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HomeMy WebLinkAboutMiscellaneous - Bldg 36Date 4 ql� I" f HORTM, TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ,SSACHUS� This certifies that �[!� . !%<.................. . has permission to perform ........ plumbing in the buildings of�3-0,/LAj�� Adkth �An4ov Mass. Fee/ic. No../. �lt?c?2 ............................. . C f? PLUMBING INSPECTOR ,- Check #-/ 5 It 'MASSACHUSETTS UNIFORM APPLICA fPrint a Type) XiAMass. Date. Building Locatlon A t � New ❑ Renovation O Rept FOR PERMIT TO DO PLUMBING FSB3 4� Permit # Owners Name S�eI-P(_/�GIrc� Type Of Occupancy �fgnVf xd Plans Submitted: Yes ❑ No /1q Installing Company Name , ( J Address 3S )el Ue!"vreu.-) JCe,�3 <I— wc� Check one:. Corporation ❑ Partnership BusinessTelephone i 3 }3710 cr !( t �� %% ��g� O hrm/Co. Name of Licensed Plumber Certificate rOfJ `� INSURANCE COVERAGE: I have a curve liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142: Yes o No ❑ If you have chedced yrj, please indicate the type coverage by checking the appropriate box A liability Insurance policy A( Other type of Indemnity ❑ Bond O 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: Owner ❑ Agent O 1 Hereby oerfiy that all of the details and information 1 have submitted for entered) in above aWmtion are true and accurate to the best of my knowledge and that all plumbing work and installations pert the for this appication well be in compliance with all Pertinent provismns of the Massachusetts State Plumbing Laws. By— Title Title g lure of LigpWum bet Type of License: Master, Joureeyman O Qty/Town ' L License Number�U tv z z m x _z O O O O z =a: > W W vi 29 z N J < 0 fr < I -z y O O z O 4 r 0 A t Z V W x < W z e. Z �. 0= 6 m N < W } < H M z O K A C 5 6 6 C O Y. 0: W f• t- W O J m C C t O W� � 19 Q > t O a 0< F' Z O p z z .W �' O V S a kc � m a c o 3= 1<- OJ 16J o a i 3 a m o SUB—BSMT. BASEMENT 1ST FLOOR 2ND FLOOR ,RD FLOOR 4TH FLOOR STH FLOOR BTHFLOOR 7TH FLOOR 8TH FLOOR Installing Company Name , ( J Address 3S )el Ue!"vreu.-) JCe,�3 <I— wc� Check one:. Corporation ❑ Partnership BusinessTelephone i 3 }3710 cr !( t �� %% ��g� O hrm/Co. Name of Licensed Plumber Certificate rOfJ `� INSURANCE COVERAGE: I have a curve liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch. 142: Yes o No ❑ If you have chedced yrj, please indicate the type coverage by checking the appropriate box A liability Insurance policy A( Other type of Indemnity ❑ Bond O 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: Owner ❑ Agent O 1 Hereby oerfiy that all of the details and information 1 have submitted for entered) in above aWmtion are true and accurate to the best of my knowledge and that all plumbing work and installations pert the for this appication well be in compliance with all Pertinent provismns of the Massachusetts State Plumbing Laws. By— Title Title g lure of LigpWum bet Type of License: Master, Joureeyman O Qty/Town ' L License Number�U tv Date .... 47 f TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .....'....:........................................- ��1/�-� has permission to perform ..........:..�-f:�......C........ v�!,..�..:....:....... �....... wiring in the building of . //�•. //f ...................... 1 � ! f�a........../.,.�s.-�............/... , 1. North Andover, Mass. -��i uj Fee.........1............ Lic. No. •..f..V ... f.I........ .... Check # 7 ELECTRICAL INSPECTOR J 5646 The Commo 'wealth of Massachusetts ollwoUe/ BOARD 0 APPLICATIO All work (PLEASE PRINT IN The undo Location Owner or Owner's F POneN No. �,) partment of Public Safety T ooauo.nry a s« FI E PREVENTION REGULATIONS 527 CMR 12:00 ym Meeve te."A FOR PERMIT TO PERFORM ELECTRICAL WORK to be performed in accordance with the Massachusetts Electrical Code. $27 CMR 12:00 R TYPE ALL INFORMATION) Date 3 - / / -0 S or Town f /4/_1c4,-; Or Dyc l- To the Inspector of Wires: ped appli s for a permit to perform the etectrial work described below. Is this permit in on' notion with a building permit: Y95,0 No ❑ (Check Appropriate Box) Purpose of Building t�cmtncrci-ac I 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 n Location and Nature of Proposec Electrical Work /3v�'/ r hg # 36 o? Y'. aT77,0 .0m S ✓.-'-w A, -,,4 fls. No. of Lighting Outlets No. of Hot Tubs No. of Transformers KVA No. of Lighting Fixtures / 9 Swimming Pool 9 Above grnd. � in. grnd. ❑ Generators KVA No. of Receptacle Outlets o? No. of Oil Burners No. of Emergency Lighting Battery Units No. of Switch Outlets o2 No. of Gas Burners FIRE ALARMS No. of Zones No. of Detection and Initiating Devices No. of Sounding Devices e,7 No. of Self Contained Detection/Sounding Devices Municipal Local 13 Connection ❑ Other No. of Ranges Total No. of Air Cond. tons No. of Disposals No. of Heat Total Total Pumps tons KW No. of Dishwashers Space/Area Heating KW No. of Dryers Heating Devices KW No. of Water Heaters KW No. of Signs No. of Ballasts Low Voltage Winn No. Hydro Massage Tubs No. of Motors Total HP OTHER: 1 ' INSURANCE COVERAGE: Pursuant to the requirements of Massachusetts General Laws I have a current Liability Insurance Policy including Completed Operations Coverage or its substantial equivalent. YES �5 NO ❑ I have submitted valid proof of same to this office. YES ,h� NO ❑ If you have checked YES. please indicate the type of coverage by checking the appropriate box. INSURANCE J9 BOND ❑ OTHER ❑ (Please Specify) Estimated Value of Electical Work $_ d 100 lEaa�rauon Date) Work to Start - / / " 0 S Inspection Date Requested: Rough Final Signed under the penalties of perjury: L FIRM NAME ar etc rr/ Ga - LIC. LIC. NO. 7 YO -J Licensee .�.Sn-oti Llan -e SignatureLIC. NO. Address lCoa5- 0/d &200t14 St &! G2' pP ¢ a mus. Tel. No. sa g ' � 9 ? � S LI of 0 Alt. Tel. No. ,Z? 3 '(0 8 OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the insurance coverage or its substantial equivalen as required by Massachusetts General Laws, and that my signature on this permit application waives this requirement. Owner ❑ Agent ❑ (Please check one) Telphone No. PERMIT FEE S islpeetu. • of Oww or AWQ CD m C m 'm V J 0 C �M CO) 10 CD C -) Z � CD 0 ACL r W CL ^• a� o p CD Q cr �• d CD O ... Q O CO CD LTJ y d O 0 C y d 0 CD O �f CD a y. CD CA O CD 0 CD V J 0 cn O cn ti 0 Q I�� Y z -•tAOQ W d O W CA c o moo: m n m C) m o yC.iao � In z Z �•p VJ � n x J o -n ° w � W aid O y W O ? W W O .. CC O W G 0 s. S O ;� W C r CE W N W W C d •W-•►• W N C O H „�'%• : Cv CA h .� a d :A wc CL yrt = W •� N W CA W � .d-•►• y O W w : " C7 : : mo W lip On O A'� wo W cD W ' o ?: cn 0 cn ti 0 Q I�� Y z o: 9z o c o moo: M cn `77° o o m In z o /lr-�1 m � n x J cn 0 cn ti 0 o7 I�� Y z ?� 9z o rfj M cn `77° o In z o /lr-�1 m � n x J o -n ° w z cn o 91 °o x O x m w O C C') O Z C/) m 0 Z C2 CA 'O C o d -oCD 0 0 Z y d O n� r c O � C = CO) o p CD O CL Q d CD CCD O CD cmw a c CD y av y —• o cQ C v CO) O Z CD O CD O C CD O V I to l d E� O -• V/ O Q N CO =t CO m Cl) C2. C-) m Z N � �•Cp y' o. -► = — m o. 77 =r CL o m m O O y O CO) O :E = m a > > cli —j tC p • o Z S. C.J. Q N p W• C y�-•� .0 10 o a .. m W ® O N ~ m .d_rt• N CO O ImCA SL Ck N C N m ((11JJc � o co ? CAO OmM CO2 f m � D m R Er caco N � O •V CD c CM3coCDs VJ � H m O n o m :� • m m r 'a a'a o : Z 0 o� ? o c) a- r 930 Ix a7d- w gi aw' c ocC gi.x