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Miscellaneous - 1160 GREAT POND ROAD 4/30/2018 (39)
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MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK `y CITY"'014 MA DATE 'G�0`rte( �� PERMIT# JOBSITE ADDRESS /60 OWNER'S NAME �G� � o�S l GOWNERADDRESS G� �G C/ ' tEL- FAX TYPE OR OCCUPANCY TYPE COMMERCIAL PRINT ❑ EDUCATIONAL [[� RESIDENTIAL❑ CLEARLY NEW:❑ RENOVATION: [L]'^ REPLACEMENT:❑ PLANS SUBMITTED: YES❑ NO❑ APPLIANCES-1 FLOORS, BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER COOK STOVE DIRECT VENT HEATER DRYER FIREPLACE ou OdV-- FRYOLATOR FURNACE GENERATOR GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER UNVENTED ROOM HEATER WATER HEATER OTHER INSURANCE COVERAGE have a current!!@bili insurance policy or its substantial equivalent which meets the requirements of MGL.Ch.142 YES ❑x NO ❑ I IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW a LIABILITY INSURANCE POLICY © OTHER TYPE INDEMNITY ❑ BOND ❑ 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 F1AGENT ❑ SIGNATURE OF OWNER OR AGENT 1 hereby certify that all of the details and information I have submitted or entered regarding this application/aret an accurat a bes wledge and that all plumbing work and installations performed under the permit issued for this application will be ilianc with Perin n vision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. / PLUMBER-GASFITTER NAME PAUL FLAHERTY LICENSE# 9059 SIGNATURE MP 0 MGF❑ JP❑ JGF❑ LPGI❑ CORPORATION®#1752 FARTNERSHIP❑# LLC❑# COMPANY NAME PAUL FLAHERTY PLUMBING& HEATING CO. INC. ADDRESS 186 FOUNTAIN STREET CITY FRAMINGHAM STATE MA ZIP 01702 TEL 508-653-1775 FAX 508-620-1775 CELL EMAIL CONTACTUS@FLAHERTYPLUMBING.COM I ROUGH GAS INSPECTION NOTES THIS PAGE FOR INSPECTOR USE ONLY FINAL INSPECTION NOTES Yes No THIS APPLICATION SERVES AS THE PERMIT ❑ ❑ FEE: $ PERMIT# PLAN REVIEW NOTES Golumb'a Gas® of Massachusetts A NiSource Company April 18, 2017 Mr. Jim Hurley Plumbing and Gas Inspector Town of North Andover 120 Main St. North Andover, MA 01845 Re: We can serve letter for new gas fueled fire pit at Brooks Academy 1160 Great Pond Rd. in North Andover, MA. Dear Mr. Hurley, This letter is to confirm that the serving gas supplier, Columbia Gas of Massachusetts (CMA), can supply sufficient gas pressure and volume to the newly installed HPC Co. Fire Pit appliance in a volume of 65 SCFH and a minimum inlet pressure requirement of 6.0" W. C. Please contact me at 978-556-8919 if you have any questions. Sincerely, Philip Sevigny New Business Development Manager Columbia Gas of Massachusetts. Date Gv //P Town of North Andover Your permit has been sent back to you for the following reasons: 1) Check amount incorrect 2) No copy of current license 3) Insurance Binder not on file or expired 4) No Workers' Compensation Insurance Affadavit Form Please call with any questions 978-688-9545. Fax 978-688-9542 Workers'Compensation Form and Schedule of Fees can be found on the Town of North Andover Website under Building Department. Mailing Address: 1600 Osgoo eet, Building 20, Suite 2035, North Andover, M 45 We have migrated to on line permitting as of April 2016. A representative from your office will need to come to our office (address above)and build a profile with an email and a password. Once your profile has been created you can then pull a permit via northandoverma.viewpointcloud.com . Please make sure you have a current insurance binder(made out to the Town of North Andover in the lower left corner of binder) and complete a Workers'Compensation Insurance Affidavit. ��� � C✓YDS. 2.�v�a,. � �2.c��: Q_(Z._`_'� � A�V CERTIFICATE OF LIABILITY INSURANCE DATE(MWDD/YYYY) 8/29/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Tina Torchic, NAME: W.T. Phelan & CompanyA/CNNo xt: (781)641-7200 A/C No:FAX (781)646-2410 645R Massachusetts Avenue AD RIESS:tina.torchio@wtphelan.com INSURERS AFFORDING COVERAGE NAIC H Arlington MA 02476 INSURERA:Travelers Indemnity of America 25666 INSURED INSURER B:AmGuard 42390 Paul Flaherty Plumbing & Heating Co., Inc. INSURER C: 186 Fountain Street INSURER D: INSURER E: Framingham MA 01701 INSURER F: COVERAGES CERTIFICATE NUMBER:2016-2017 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IR' TYPE OF INSURANCE ADDL SUER POLICY NUMBER MM%DY EFF MMLDDY EXP LT YYY LIMITS LTR� X I COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 11000,000 7 DAMAGE TO RENTED A CLAIMS-MADE I X I OCCUR PREMISES Ea occurrence $ 300,000 X Per Project Aggregate 680-9E182725 9/1/2016 9/1/2017 MED EXP(Any one person) $ 5,000 X� $10M Max Annual Agg PERSONAL&ADV INJURY $ 11000,000 GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 _j POLICY! JECT I LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 11000,000 Ea accident A ANY AUTO BODILY INJURY(Per person) $ ALL OWNEDX IAUTOS SCHEDULED BA-9E183457 9/1/2016 9/1/2017 BODILY INJURY(Per accident) $ 'IAUTOS NON-OWNED PROPERTY DAMAGE X 'I = NON-OWNED Per accident) ccident $ HIRED AUTOS ��AUTOS I 1 $ � X UMBRELLA LIAB I X I OCCUR EACH OCCURRENCE $ A EXCESS LIAR CLAIMS•MADE AGGREGATE $ IDED RETENTION$ CUP-9E197044 9/1/2016 9/1/2017 $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY Y/N STATUTE _ ER .ANY PROPRIETOR/PARTNER/EXECUTIVEE.L.EACH ACCIDENT $ 11000,000 OFFICER/MEMBER EXCLUDED? N N/A B ,(Mandatory in NH) PAWC667791 9/1/2016 9/1/2017 E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE.POLICY LIMIT $ 1,000,000 i DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Inspectional Services ACCORDANCE WITH THE POLICY PROVISIONS. 1600 Osgood Street North Andover, MA 01845 AUTHORIZED REPRESENTATIVE R Ramsey, Jr./TORCTD ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025(201401) The Commonwealth of Massachusetts A z Department of Industrial Accidents d I Congress Street,Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Le ibl ,n Name (Business/Organization/Individual): > Address: Igo (��Pfi2�4 ae,�t City/State/Zip: Fm (' *phone (2 if Z�i: Are you an employer?Check the appropriate b Type of project(required): l am a employer with employees(full and/or part-tone)."` 7. New construction 2. I am a sole proprietor or partnership and have no employees working for me in 8. 0 Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition 3.01 am a homeowner doing all work myself.[No workers'comp.insurance required.]' 10E]Building addition 4.0 1 am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees 12.[:]Plumbing repairs or additions 5.01 am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.0 Roof repairs These sub-contractors have employees and have workers'comp.insurance.: 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.0 Other 152,§1(4),and we have no employees.[No workers'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 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 state whether or not those entities have employees. if the sub-contractors have employees,they must provide their workers'comp.policy number. I ant an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. ame:PInsurance Company Name:— Policy olicy#or Self-ins.Lic.#: A4(2204,"1 c2"7 / Expiration Date: �( / Job Site Address: 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 MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. 1 do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. Signature: Date: r 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#: CONTROL# J5 97 4 G 2 IMPORTANT If your license is lost,damaged or destroyed;is inaccurate;or needs to be corrected,visit our web site at mass.gov/dpi for instructions to ensure the proper mailing of your Renewal Application and any other correspondence. This license is subject to Massachusetts General Laws and regulations.Your license is a privilege,and cannot be lent or assigned to any person or entity under penalty of law. Keep this license on your person or posted as required by law and/or regulations. 81 OZ.A 81,09V 16 ZI »>><:57fl8 Od 6906W ONI DIH V 8�d>1LL3 G, ;>'J11213H11��d in, ""V+SV a3IS13 ' 3SNIr'i'9NIMO��Od 31Y S3f1SSl Q11tw:asBWfl'lld MNOWWO .'` '< . SAGAMORE PLUMBING & HEATING, INC. Mechanical Contractors 90 Libbey Industrial Parkway Weymouth, MA 02189 Phone(781)331-1600 Fax(781)331-8641 'f ' 1 I yr PIPING TEST REPORTS DATE: ' JOB r• k JOB NO. � ?' O LLE i JOB ADDRESS 'A(,0 Cwt Guy i3•,n 12 �► �.'