Engineers & Lana Planners Thomas E Galvin,AIA
Julianna E.Hoch,RA
CONSTRUCTION CONTROL AFFIDAVIT
PROJECT NUMBER: 2161Z PROJECT TITLE: Unisex HP Toilet
PROJECT LOCATION: 451 Andover Street,3`d Floor Common Corridor
NAME OF BUILDING: Building 1
SCOPE OF PROJECT: Renovation of existing toilet to construct a unisex HP compliant toilet, 3`d Floor, 451
Andover Street.
In accordance with Section 116.0 of the Massachusetts State Building Code,
I, 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 in 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.
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.
p�Gcy�TF Joseph D.LaGrasse,AIA
q L
' No.4153 m
� jyGgA Signature of Architect/Engineer Date
IrNH OF MPSgP
Offices
One Elm Square T 978.470.3675
Andover,MA 01810 F 978.470.3670
1420 Celebration Blvd. www.lagrassearchitects.com
Celebration,FL 34747
AA26001333