C7 0Cl) CD rGJ ,E� WO dz M Qo �►�° rbCA y \\1'� tri ;E V. \o w H 0 O C ►s j roW f�. i� �•' 0� xx �dCL xx �dCL 0 oxo m C z -n z c CD n yz C d m °z m >x� y x J O o n Cf)poem . y y M 9.0 y O ® n o Uzi A �. Z tv 0 z tz tai G FILam E Tour Andover Controls Construction Meeting Minutes J. Calnan & Associates, Inc. 10 Granite Street Quincy, MA 02169 Tour Andover Controls 1 High Street North Andover, MA JC&A Project # 04-116 Meeting: Meeting Date: Meeting Min Ref: Review Date Pre -Construction Mtg February 24 2005 3 : Rate! Start )Jnd: :' ?Next �'Iee#'in • _. �'ext'i�uie �`` f _ 2/24/05 1:15 PM 1:45 PM 3/3/05 I high Street BldE, 5 Caf JCA ur� r `Loca#ion , ' o _1 Geilei'e.` tes Construction Meeting I High Street I Teleconference # Passcode# Atte ' d'" � k . •-t � _ � Rick Borden (JCA) rborden@icalnan.com All attendees and the following individuals Chirs Dennis (JCA) cdennis@icalnan.com Jay Calnan (JCA) Charlie Manahan (TAC) c.manahan@tac.com Mike Crowther (JCA) Edward Howlett (TAC) ed.howlett@tac.com Bill Thomson (JCA) bthomson@icalnan.com Steve McNeice (IDG) smcneicegid roupae.com Ken Cristofori (IDG) kcristofori@idgroupae.com f Tom Kinslow (IDG) tkinslow@idarou ap e.com wTAC — Torr Andover Controls ` Hee-Won Lee (IDG) Item Summary,Of Meeting 3 t " A tion by c Finish ?Noy `t. bbreviatt►oris Date f wTAC — Torr Andover Controls ` o lg` °x =� ;i DG Intergraded Design Group JCA JCalna�&_Associates ' t;orrections 1'o Prior Minutes None II Inspectional Service — N. Andover 2.01 JCA stated that a rough plumbing for Building #37 is complete III Building Owner/Property Owner 1.02 JCA to provide hot work permit for welding of 2" gas connection. This is to be coordinated with Schneider Electric. (2-10-05) JCA and. Schneider still need to coordinate - IV Design — Architectural 1.05 TAC questioned the color of the lockers (2-10-05) TAC stated that the Lockers and locker bench would come from the existing gym. JCA requested any blocking requirements V Div#2 & #3 (Demolition & Concrete) 1.06 JCA stated that concrete cutting is scheduled for Friday 2/4/05. All other demolition work is complete. (2-10-05) Concrete Cutting is complete and underground plumbing is schedule for 2-11-05 and repour slab on Monday 2-14-05 (2/17/05) Slab work complete JCA Rec. Pre -Construction — Tour Andover Controls - Meeting Minutes No. 1 — Page 1 of 1 VI Div#6 & #7 (Millwork & Caulking) 1.07 JCA stated that shops for Millwork were underway. P -lam color for millwork in building 5 was to match existing p -lam in bathroom of 5 (2-10-05) JCA stated that shops will be in this week (2-24-05) Shop drawings have been submitted and approved by architect. Millwork expected on site week of 2/28/05 VII Div#8 & 9 (Doors & Finishes) 1.08 Doors are scheduled to be removed from 300 Brookstone for Saturday JCA/TAC 2/12/05 and 2/19/05 (2-24-05) All available doors and frame have been moved and installed. Some frames and doors could not be moved and JCA to price provide new doors for ones that could not be moved. JCA stated that they feel that the additional doors can be purchased for under the budget amount 1.09 GWB work is ongoing in all buildings. Taping has started and painters are JCA scheduled for next week. (2-10-05) Taping is ongoing in building 6 and building 5. all taping work should be complete by end of next week. (2-24-05) Taping is still ongoing and should be complete In building 6 this week and finished in building 5 next week 2..02 JCA stated that tile is onsite for building 6 and is schedule for install on 2- JCA 14-05 (2-24-05) Tile work in building 6 is complete. Building #37 to start on or about 3/1/05 VIII Div#10 & 12 (Toilet Accessories & Window Treatment) 1.10 Toilet Accessories have been purchased and submittals will be forthcoming next week 1.11 JCA stated that window treatment is schedule for all but three windows looking onto building 37. TAC requested that all windows have blinds (2-24-05) Window treatment has been ordered for Building 37 and is expected on site week of 2/28/05 IX Div#15 (Plumbing) 1.12 JCA stated that Rough is complete for Bldg 6 and 5. Underground plumbing for Bldg 37 will take place next week Gas tap to be coordinated with Schneider Electric X Div#15 (HVAC) 1.13 Dockworker is schedule for tomorrow to start work. (2-10-05) Ductwork is complete in Building 37 and Building 5 and 6 are schedule to be complete by mid next week 2.03 JCA stated that there is problem with the HVAC design in Building #37. No heat comes from the existing roof top unit. IDG to design adding electric duct heaters for gym, shower room and office area XI Div#15 (Fire Protection) Pre -Construction — Tour Andover Controls - Meeting Minutes No. 1— Page 2 of 2 Summary Otmeeting . Action by I fnish A reviations' Date K TAC — Tour Andover Contro; a DG — Intergraded Design Group the Ifit- A Calnan Asbcinte` ------------------ VI Div#6 & #7 (Millwork & Caulking) 1.07 JCA stated that shops for Millwork were underway. P -lam color for millwork in building 5 was to match existing p -lam in bathroom of 5 (2-10-05) JCA stated that shops will be in this week (2-24-05) Shop drawings have been submitted and approved by architect. Millwork expected on site week of 2/28/05 VII Div#8 & 9 (Doors & Finishes) 1.08 Doors are scheduled to be removed from 300 Brookstone for Saturday JCA/TAC 2/12/05 and 2/19/05 (2-24-05) All available doors and frame have been moved and installed. Some frames and doors could not be moved and JCA to price provide new doors for ones that could not be moved. JCA stated that they feel that the additional doors can be purchased for under the budget amount 1.09 GWB work is ongoing in all buildings. Taping has started and painters are JCA scheduled for next week. (2-10-05) Taping is ongoing in building 6 and building 5. all taping work should be complete by end of next week. (2-24-05) Taping is still ongoing and should be complete In building 6 this week and finished in building 5 next week 2..02 JCA stated that tile is onsite for building 6 and is schedule for install on 2- JCA 14-05 (2-24-05) Tile work in building 6 is complete. Building #37 to start on or about 3/1/05 VIII Div#10 & 12 (Toilet Accessories & Window Treatment) 1.10 Toilet Accessories have been purchased and submittals will be forthcoming next week 1.11 JCA stated that window treatment is schedule for all but three windows looking onto building 37. TAC requested that all windows have blinds (2-24-05) Window treatment has been ordered for Building 37 and is expected on site week of 2/28/05 IX Div#15 (Plumbing) 1.12 JCA stated that Rough is complete for Bldg 6 and 5. Underground plumbing for Bldg 37 will take place next week Gas tap to be coordinated with Schneider Electric X Div#15 (HVAC) 1.13 Dockworker is schedule for tomorrow to start work. (2-10-05) Ductwork is complete in Building 37 and Building 5 and 6 are schedule to be complete by mid next week 2.03 JCA stated that there is problem with the HVAC design in Building #37. No heat comes from the existing roof top unit. IDG to design adding electric duct heaters for gym, shower room and office area XI Div#15 (Fire Protection) Pre -Construction — Tour Andover Controls - Meeting Minutes No. 1— Page 2 of 2 1I#c► Summary Of 1Vleeting Na:' `4 Action by pinis 1Vo AblsreviatiousI., Date t