`;� ' �. #'���+eve; A I SUB-CONTRACTOR DESCRIPTION & LOCATION OF PIPING TESTED a S w TYPE OF TEST SPECIFIED & EMPLOYED TEST EXPERIENCED: I DURATION: FROM TO = HR. PRESSURE: START END = LOSS COMMENTS: i TEST WITNESSES SAGAMORE PLUMBING&HEATING,INC. f GENERAL CONTRACTOR 4 SUB-CONTRACTOR - - INSPECTOR OTHERS f t SAGAMORE PLUMBING & HEATING, INC. Mechanical Contractors 90 Libbey Industrial Parkway Weymouth, MA 02189 Phone(781)331-1600 Fax(781)331-8641 PIPING TEST REPORTS DATE: Pi r: JOB t .. `�� i �, 1 � f JOB NO. ' JOB ADDRESS 1160 Q- SUB-CONTRACTOR DESCRIPTION & LOCATION OF PIPING TESTED 02 TYPE OF TEST SPECIFIED & EMPLOYED TEST EXPERIENCED: DURATION: FROM TO = HR. PRESSURE: START END = LOSS COMMENTS: TEST WITNESSES SAGAMORE PLUMBING&HEATING,INC.- GENERAL CONTRACTOR SUB-CONTRACTOR `, 'f •_ :A--* INSPECTOR OTHERS SAGAMORE PLUMBING & HEATING, INC. Mechanical Contractors 90 Libbey Industrial Parkway Weymouth, MA 02189 Phone(781)331-1600 Fax(781)331-8641 PIPING TEST REPORTS DATE: An( J JOBc a��/.5 � �� JOB NO. f r) � '?JOB ADDRESS ADDRESS \V'n (-vrc,� SUB-CONTRACTOR DESCRIPTION & LOCATION OF PIPING TESTED � 4 M TYPE OF TEST SPECIFIED & EMPLOYED TEST EXPERIENCED: DURATION: FROM TO = HR. PRESSURE: START END = LOSS COMMENTS: TEST WITNESSES SAGAMORE PLUMBING&HEATING,INC. GENERAL CONTRACTOR SUB-CONTRACTOR INSPECTOR Y' p OTHERS SAGAMORE PLUMBING & HEATING, INC. Mechanical Contractors 90 Libbey Industrial Parkway Weymouth, MA 02189 Phone(781)331-1600 Fax(781)331-8641 a PIPING TEST REPORTS DATE: A , I JOB `w E 2121S6 �)C� JOB NO. t0_ 02- C)' 2 I � JOB ADDRESS—\ ��. �-t �c•, i7At .1�c�� 4,�• !c+, 1�1i� I SUB-CONTRACTOR DESCRIPTION & LOCATION OF PIPING TESTED P�-*�6\,,\ if II I I I TYPE OF TEST SPECIFIED & EMPLOYED i TEST EXPERIENCED: DURATION: FROM TO = HR. PRESSURE: START END = LOSS I I t V COMMENTS: TEST WITNESSES SAGAMORE PLUMBING&HEATING,INC. GENERAL CONTRACTOR SUB-CONTRACTOR ` i. R- -• INSPECTOR E j OTHERS SAGAMORE PLUMBING & HEATING, INC. Mechanical Contractors 90 Libbey Industrial Parkway Weymouth, MA 02189 Phone(781)331-1600 Fax(781)331-8641 PIPING TEST REPORTS DATE: Afj-, \ �' JOB �W 7)DVN 4) �33\ JOB NO. JOB ADDRESS G-CeGl� 3 i� torir :)��Jr r !►�} SUB-CONTRACTOR DESCRIPTION & LOCATION OF PIPING TESTED � TYPE OF TEST SPECIFIED & EMPLOYED TEST EXPERIENCED: DURATION: FROM TO = HR. PRESSURE: START END = LOSS COMMENTS: TEST WITNESSES SAGAMORE PLUMBING&HEATING,INC.- GENERAL CONTRACTOR SUB-CONTRACTOR - •�^--�-� INSPECTOR OTHERS Date.//� .'Jf.J'. :.... 02 �` TOWN OF NORTH ANDOVER n • PERMIT FOR GA IN '/ STALLATION �9SSACHUSEt This certifies that . . u l .� . . . . .. . .. . . . . . . . . . . . . . . . . has permission for gas installation . .Cs r f`/ . . . . . . . . . . . in the buildings,of . . . . `' s �'� (. . . . . . . . . . . . . . . ` at . . . . . . �1 e f-I . . . . ;� North Andover, Mass. r wn Fee. �. . . . Lic. No.�7G l� . . . . . . . . . `l . . . . . . .. . . GAS INSPECTO Check# 629 MASSACHUSETTS UNIFORM APPUCATON FOR PERMIT TO DO GAS FITTING (Type or print) Date — NORTH ANDOVER,MASSACHUSETTS Building Locations 0 ��JP6 N Permit# moun Owner's Name �O k New Renovation ❑ Replacement ❑ Plans Submitted ❑ a � w a C G = C N x v v w za > W a x >o x ir A C7 .a U C > O off, 1- KU B-BASEM ENT i BASEMENT 1ST. FLOOR 2ND. FLOOR 3RD . FLOOR t 4TH . FLOOR 5TH . FLOOR 6TH . FLOOR 7TH . FLOOR 8TH . FLOOR (Print or type) he one: Certificate Installing Company Name 1 Corp. Address Partner. Business Telephone - p ❑ Firm/Co. Name of Licensed Plumber'or Gas Fitter V INSURANCE COVERAGE Check one: I have a current liability Insurance,policy or it's substantial equivalent. Yes ❑ No❑ If you have checked ygs,p ase indicate the type coverage by checking the appropriate box. 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 142 of the Mass.General Laws,and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent ❑ 1 hereby certify that all of the details and information I have submitted(or entered)in ab lication are true and accurate to the best of my knowledge and that all plumbing work and ins ion pert ed under ermit Is fo this application will be in compliance with all pertinent provisions of the Massac usetts to o apter of a General Laws. t By: Signature of Licensed Plumber Or Gas Fitter Title ❑ Plumber a C City/Town: ❑ Fitter icense um er Master _ APPROVED(OFFICE USE ONLY) ❑ Joumeyman I .:1 D/e /1'. li. ... . . f N°RTMl1 ` TOWN OF NOVER } • - PERMIT FOR GAS INSTALLATION s • �9SSACHUSES 4 s Y This certifies that . . . . . . . . . .. . . . �. . .y. . . .��. has permission for gas installation .., ✓. .Gt`.`. .l . . . . . . in the buildings of . . . .R . . . . . . . . . . �r at . � ' { �` . 1. `�r-�. North Andover, Mass. FeeJ.W,. . . . Lic. No.. . . . . . . . . . . . N74 .. . . . . . . ff .AS INSPECTOR Check# b 35. 5..-6..----� MASSACHUSETTS UNIFORM APPUCATON FOR PERMIT TO DO GAS FITTING (Type or print) Date W. VIU07 NORTH ANDOVER,MASSACHUSETTS Building Locations �9WIS ISCROO , , NEW &4EAM �Permit# Amount$ SO gr�oV-S0 Owners Name New Renovation ❑ Replacement ❑ Plans Submitted ❑ w � . 0 H v O w C a C O Z w V W < Z W o+ C w d 0 w , G Z , ox w a = } Om z 0 z $ w H N SUB-BASEM ENT a ° 9 > o BASEM ENT 1ST. FLOOR 2ND . FLOOR 3RD . FLOOR 4TH . FLOOR 5TH . FLOOR 6TH . FLOOR 7TH . FLOOR 8TH . FLOOR i (Print or type) Check one: Certificate Installing Company Name- 12gAWIX MEGAAwCAL wrCorp. Address I -% yj JCJC—AMQA L ❑ Partner. IC Business Telephoneboa 66Q 1:1 ❑ Firm/Co. Name of Licensed Plumbeior Gas Fitter I, INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ® No❑ If you have checked Les,please indicate the type coverage by checking the appropriate box. Liability insurance policy 9 Other type of indemnity ❑ Bond ❑ Owner's Insurance Waiver: I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the 1 Mass.General Laws,and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Aft Owner ❑ Agent ❑ I hereby certify that all of the details and information I h e s miffed(or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and in allati s p ormed and Permit Issued for this application will be in compliance with all pertinent provisions of the Massach etts Ste as Coe hapter 142 of the General Laws. By: Sign a Licenseupjer Or Gas Fitter Title ❑ Plumber City/Town, ❑ Gas Fitte License Number ❑ Master _ APPROVED(OFFICE USE ONLY) ❑ Journeyman Date...a!:` 7:.,.�. ...�..�. NORTH °!t 6. TOWN OF NORTH ANDOVER p PERMIT FOR WIRING s o� ,_,�•"a This certifies that ...... ` , n V............................. - .-� .... has permission to perform ......,./ ::,r � ............................ } wiring in the building of.. .... .....:`--. *� ��".................. at.... ......,.-4?:::..:.:................ ...... ,North Andover,Mass. Fee... 1Lic.No.............. ....... . �: i ELECTR[ AL INSPE R j Check # 0 y-11XF -7841 Date6 / d { "a' r`C :'4 } tf ,40RTI{ ♦-; 3?0;tom``°::� "°,� TOWN OF NORTH AN o , a PER,MI.T� FOR 1WIRIiVG ,6 This certifies that ... has permission to perform. .. ;. ....... -'. r.... - ....... wiring in the building of.. .-:��*. ..... .. A... ` .......... } ........... ! at Zd... ................... ... ,North'A lover,Mass. ' �j Fee% 3 Lic Noftl`.G ....... . ... ...... .. .. ....� y ELECTRICAL INSPECT U Check it C�y fLS'30 t840 Commonwealth of Massachusetts Official Usel�Only Department of Fire.Services Permit No. 7 BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev.9/051 leave blank APPLICATON FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLE iSE PRINT IAT INK OR T1,rPFffALL INFORMATION) Date: 111510 City or Town of- Orjoyer 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) �k(oZi &0;A 'p -,A Owner or Tenant Ltd t skl_�� Telephone No. ryg18' -16101 Owner's Address woo Gm& Pow 9-Cac1t Is this permit in conjunction with it building permit? Yes Y No ❑ (Check Appropriate Box) Purpose of Building SCkf-,CC. QAikdiN Utility Authorization No. Existing Service Amps / Volts Overhead❑ Undgrd❑ No. of Meters New Service 10 Amps f / Volts Overhead❑ Undgrd No.of Meters Number of Feeders and Ampacity 3 Sos p F 5 443c)0KCr•1i_ Location and Nature of Proposed Electrical Work: Com letion of thefibl7owing table may be waived by the Inspector of Wires. No.of Recessed Luminaires No.of Ceil.-Sus . addle Fans No.of Total N r p ) Transformers KVA No.of Luminaire Outlets No:of Hot Tubs I Generators — KVA No.of Luminaires . Swimming Pool Above ❑ In- ❑ o.o mergency ig mg rnd. rnd. Batte Units No.of Receptacle Outlets �SLI No.of Oil Burners O I=ALARMS No.of Zones No.of Detection and No.of Switches �� No.of Gas Burners �, Initiating Devices Total No.of Ranges ® No.of Air Cond. 3 Tons (o 0 No.of Alerting Devices S(p Heat PumNumber Tons Im No.of Se Contained No.of Waste Disposers 0 Totals - _ IDetection/Alertin Devices. O No. of Dishwashers ® Space/Area HeatingKW Local Connection. ElOther yy No.of Dryers © Heating Appliances W Sec No of De Ts: or u�ival nt ` o. of Water No.of NO.of Heaters � KW Ballasts Data Wiring: o+ y �trs Signs No.of Devices or Equivalent i No.Hydromassage Bathtubs No.of Motors`�� Total HP �j(� Telecommunications Wiring: tS-y 6OZNo.of Devices or E,uivalent OTHER: '0.6 u� t�54►,. . 1�� 5�� - . .� � �tk��(e� Attach additional detail if desired or as required by the Inspector of Wires. 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 ® BOND ❑ OTHER ❑ (Specify:) GENERAL LIABILITY INS. 7/31/08 o� (Expiration Date) Estimated Value of Electrical Work: OL 0 (VJhen required by municipal policy.) Work to Start: 1111,110-) Inspections to be requested in accordance with MEC Rule 10,and upon completion. I cert j6�,under the pains and penalties q f perjury,tliat the information on this applieadon is true and complete. FIRM NAME: REILLY ELECTRICAL CONTRACTORS INC. LIC.NO.: A16666 Licensee: JAMES J.REILLY Signature: LIC.NO.: flf opplicab e,enter `exempt"in the license number—line.) Bus.Tel.No.: 509-210-900L— Address: Address: 14 NORFOLK AVENUE EASTON .MASS.02375 FAX.508-230-8885 Alt.Tel.No.: OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liabilityinsurance coverage normally required by law. By my signaturgbelow,-I-hereby_waive..this requirement....I-am the(check one)❑owner ❑owner's a ent. Owner/Ag1iT ent t �> Signature Telephone No. SLR;: $ J 3 I 5Z < dk-. all I5� ERRA FIELD REPORT Project: Brooks School Project No.: 2006-03 New Science Building Report No.: 3 Location: North Andover, MA Date: October 25,2007 Client: Brooks School Contractor: Consigli Construction Co. Milford, MA Weather: Cloudy, light rain Temperature: 40s Reported by: Christie Roach Time spent on site: 3 hours Distribution: John Trovage Brooks School Len Bisson Brooks School Rich Scopelliti Consigli Construction Co. Michael Hansen Consigli Construction Co. Terry Lauderback Souza True&Partners Ken Garry Rist-Frost-Shumway Engineering Ted Lempka Rist-Frost-Shumway Engineering Gerry Brown Town of North Andover Architerra Team Contractor's Activities: • Elevator shaft constructed. • Credits sought for owner due to 15 holes that were removed in an addendum change. • Divisions 1-4 steel delivered to site and erected. Concrete slab will be poured after all steel is erected. • Milling trees sent to Milbury to be milled. • Final repairs to drainage board performed,waterproofing reviewed by Terry Lauderback. • CADD welding from Phase I redone. • EMCI finalized as electrical subcontractor. Window subcontractor also'finalized. • Anchor bolts drilled,set and pull-test approved. • Detention pond hydro-seeded. • Underground plumbing has begun. • Tree and root protection materials arrived and installed. Architects's Activities: • Drawings and affidavits prepared for Phase II permit application. Permit received on 10-23-07. Subsequent peer review found no structural issues. Construction continues. • Architerra has reviewed all steel shop drawings. • Punch list received from contractor 10-12-07. RFS and Architerra have added comments and returned to Consigli. New list under review. • Glu-lam shop drawings,and underslab plumbing submittals received and in review. Photos: ARCHITERRA INC. 68 Long Wharf Boston MA 02110 T 617.778.2470 F 617.904.1770 www.architerra-inc.com a ERRA .4 � ARCHITERRA INC. 68 Long Wharf Boston MA 02110 T 617.778.2470 F 617.904.1770 www.architerra-inc.com n A I ERRA FIELD REPORT Project: Brooks School Project No.: 2006-03 New Science Building Report No.: 1 Location: North Andover, MA Date: September 20,2007 Client: Brooks School Contractor: Consigli Construction Co. Milford, MA Weather: Sunny Temperature: 60s Reported by: Christie Roach Time spent on site: 3 hours Distribution: John Trovage Brooks School Len Bisson Brooks School Rich Scopelliti Consigli Construction Co. Michael Hansen Consigli Construction Co. Terry Lauderback Souza True&Partners Ken Garry Rist-Frost-Shumway Engineering Ted Lempka Rist-Frost-Shumway Engineering Gerry Brown Town of North Andover Architerra Team Contractor's Activities: • Acid chamber and cover on site. • Anchor bolts not yet arrived but are due to imminently. • Detention pond at 90%completion. • Steel shops from Canatal have not yet arrived;steel set to be on site 10-18-07. • Drainage and sewer work complete. Detention pond structure delivered on site and will be placed as soon as the excavation work is completed next week. • ACME has finished work on waterproofing,addressing Architerra concern with the drainage board installation. Steel and glu-lam contract finalized;subcontractors to be Canatal and Architectural Timber respectively. • Consigli has begun putting together Value Engineering scope to be reviewed by Architerra and consultants. • Drain line tie in is complete. • Milling trees to arrive;will coordinate with Sharon Timber for milling. • The stone wall which has been used to support oak tree roots to be determined whether or not it can remain. Root protection may have to be put into place. • Letter from structural engineer stating the approval to use straight epoxy Hilti bolts at the column base plates was submitted to the town of North Andover inspector. Consigli has also forwarded copies of Briggs testing reports and is putting together a complete binder to be submitted to them by the end of the project. • Plumbing and electrical testing is being scheduled for review before Phase II begins. • Dust control needs to and will be monitored. Architects's Activities: • RFI#21 Outrigger Details has been answered by Architerra in CCA#6. • Dimensions for mechanical shaft locations unclear on metal deck submittals o Action: Shaft dimensions along column lines shown on sketches to be issued • Exact slab placement for upper level railing not shown ARCHITERRA INC. 68 Long Wharf Boston MA 02110 T 617.778.2470 F 617.904.1770 www.architerra-ine.com ERRA FIELD REPORT Project: Brooks School Project No.: 2006-03 New Science Building Report No.: 2 Location: North Andover, MA Date: October 13,2007 Client: Brooks School Contractor: Consigli Construction Co. Milford, MA Weather: Cloudy,no rain Temperature: 50s Reported by: Christie Roach Time spent on site: 2 hours Distribution: John Trovage Brooks School Len Bisson Brooks School Rich Scopelliti Consigli Construction Co. Michael Hansen Consigli Construction Co. Terry Lauderback Souza True&Partners Ken Garry Rist-Frost-Shumway Engineering Ted Lempka Rist-Frost-Shumway Engineering Gerry Brown Town of North Andover Architerra Team Contractor's Activities: • Construction trailers brought to site and hooked up. Otis elevator bought. • Credits sought for owner due toll holes that were removed in an addendum change. • Milling trees arrived. Will be sent to Milbury for milling. • Final repairs to drainage board performed,waterproofing work done by ACME. • Greenhouse deleted from building scope due to Value Engineering. • Air intake from site to existing Johnson building is monitored for proper air quality. Architects's Activities: • Architerra reviewed Divisions 1-2 steel shop drawings. • Punch list received from contractor 10-12-07 and is currently under review. Photos: r Nat, 6 r �'"- ..•t' - !rte .,nfe .: ,'>s� . . . d ARCHITERRA INC. 68 Long Wharf Boston MA 02110 T 617.778.2470 F 617.904.1770 www.architerra-inc.com r u a ERRA o Action: Railing dimensions sketch to be issued Photos: 1LR31J 74 7ICA • - _ °s'x ARCHITERRA INC. 68 Long Wharf Boston MA 02110 T 617.778.2470 F 617.904.1770 www.arch iterra-inc.corn 11 ?�tNv cT ass �0 =Bldg. ZBA Con/Com Health * - ,� �1E. 'C E I V E O^ r i T0W �� },K, S Or FIC:. Fire Chief Police Chief o } cecwrcw.a� 1• Town Clerk DPW/Engineer< 'rs.9+�'� ,��` , 2001 AUK 2 7 AM 1(: 55 Ss�+cHuset TON OF PLANNING DEPARTMENT NORTH APDOV.F-R Community Development Division MASS ACHJS�t f S 1600 Osgood Street North Andover, Massachusetts, 01845 Phone: 978-688-9535 Fax: 978-68&9542 NOTICE OF DECISION Any appeal shall be filed within(20)days atter the date of filing this notice in the office of the Town Clerk Date: June 27,2007 Date of Hearing: May 1, 2007, June 5 and June 26, 2007 Date of Decision: June 26, 2007 Petition of: Brooks School 1160 Great Pond Road North Andover,MA 01845 Premise$Affected: Brooks School, 1160 Great Pond Road,Assessors Map 90C,Parcel 25 and Map 103,Pared 28. Referring to the above petition for a Watershed Special Permit from the requirements of the North Andover Toning Bylaw,Section 4.136.3(b)(iXl). So as to allow. the construction of a detention pond and outlet suuctures within the Non Discharge buffer zone of the Watershed Protection District within the Residential 2(R2)Zoning District. After a public hearing given on the above date, and upon a motion by Richard Rowen and 2ad by John Simons to APPROVE a Watershed Special Permit as amended and based upon the following conditions. Vote was unanimous 4-0. 