our Aicloder Controls 0)G'— I tergratled Design Gkoiip inc g 4. JV J Calna & 'ssoeiates. ,' 1.14 All Fire Protection drawing to be submitted to FM Global for approval. Drawings expected next week (2-10-05) drawings still have not arrived but are scheduled before weeks end (2-24-05) Fire Protection work for building 5 to be completed on weekend due to the gas valve shuts down when the sprinkler system is drained. This will be complete over the next two weekend XII Div#16 (Electrical & Tel/Data) 1.15 Electrical and Tel/Data is on going. Crew is up to 10 men. 2.04 JCA stated that there are some electric extra in building #37 to move transformer. JCA also stated that some electric panels will be in office. TAC responded that it was OK XIII Information Technology 1.16 TAC is working with there IT Department for moving schedule XIV Move Coordination 1.17 Meetings are schedule for Tuesday at 2:00 with move vendor. (2-10-05) TAC&JCA have schedule the furniture installation Building #6 for the week of 3/7/05 to 3/13/05. Building #5w will start installing the 40 stored furniture cubes starting 3/7/05 but the major move would happen the week of 3/14 to 2/20. Building #37 will start 2/21/05 to 2/27/05. XV Added Scope Change 2.05 TAC is looking for a price for changes in the demo room. XVI Schedule 1.18 JCA issued revised construction schedule. JCA to update weekly (2-10-05) JCA distributed revised construction schedule and stated that we are on or ahead of schedule (2-24-05) JCA distributed revised schedule and stated that we are about one week ahead of original schedule XVII FF&E 1.19 40 Cubes of furniture is stored in trailer. 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I =S N �r N LL C N R pl F U e8 U O LL Q� a m. � ui >g m Q U N m o ui 0 03� cU>i$ �V c I� �`-p0 c c y2 o LL' LL' C7 d a' Q S _ Q it Q w 0 N W j IL Location No. CDate -07 �l' 00 0 y NaRTof A TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ s�CHus Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # $ `� Q I 13 ('55) Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING Section for Official Use OnI BUILDING PERN41T NUMBER .2 DATE ISSUED: SIGNATURE: qA"Aw- Building Commissioner/I or of Buildings Date 1.1 Property ess 1.2 Assessors Map and Parcel Number. Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area (sf) Frontage (11) 1.6 WELDING SETBACKS (ft) Front Yard Side Yard RM Yard Required Provide Required Provided Required Provided 1.7 Water Supply M.GJ,.C.40. 54) 1.5. Flood lane Information: 1.9 Sewerage Disposal System: Public 0 Private 0 zone - Outside Flood Zone 0 Municipal On Site Disposal System 0 '44 ,4 1. V. A ,,, " I !, 2.1 Owner of Record Nanle (Print)Address for Service: ST�E gitiiJ ?78- W,S 2,573 Signature Telephone 2.2 Authorized Agent Name Print Address for Service: — Signature Telephone N I 3.1 Licensed Construction Supervisor Not Applicable 0 b0wt® %&ceA CS OW3S- 61' 0 a 7.) 5 - Address License Number %-2- 6-06 Licensed Construction Supervisor: SOS - sc(?3 Expiration Date Signature Telephone 3.2 Registered Home Improvement Contractor Not Applicable 0 Company Name Registration Number Address ENpration Date Signature Telephone ft M M Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yea ...... No.......❑ SECTION S -;PRO ESStQN.4LA" ST :� C SMCx14VI,s�Rv�[C>�s 1CtF�$ B1�LU$�t� ANDS ITC)�I1t�S S� ,�ONSZ'RIICT)fQN COl�i'iRt)L �� 5.1 Registered Architect. Name: 411P - Address l S E'E A-� N i4tl� crT Signature Telephone Company Name: R&j tc %\ ,jAk awDP—LaXUIc 111 %..hill r�C. V1 %.VMLJ LU;Uon Nu k_ vjV L Not Applicable ❑ Area of Responsibility Registration Number Expiration Date Name: Address: Signature Total Not applicable ❑ Registration Number Expiration Date Name: Address Signature Telephone Area of Responsibility Registration Number ti Expiration Date Name Address Signature Telephone Area of Responsibility Registration Number Expiration Date Name Address Signature v Telephone �i'i �F—rYi?