0'nlebalfofthe North er Planning Board Richard Nardella,Chairman John Sinwns,VicOChairman Richard Rowen Jennifer Kusek 1 r 1 Brooks School, 1160 Great Pond Road Map 90C,Parcel 25&Map 103,Parcel 28 Watershed Special Permit-Construction of detention pond and outlet structures The public hearing on the above referenced application was opened on May 1, 2007 and closed by the North Andover Planning Board on June 5, 2007. On June 26,2007, upon a motion,made by Richard Rowen and seconded by John Simons to GRANT a Watershed Special Permit as amended in order to construct a detention pond and outlet structures within the Non-Discharge buffer zone of the Watershed Protection District associated with Lake Cochichewick. The proposed detention pond and outlet structures are located at 1160 Great Pond Road,North Andover, Massachusetts,01845,Map 90C,Parcel 25 and Map 103,Parcel 28 and is located within the Non-Discharge Zone of the Watershed Protection District under the requirements of Section 4.136& 10.3 of the North Andover Zoning Bylaw.This Special Permit was requested by Brooks School,Trustee, 1160 Great Pond Road,North Andover,MA 01845. The applicant submitted a complete application,which was noticed on April 3& 10,2007,and reviewed in accordance with Section 4.136 of the Town of North Andover Zoning Bylaw and MGL Chapter 40A,Section 9. The lot was created in 1928 and is subject to the Watershed Protection District provisions for lots before October 24, 1994. Public hearings were held on May 1,2007, June 5,2007,and June 26,2007. The Planning Board voted on the motion by Richard Rowen and seconded by John Simons to approve the Watershed Special Permit. A special permit issued by the special permit granting authority requires a vote of at least four members of a five-member board The applicant is hereby notified that should the applicant disagree with this decision, the applicant has the right, under MGL Chapter 40A, Section 17, to appeal to this decision within twenty days after the date this decision has been filed with the Town Clerk. In accordance with 4.136 the Planning Board makes the finding that the intent of the Bylaw, as well as its specific criteria, are met. This decision specifically stated by the Planning Board makes the following FINDINGS OF FACT: 1) That as a result of the proposed construction in conjunction with other uses nearby,there will not be any significant degradation of the quality or quantity of water in or entering Lake Cochichewick. The Planning Board bases this finding on the following facts: i a) The proposed- detention" pond and outlet structures will- have a negligible impact on Lake Cochichewick given the design and function/purpose of the pond and proximity to the Lake. Further, the detention pond and outlet structures will be constructed using Best Management Practices; b) The topography of the site will not be altered substantially. The detentionP and and outlet structures were specially designed and located to minimize the amount of grading/topographical changes and take advantage of natural features of the property. Further,construction of the proposed storm water management measures and erosion control measures will use Best Management and Engineering Practices and not substantially alter the topography of the site; c) The limit of clearing and impact is restricted to the minimum necessary to construct the proposed detention pond and outlet structures as shown on the plan;and d) The construction of the detention pond and outlet structures and storm water management plan have been reviewed by the Town's outside consultant and Town Planner and determined that there will be 2 Brooks School, 1160 Great Pond Road Map 90C,Parcel 25&Map 103,Parcel 28 v Watershed Special Permit-Construction of detention pond and outlet structures no degradation to the quality or quantity of water in or entering the isolated vegetated wetland or Lake Cochichewick. 2) There is no reasonable alternative location outside the Non-Discharge Zone for any discharge, structure or activity. In accordance with Section 10.31 of the North Andover Zoning Bylaw, the Planning Board makes the following FINDINGS OF FACT: 1) The specific site is an appropriate location for the proposed use as all feasible storm water and erosion controls have been placed on the site. The project will be built using Best Management Practices; 2) The use will not adversely affect the neighborhood as the lot is located in a Residential 2 Zoning District 3) There will be no nuisance or serious hazard to vehicles or pedestrians; 4) Adequate and appropriate facilities are provided for the proper operation of the proposed use; 5) The Planning Board also makes a specific finding that the use is in harmony with the general purpose and intent of the North Andover Zoning Bylaw, Upon reaching the above findings,the Planning Board approves this Special Permit based upon the following SPECIAL CONDITIONS: 1) The Town Planner shall approve any changes made to these plans. Any changes deemed substantial by the Town Planner would require a public hearing and modification by the Planning Board. 2) Prior To Any Work On Site: a. A performance guarantee of two thousand dollars ($2,000) in the form of a check made out to the Town of North Andover must be posted to insure that construction will take place in accordance with the plans and the conditions of this decision and to ensure that the as-built plans will be submitted. b. The limit of work as shown on the plan by the erosion control line must be marked in the field and must be reviewed and approved by the Town Planner and Conservation Department. c. All erosion control measures as shown on the plan must be in place and reviewed by the Town Planner and Department. Deteriorated erosion control measures shall be replaced and maintained throughout the duration of the project. d. If applicable, the site shall have received all necessary permits and approvals from the North Andover Conservation Commission,Board of Health,Zoning Board of Appeals and the Department of Public Works and be in compliance with the above permits and approvals. 3) Prior to issuance of a building permit: a. The Planning Board must endorse the final site plan mylars and three copies of the signed plans must be delivered to the Planning Department. b. The decision must be filed with the North Essex Registry of Deeds. One certified copy of the recorded decision must be submitted to the Planning Department. 3 Brooks School, 1160 Great Pond Road Map 90C,Parcel 25&Map 103,Parcel 28 Watershed Special Permit-Construction of detention pond and outlet structures c. No pesticides,fertilizers or chemicals shall be used in lawn care or maintenance within 325' of Lake Cochichewick or within 325' of wetland resource areas. The applicant shall incorporate this condition as a deed restriction, and a copy of the recorded deed shall be submitted to the Town Planner and included.in the file. d. All erosion control measures as shown on the plan must be in place and reviewed by the Town Planner and Conservation Department. 5) Prior to release of the Performance Bond: a) The applicant shall submit an as-built plan stamped by a Registered Professional Engineer in Massachusetts that shows all construction, including storm water management services and other pertinent site features. This as-built plan shall be submitted to the Town Planner for approval. The applicant must submit a certification from the design engineer that the site was constructed as shown on the approved plan. b) The Planning Board must by a majority vote make a finding that the site is in conformance with the approved plan. 6) In no instance shall the construction of the project as proposed be allowed to further impact the site than as shown on the plan referenced in Condition#11. 7) No open burning shall be done except as is permitted during burning season under the Fire Department regulations. 8) The Contractor shall contact Dig Safe at least 72 hours prior to commencing excavation. 9) The provisions of this conditional approval shall apply to and be binding upon the applicant, it's employees and all successors and assigns in interest or control. 10) This special permit was issued on June 26, 2007, however, this Special Permit shall be deemed to have lapsed after a two (2) year period on June 26, 2009 unless substantial use or construction has commenced. 11) This decision must be filed with the North Essex Registry of Deeds. The following information is included as part of this decision: Plan titled: Brooks School New Science Building Prepared for. Brooks School 1160 Great Pond Road North Andover,MA 01845 Prepared by: Architerra Inc. 68 Long Wharf Boston,MA 02110 Scale: 1"=20' Date: March 16,2007,revised 4/5/07 Sheets: A0.00, A2.01, A2.02, C0.01, C0.02, C2.01, C3.01, C3.02, C4.01, L1.00, L2.00, L3.01,L3.02,L4.00 4 Brooks School, 1160 Great Pond Road Map 90C,Parcel 25&Map 103,Parcel 28 Watershed Special Permit-Construction of detention pond and outlet structures cc: Town Departments Applicant Engineer Abutters Assessor 5 O' { �� bis . � RECEIVED �'_Ffi;�'S OFFIC7 : f nW! �9SS�+ s 2001 JUN 27 AM 11: 55 cNu 0!,-,,'N OF PLANNING DEPARTMENT NORTH MOVE!:'" Community Development Division MASSACF, F1 i 1600 Osgood Street North Andover, Massachusetts, 01845 NOTICE OF DECISION Any appeal shall be filed within(20)days after the date of filing this notice in the office of the Town Clerk. Date: June 27,2007 Date of Hearing: May 1, 2007, June 5, and June 26, 2007 Date of Decision: June 26, 2007 Petition of: Brooks School 1160 Great Pond Road Norah Andover,MA 01845 Premises Affected: Brooks School,1160 Great Pond Road,Assessors Map 90C,Parcel 25 and Map 103,Parcel 28. Referring to the above petition for a Site Plan Special Permit from the requirements of the North Andover Zoning Bylaw,Sections 8.3, 10.3,and 10.31 and MGL C.40A,Sec.9 So as to allow:&e construction of a(+)29,447 sq.$. Science Building, 12 L x 20 L greenhouse structure, interim landscaped courtyard, installation of drainage and storm yIt#er management syr, 2 additional parking spaces,installation of rmderWound utilities,construction of detention pond and outlet structures,and limited grading work within the RmdentW 2(R2)Zoning District. After a public hearing given on the above date,and upon a motion by John Simons and 21 by Jemiifer Kusek to APPROVE the Site Plan Special Permit as amended and based upon the following conditions. Vote yeas unanim004-0.. 2-A/I On behalf of the Nom Andover Planning Bayard Richard Nw della,Chairman John Simons,Vice- Chairman Richard Rowen Jennifer Kusek 1 N1 Brooks School, 1160 Great Pond Road Map 90C,Parcel 25&Map 103,Parcel 28 Site Plan Special Permit-Construction of Science building and greenhouse The Planning Board herein APPROVES the Site Plan Special Permit to construct a 29,447 sq. ft. Science Building, 12 ft.x 20 ft.greenhouse structure,interior landscaped courtyard,installation of drainage and storm water management system,2 additional parking spaces,installation of utilities,construction of detention pond and outlet structures, and limited grading work. The project is located at 1160 Great Pond Road, North Andover, Massachusetts, 01845, Map 90C, Parcel 25 and Map 103, Parcel 28 in the Residential 2 (R2) Zoning District. The parcels total approximately 7,187,000 s.f with frontage on Great Pond Road. This Special Permit was requested by Brooks School, 1160 Great Pond Road, North Andover MA 01845. The application was filed with the Planning Board on March 16, 2006. The public hearing on the above referenced application was opened on May 1,2007 and closed by the North Andover Planning Board on June 5, 2007. The applicant submitted a complete application, which was noticed and reviewed in accordance with Section 8.3, 10.3,and 10.31 of the Town of North Andover Zoning Bylaw and MGL C.40A, Sec. 9. The Planning Board makes the following findings as required by the North Andover Zoning Bylaws Section 8.3 and 10.3: FINDINGS OF FACT: 1) The specific site is an appropriate location for the project as it is located in the Residential 2 (R2) Zoning District and consists of the construction of a 29,447 sq. ft. Science Building, 12 ft. x 20 ft. greenhouse structure, interior landscaped courtyard, installation of drainage and storm water management system, 2 additional parking spaces, installation of utilities, construction of detention pond and outlet structures, and limited grading work. The proposal is a function of the capital improvements and designed to harmonize with the existing campus architecture and natural landscape and incorporates green and energy efficient technologies into the design. The project is located at the southern end of the campus and will not visually impact the surrounding properties. 2) The use as developed will not adversely affect the neighborhood as a sufficient buffer has been provided. The overall layout of the site has been designed to focus on traditional architecture and provide site amenities designed at a pedestrian scale. 3) There will be no nuisance or serious hazard to vehicles or pedestrians. The proposal will have a negligible impact on pedestrian safety and vehicular circulation within the site as the project will not add- additional vehicle trips to the site. The intent of the project is to add additional science classroom space for the current student population and employees of the School. The project will not result in the increase in enrollment or staff. 4) The landscaping and lighting plans approved as part of this plan meet the requirements of Section 8.4 as amended by the Planning Board of the North Andover Zoning Bylaw. The lighting plan consists of shielded downcast lighting that has been arranged to provide adequate safety for students and employees and shall not impact abutting properties. The landscaping has been placed so as to maintain and enhance the appearance of the campus and site. 5) The applicant has met the requirements of the Town for Site Plan Review as stated in Section 8.3 of the Zoning Bylaw; 6) Adequate and appropriate facilities will be provided for the proper operation of the proposed use. The new Science Building and greenhouse will be serviced by town water and sewer. The Division of Public Works, and the outside consulting engineer, Vanasse, Haagen Brustlin, Inc, have reviewed the application, utilities, and drainage and storm water management plan and deemed them to be 2 BrooksSchool, 1160 Great Pond Road Map 90C,Parcel 25&Map 103,Parcel 28 Site Plan Special Permit-Construction of Science building and greenhouse adequate. Finally the Planning Board finds that this project generally complies with the Town of North Andover Zoning Bylaw requirements as listed in Section 8.3.5, but requires conditions in order to be fully in compliance. The Planning Board hereby grants an approval to the applicant provided the following conditions are met:, SPECIAL CONDITIONS: 1) Permit Definitions: A) The"Locus"refers to the 7,187,000 sq. ft. parcel of land with land fronting on Great Pond Road as shown on Assessors Map 90C, Parcel 25 and Map 103, Parcel 28, and also known as 1160 Great Pond Road,North Andover,Massachusetts. B) The "Plans" refer to the plans prepared by Architerra Inc., 68 Long Wharf, Boston, MA 02110 entitled "Brooks School New Science Building", dated March 16, 2007, revised 4/5/07, and consisting of Sheets A0.00,A2.01,A2.02,C0.01,C0.02,C2.01,C3.01,C3.02,C4.01,L1.00,L2.00, L3.01,L3.02,14.00,Lighting Plan. C) The"Project" or "Brooks School, 1160 Great Pond Road"refers to the construction of a 29,447 sq. ft. Science Building, 12 ft. x 20 ft. greenhouse structure, interior landscaped courtyard, installation of drainage and storm water management system, 2 additional parking spaces, installation of utilities, construction of detention pond and outlet structures, and limited grading work. D) The"Applicant"refers to Brooks School, 1160 Great Pond Road,North Andover,MA 01845,the applicants for the Special Permit. E) The"Project Owner"refers to the person or entity holding the fee interest to the title to the Locus from time to time,which can include but is not limited to the applicant, developer,and owner. 2) The developer shall designate an independent Environmental Monitor who shall be chosen in consultation with the Planning and Community Development Staff. The Environmental Monitor must be available upon four (4) hours notice to inspect the site with the Planning Board designated official. 3) The applicant shall designate an independent construction monitor who shall be chosen in consultation with the Planning Department. The construction monitor must be available upon four(4) hour's notice to inspect the site with the Planning Board designated official. The construction monitor shall make weekly inspections of the project and file monthly reports to the Planning Board throughout the duration of the project. The monthly reports shall detail area of non-compliance, if any, and,actions taken to resolve these issues. 4) Prior to the Endorsement of the Plans by the Planning Board, the Applicant MUST comply with the following conditions: A) The final plans must be reviewed and approved by the DPW and the Planning Department and be endorsed by the Planning Board. The final plans must be submitted for review within ninety(90) days of filing the decision with the Town Clerk. 3 Brooks School, 1160 Great Pond Road Map 90C,Parcel 25&Map 103,Parcel 28 .. Site Plan Special Permit-Construction of Science building and greenhouse B) The final site drainage system must be designed in accordance with the Town Bylaw requirements and reviewed by the Division of Public Works. All storm water drainage control facilities utilized by the site shall be shown on the site plan. Storm water drainage calculations which support the design of the control facilities shown the plan shall be submitted to the Department of Public Works for review and approval. Written confirmation of said review and approval by the Department of Public Works must be submitted to the Planning Department. 5) PRIOR TO THE START OF CONSTRUCTION A) A detailed construction schedule shall be submitted to the Planning Staff for the purpose of tracking the construction and informing the public of anticipated activities on the site. B) All applicable erosion control measures must be in place and reviewed and approved by the Planning Department. C) It shall be the responsibility of the developer to assure that no erosion on the site shall occur which will cause deposition of soil or sediment upon adjacent properties or public ways,except as normally ancillary to off-site sewer or other off-site construction. Off-site erosion will be a basis for the Planning Board making a finding that the project is not in compliance with the plan; provided, however,that the Planning Board shall give the developer written notice of any such finding and ten days to cure said condition. D) Yellow"Caution"tape must be placed along the limit of clearing and grading as shown on the plan. The Planning Department must be contacted prior to any cutting and or clearing on site. E) A pre-construction meeting must be held with the developer,their construction employees,Planning Department and Building Department (and other applicable departments) to discuss scheduling of inspections to be conducted on the project and the construction schedule. E) The developer shall provide the Planning Board with copies of permits, plans and decisions received from all North Andover Land-Use Boards. F) A bond in the amount of ten thousand dollars ($10,000.00)_ shall be posted for the purpose of insuring that a final as-built plan showing the location of all on-site structures. The bond is also in place to insure that the site is constructed in accordance with the approved plan. This bond shall be in the form of a check made out to the Town of North Andover. This check will then be deposited into an interest bearing escrow account. 6) PRIOR TO THE ISSUANCE OF A BUILDING PERMIT A) Three(3)copies of the signed,recorded plans must be delivered to the Planning Department. B) One certified copy of the recorded decision must be submitted to the Planning Department. 'n DURING CONSTRUCTION A) Dust mitigation must be performed weekly, or more frequently as directed by the Town Planner, throughout the construction process. B) Any stockpiling of materials (dirt, wood, construction material, etc.) must be shown on a plan and 4 Brooks School, 1160 Great Pond Road Map 90C,Parcel 25&Map 103,Parcel 28 Site Plan Special Permit-Construction of Science building and greenhouse reviewed and approved by the Planning Staff. Any approved piles must remain covered at all times and fenced off to minimize any dust problems that may occur with adjacentPro erties. P C) In an effort to reduce noise levels, the developer shall keep in optimum working order, through regular maintenance, any and all equipment that shall emanate sounds from the structures or site. 8) PRIOR TO THE ISSUANCE OF A CERTIFICATE OF OCCUPANCY A) The applicant must submit a letter from the architect and engineer of the project stating that the building, landscaping, lighting and site layout substantially comply with th eP fans referenced at the end of this decision as endorsed by the Planning Board. Alternatively,the applicant and/or property owner may provide a bond, determined by the Planning Board, to cover the full amount of the landscaping materials and installation if weather conditions do not permit the completion of the landscaping prior to the use of the parking area B) The Planning Staff shall approve all artificial lighting used to illuminate the site. All lighting shall have underground wiring and shall be so arranged that all direct rays from such lighting falls entirely within the site and shall be shielded or recessed so as not to shine upon abutting properties or streets. The Planning Staff shall review the site. Any changes to the approved lighting plan as may be reasonably required by the Planning Staff shall be made at the owner's expense. C) The applicant shall adhere to the following requirements of the North Andover Fire Department and the North Andover Building Department: All structures must contain a commercial fire sprinkler system. The commercial fire sprinkler systems must be installed in accordance with referenced standard NFPA 13D and in accordance with 780 CMR, Chapter 9 of the Massachusetts State Building Code. Certification that the systems have been installed properly in accordance with the above referenced regulations must be provided from both the North Andover Fire Department and the North Andover Building Department to the applicant. The applicant must then provide this certification to the North Andover Planning Department. 9) PRIOR TO THE FINAL RELEASE OF ALL SECURITY AND ESCROWED FUNDS A) The Planning Staff shall review the site. Any screening as may be reasonably required by the Planning Staff will be added at the Project Owner's expense. B) A final as-built plan showing final topography,the location of all on-site utilities,structures,curb cuts,parking spaces and drainage facilities must be submitted to the Planning Department. 10) GENERAL CONDITIONS A) Any plants,tree, shrubs, or fencing that have been incorporated into the Landscape Plan approved in this decision that die or fall into disrepair must be replaced by the project owner in perpetuity. B) Snow removal shall be maintained in accordance with the current facility management plan. C) There shall be no dumpsters or outside storage of materials/refuse on site. All materials/refuse to be stored inside of the building. D) The contractor shall contact Dig Safe at least 72 hours prior to commencing any excavation. 5 Brooks School, 1160 Great Pond Road Map 90C,Parcel 25 8t Map 103,Parcel 28 Site Plan Special Permit-Construction of Science building and greenhouse E) Gas, Telephone, Cable and Electric utilities shall be installed underground as specified by the respective utility companies. F) The hours for construction shall be limited to between 7:00 a.m. and 5:00 p.m. Monday through Friday and between 8:00 a.m.and 5:00 p.m. on Saturday. G) No open burning shall be done except as is permitted during burning season under the Fire Department regulations. H) No underground fuel storage shall be installed except as may be allowed by Town Regulations. 1) The provisions of this conditional approval shall apply to and be binding upon the applicant, its employees and all successors and assigns in interest or control. n Any action by a Town Board, Commission, or Department, which requires changes in the plan or design of the building, as presented to the Planning Board, may be subject to modification by the Planning Board. K) Any revisions shall be submitted to the Town Planner for review. If these revisions are deemed substantial,the developer must submit revised plans to the Planning Board for approval. L) This Special Permit approval shall be deemed to have lapsed after June 26,2009(two years from the date permit granted), exclusive of the tune required to pursue or await determination of any appeals, unless substantial use or construction has commenced within said two-year period or for good cause. For purposes of this development,the developer shall be deemed to have undertaken substanU use or construction if the developer has begun renovation of the existing structures. M) The following information shall be deemed part of the decision: Plan titled: Brooks School New Science Building Prepared for: Brooks School 1160 Great Pond Road o er, MA 01845 Prepared by: Architerra Inc. 68 Long Wharf Boston,MA 02110 Scale: 1"=20' Date: March 16,2007,revised 4/5/07 Sheets: A0.00,A2,01,A2.02,C0.01,C0.02,C2.01,C3.01,C3.02,C4.01,L1.00,L2.00, L3.01,L3.02,14.00. Plan titled Drainage Calculations for New Science Building Prepared for: Brooks School 1160 Great Pond Road North Andover,MA 01845 Prepared by. Rist-Frost-Shumway Engineering,P.C. Laconia,New Hampshire Post Development Drainage Analyses Revised May 1,2007 6 Brooks School, 1160 Great Pond Road Map 90C,Parcel 25&Map 103,Parcel 28 Site Plan Special Permit-Construction of Science building and greenhouse Scale: 1"-40' Date: 3/15/07 revised 4/30/07 Sheets: Drawings 1 &2 cc: Town Departments Applicant Engineer Abutters Assessor 7 0 Date..D..—).q..........1. TOWN OF NORTH ANDOVER 0 0 PERMIT FOR WIRING ,SSACHU This certifies that ............... ............................................+-,.......... . .................. has permission to perform ....L) d ......`.... .. �-- wiring .... ......................................... wiring in the building of........... ............... . ........................... ... ... ........ 2 e e r7W - at Old 1 24114 .... .North Andover,Mass. Feeld..'r...... .L i c.No, Q.Sf.zz . ........ ICALINSPECfOR INS Check At 88b8 : �-� Commonwealth of Massachusetts Official Use o y Department of Fire Services Permit No. BOARD OF FIRE PREVENTION REGULATIONS Occupancy and Fee Checked [Rev. 1/071 (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 PRINTININK OR TYPE ALL)NFORMATION) Date: 3 09 City or Town of. NORTH ANDOVER To the Ins ector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) (o 0 G C ep,- Pp f)A c RA Owner or Tenant )m Telephone No. �$ GaG Owner's Address 7,?S- 7 Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building �ama+- ,-A Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Und rd g ❑ No.of Meters New Service Amps / Volts Overhead❑ Und rd g ❑ No,of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Vo��-a42 �-2i ephc�ll2 r a Completion of the followin table may be waived by the Inspector of Wires. 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 ❑ o,o mergeNo.of Luminaires SwimmingPool ncy ig gd11nrnd. a Units —. FNo. of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones f Switches No.of Gas Burners No..of Detection and Initiating Devices No.of Ranges No.of Air Cond. To—tTons No.of Alerting Devices No.of Waste Disposers Heat P Totals: -_..._....._......._........._....._.Number Tons KW ............... - No.of Self-Contained Detection/Alertin o,Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances KW Security Systemrs:* No.of WaterNo.of Devices or Equivalent No.of No.of Heaters KW Data Wiring: � - Si s Ballasts. No.of Devices or E Trivalent No.Hydromassage Bathtubs No.of Motors Tom Hp Telecommunications Wiring: OTHER: No.of Devices or Equivalent Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: a '9 •OO (When required by municipal policy.) ' Work to Start: �J Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE COVE G _: 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 ❑ BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME. LIC.NO.: ©Do5 9a653 Licensee: (Y),+- )ew Signature LIC.NO.: (If applicable, enter"exempt"in the license number line.) Address: I OSz/ Bus.Tel No.: n Alt:Tel.No.: *Per M.G.L c. 147,s. 57-61,security work requires Departure t of Public Safety"S"License: Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance cove ge normally required bylaw. By my ' afore below,I hereby waive this requirement. I am the(check one) ❑owner Aj owner's agent. Owner/Agent Signature Telephone No. 003_t�a�-a i y7 PERMIT FEE: $ ,i ��,�' �F ��� � 7����� Ind � � Y° �f 1 r ;a The Commonwealth of Massachusetts kj ! Department of Industrial Accidents • Office of Investigations 600 Washington Street Boston, MA 02111 www r ass gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors /Electricians/Plumbers At►)Hc ant Information Please Print Legibly Name (Business/Organizadon/individual): N0C � CCS_ l Address: Ib� City/State/Zip: N wZ D?)dS� Phone 37y, Are you an employer?Check.the appropriate box: T of ro'ect(required): Type pro ( es{ ired): I.❑ I am a employer with 4. ❑ I am a general contractor and T b, �Newconstruction employees(full and/or part-time),* have hired the sub-contractors 2.❑ I am a.sole proprietor or partner- listed on the attached sheet 1 7. Remodeling ship and have no employees These sub-contractors have 8. Q Demolition working for .in any capacity, workers' comp.insurance. g. Building addition [No workers'comp.insurance 5.V 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 I I Z Plumbing repairs or additions myself.[No•workers'comp, c. 1.52, §1(4),and we have no 12.M Roof repairs insurance required.]t employees. [No workers' comp. insurance required.] 13-❑.Other ' Any applicant that checks bore#t must also fill out the section below showing their workets'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. 4Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy inforrradon. t 1 am an employer that is providing:workers'compensation insurance for my employees; Below is the policy and job site information. Insurance Company Name: S I 1 N1 �S U�Q(1�2 Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: City/State/Zip: 03�7�7 Attach a copy of the workers'.compensation policy declaration page(showing the policy num er 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 forth 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 cert y under the pains and penalties of perjury that the information provided above is true and correct Signature: Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# i :--:77 ssuing Authority(circle one): 1. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other �, Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees, r 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 re.ceiver 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 st=all 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),addresses)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 cant'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 numberlisted below. Self-insured companies should enter their self insurance license number on the appropriate tine. 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 A ill 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 bum 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. r 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 1-8.77-MASSAFE Revised 5-26-05 Fax#617-727-770 www.mass.gov/dia l ' Date.....7 ...................... j0RT#f 0 TOWN OF NORTH ANDOVER 0 PERMIT FOR WIRING CHU5 This certifies that ....................... ......................... has permission to perform wiring in the building of.. ..........-;'rA-'A94................... ....... at....114 ......... ............. ... ... . :�orlh Andover,Mass. Fee..125-040.. Lic.No.1:Vis, ........ .. EL ICAL INSPECTOR ✓ Check 4504�- 8870 Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit N°. BOARD OF FIRE PREVENTION REGULATIONS Occupancy and,Fee Checked ' [Rev. 1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK i All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASEPRINTININK OR TYPE ALL INFORMATION) Date: — (j_ (, 5 City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her inter ' n to perform.the electrical work described below. Location(Street&Number) �f�� pp„ /77A Owner or Tenant 6 /0 0 �� � � Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building 6 2oovr.S -0 �� Utility Authorization No. A k f�taso p CO oa, F11. r 1 Existing Service Amps / Volts verhea ❑ 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: SRS t( a _ FPa fG44 c vI c S 4�) lli om owin table m be waived b th Ins ector of Wires. No.of Recessed Luminairesb' No.of Ceil:Susp.(Paddle)Fans No.of r- Total Transformers KVA No.of Luminaire Outlets No.of Hot TubsGenerators KVA No.of LuminairesSwimming Pool Above In- — IN❑ -of Emergency ig g d. d. Batte Units r-- --, No.of Receptacle Outlets O No.of Oil Burners FIRE ALARMS No of Zones ' i No.of Switches No.of Gas Burners No.-of Detection and InitiatingDevices e - No.of Ranges No.of Air Cond. Total No.of Alerting Devices Tons �- �--- No.of Waste Disposers Heat Pump INumber TonsKW No.of Self-Contained Totals: - - Detection/Alerting Devices No.of DishwashersSpace/Area Heating KW Local Municipal ❑ Connection ❑ Other No.of Dryers — Heating Appliances ---- KW Security Systems:* r No.of Devices or Equivalent W e No.of Water KNo.of o.of Data Wiring: Heaters Signs Ballasts . No.of Dvices or E Devices No.Hydromassage Bathtubs No.of Motors — Total HP _Telecommunications 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=��OlSt;)C7-Oct: (When required by municipal policy.) Work to Start -60- O`"l 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 [R BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and p nalties of perjury, that the information on this application is true and complete FIRM NAME. d ' LIC.NO.: D Licensee: ZfMe-I- /� �u (' !4— Signature LIC.NO.: � � (If applicable, enter"exempt"in the lice a number line.) �" 5^ y Address: P =;fn *a Bus.Tel.No.: *Per M.G.L c. 147,s. 57-61,security work requires D artment of ubIic Safety"S"License: ��Licl.No.: 2 f/L �O 6 -r 3^/� 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 FEE: $ r �,-: i. M (f..., ` 4r ' �� �K -���� t I . 7 � - � �� � �1 �. v 4 w The Commonwealth of Massachusetts Department of Industrial Accidents i • Office of Investigations 600 Washington Street .i. Boston, MA 02111 www massgov/dia . Workers' Compensation Insurance Affidavit. Builders/Contractors/Electricians/Plambers Al plicant Information Please Print Legibly Name(Business/organiration/individual); Address: } p�,f// 5 •� City/.:State/Zig: i /ea GIiL �_ Phone Are you an employer?Cheek.the appropriate box: Type of I.� prefect(required):I am a employer with 2 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.E3 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. g Building addition [No workers'comp.insurance 5. ❑ 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. 1.52, §1(4),and we have no 12.❑Roof repairs insurance required.]t .employees. [No workers' comp. insurance required_] 13 Other Any applicant that checks bout#1 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. ;Coattaotors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp,policy inforr^ation. 1 ant an employer that is.providingworkers'compensation insurance for my employees: Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins. Lie.#: K)CT.�S-� Q Expiration Dater Job Site Address- ( n City/State2ip: Nov 4,41 14yV br r„!1�-• 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 tip 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. Ido hereby ce7trYy under t pai and naldes of perjury that the information provided above is true and correct Si tore: Date. cj Phone#: `b fC �f �. 7 ficial 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#: e Information and Instructions �A 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 mom 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 evideace..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,notthe 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 numberlisted below. Self-insured companies should enter their f 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 indicatingcurrent policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of tine 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 bum leaves etc.)said person is NOT.requimd 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 1-8.77-MASSAFE Revised 5-26-05 Fax#617-727-7744 , v^m.mass.gov/dia �.a. Date......7.. t7—O '7 � NORT1� TOWN OF NORTH ANDOVER ' PERMIT FOR WIRING ,SSAGMUS� This certifies that E M G U� ,�/2 ova J has permission to perform 4 c / �P 7 wiringin the building of BR-P'0,�S S S ....................................................... at........................................................ p ! 'PJ .....,North Andover,Mass. Fee..P?^� Lic.No.1. ..1..3l ......... /Q4� ELECTRICAL INSPECTOR 3 Check # 7509 Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. Occupancy and Fee Checked r BOARD OF FIRE PREVENTION REGULATIONS [Rev.9/05] leaveblank 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)1160 GREAT POND ROAD SCIENCE BUILDING Owner or Tenant BROOKS SCHOOL Telephone No. Owner's Address Is this permit in conjunction with a building permit? Yes ✓❑ No ❑ (Check Appropriate Box) Purpose of Building SCHOOL 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: UNDERGROUND CONDUITS FOR MAIN POWER, STAIR LIGHTING. GROUNDING BUILDING &TRANSFORMER Completion of thefollowing table may be waived by the Inspector of Wires. 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 Above In- o.o Emergency Lighting No.of Luminaires Swimming Pool rnd. ❑ rnd. El Battery Units No.of Receptacle Outlets No.of Oil Burners FIRE ALARMS No.of Zones of 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 Pump Number Tons KW No.of Self-Contained Totals: .."'""""' Detection/Alerting Devices No.of Dishwashers Space/Area Heating KW Local❑ Municipal ❑ Other Connection No.of Dryers Heating Appliances Kms, Security Systems:* No.of Devices or Equivalent No.of Water Kms, No.of No.of Data Wiring: Heaters Signs Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No.of Motors Total HP Telecommunications Wiring: No.of Devices or Equivalent OTHER: Attach additional detail if desired,or as required by the Inspector of Wires. Estimated Value of Electrical Work: 9,900.00 (When required by municipal policy.) Work to Start: AUGUST 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 ❑ BOND ❑ OTHER ❑ (Specify:) I certify,under the pains and penalties of perjury,that the information on this application is true and complete. FIRM NAME:Electrical Maintenance& Construction Inc. LIC.NO.: A 16931 Licensee: Brian Lamontagne Signature LIC.NO.: A 16931 (If applicable,enter "exempt"in the license number line) Bus.Tel.No..508-796-0355 Address: 270 South West Cutoff, Worcester, MA 01604 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 PERMIT FEE. $ Signature Telephone No. pile 1 a I i Date... . . 7 of Ha pT a 1a TOWN OF NORTH ANDOVER 4 o p PERMIT FOR GAS INSTALLATIONg SSACHUSEt This certifies that . . .". . . .r r. . . . .'. . t{ . . . .�. . .� � has permission for gas installation-+`-�,l :�'.�. •f . . . .'. . . . :. . . . in the buildings of . r. �. yl'�'.r f ��. -}�l.!i . . . . ::�. .' .t:. . . . .. at North Andover, Mass. J f'f Fee. Lic. No.. . a I . . . . . . . . . . . . . . . . . . . . . . . . . . -41 -�t l 1 GAS INSPECTOR WHITE:Applicant CANARY: Building Dept. PINK:Treasurer GOLD: File e V MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTIN( (Print or Type) l NORTH ANDOVER Mass. Date Buildina Location 12?1-oerLs S d-)cr , Permit # f Owners Name • New 77 Renovation R acement Plans Submitted �] FIX-Tl)?�'c j � w N cc 0 cc GW a Ot O U cc p _ cc C—N o us a -X a o Q a z w d m W a W W O a sr W 4 F- N / N C W Z U CL W Vf j 4 a O t] y W !/7 w w - a = a W a a w L" w F' co cc W ff (7 F- f J Ir z f. W W O ? LL t- V .,t F.. W Z d f• y. to W W W tr Q C Q < 0 O O W 2 C u C W ¢ O O W _ O W N STIR ESt.tT. i BASEMENT IST FLOOR 2ND FLOOR 0 3RD FLOOR 4TH FLOOR 5TH FLOOR 6TH FLOOR TTti FLOOR 8TH FLOOR (Print or Type) Check one: Certificat Installing Company Name ,L) hI le /,?C/G/( 'P tW (race FLOx,�r Corp. Address 72 Partner. AJO Ahddver /V',.1� �� g QSr �f Firm/Co. Business Telephone: C/?)— Name of Licensed Plumber or Gas Fitter 9 J qZ Insurance Coverage. Indic=te the type of insurance coverage by checking the appropriate box: Liability insurance policy her type of indemnity Q Bond Ej Insurance Waiver: I , the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance coverages. Signature of owner/agent of property Owner 17 Agent El I hereby certify that all of the details and information i have submitted (or entered)in above application are true and accurate to the best of my knowledge and tlut aU plumbing work and Installations performed under Permit issued for this application wW-be in compliance with all pertinent provisions of the Massachusetts Slate Cas Code snd Chapter 14I of tho Genual Laws. By TYPE LICENSE: - Plumber Title Plumber Signature of Licensed GasfitCity/Town: Master Plumber Gasfitter Journeyman APPROVED (OFFICE USE ONLY) License Number