�(Gi'ihVdn� aL•E%a,,. 1._�'�3t''»-�'Y, „5:.;-•r.. Company Name: R&j tc %\ ,jAk awDP—LaXUIc 111 %..hill r�C. V1 %.VMLJ LU;Uon Nu k_ vjV L Not Applicable ❑ New Construction ❑ Existing Building Ik Repair(s) ❑ Alterations(s) Addition ❑ Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify Brief Description of Proposed Work: Si -Q -,J C -T-101\) '��71JD + G\( W�4o�-J-- ve-S-41&e (C ��,(- 1ci tis + (oo� Independent Structural Engineering Structural Peer Review Required Yes ❑ No ❑ SECTION 10a Owner Authorization - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, �- F kv\� � R � A'J tT as Owner of the subject J property Hereby authorize to act on My behalf, in all matters relative two work authorized by this building permit application Signature of Owner Date USE GROUP Check as applicable) CONSTRUCTION TYPE A Assembly ❑ A-1 ❑ A4 ❑ A-2 A-5 ❑ A-3 ❑ 0 IA IB ❑ ❑ B Business ❑ 2A 2B 2C ❑ ❑ ❑ C Educational ❑ F Factory ❑ F-1 ❑ F-2 ❑ H High Hazard ❑ 3A 3B ❑ ❑ IInstitutional ❑ I-1 ❑ I-2 ❑ 1-3 ❑ M Mercantile ❑ 4 ❑ R residential ❑ R-1 ❑ R-2 ❑ R-3 ❑ 5A 5B ❑ ❑ S Storage ❑ S-1 ❑ S-2 ❑ U Utility M Mixed Use S Special Use ❑ ❑ ❑ Specify: Specify: Specify: COMPLETE THIS SECTION IF EXISTING WELDING UNDERGOING RENOVATIONS, ADDITIONS AND OR CHANGE IN USE Existing Use Group: Existing Hazard Index 780 CMR 34: Proposed Use Group: Proposed Hazard Index 780 CMR 34: Independent Structural Engineering Structural Peer Review Required Yes ❑ No ❑ SECTION 10a Owner Authorization - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, �- F kv\� � R � A'J tT as Owner of the subject J property Hereby authorize to act on My behalf, in all matters relative two work authorized by this building permit application Signature of Owner Date as Owner/Authorized Agent Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury P.S �S Print Name la Signa e f Owner/Agent Date Item Estimated Cost (Dollars) to be Completed by applicant h permit ,. 1. Building (a) Building Permit Fee 1 QDQ . 0 Multiplier 2 Electrical (b) Estimated Total Cost of A ' V Construction from (6) 3 Plumbing Building Permit fee t,l X (b) 4 Mechanical (HVAC) 5 Fire Protection Gco 00 6 Total (1+2+3+4+5) �JCC)00 Check Number �, is r CyW)h3 44�.iY `'' { S .. i `� l�at✓ 1 xY Yh* :.h'1 P�lx Y,;:. i 3 i h3�'+ �Y? „ii. ... Y,.�„� s� z 1'.'!kr aSf'ijS, .i h-L:F.r/i #+ i+/ �.•..`i7.r,'E l,.;,-$��,j`�c $..3 i Rr i'. �. ,A,;. t ( 4� 5 P � t T 3 t{,. : .# d¢ ] :• 1`4{� 3 !1 ,L 3 to n4x,t :f } _; �'. �4 r 3! z t v� ` r r Y S 3nN": Y.,:4 .N .SIJ hiY k�}n"h tll 'Y P r #i�`' 9. .e, x :L" .'�+z E„» .Y & NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1 sr 2 No 3 RD SPAN DEMENSIONS OF SILLS DEMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL_ GAS LINE SO y' RX�k•>;v 5?': FORM - U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all -necessary approval / permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and or landowner from compliance with any applicable requirements. APPLICANT Olt ��peEz�G� 5C� "IN IN � � IC'GPHONE �%� ASSESSORS MAP NUMBER SUBDIVISION LOT NUMBER OT NUMBER STREET ISG - % 3 V STREET NUMBER % OFFICIAL USE ONLY ......................................................................ERNE. RECOMMENDATIONS OF TOWN AGENTS CONSERVATION ADMINISTRATOR COky1ENt'S TOWN PLANNER COMMENTS FOOD INSPECTOR - HEALTH SEPTIC INSPECTOR - HEALTH CONIlvIENTS PUBLIC WORKS - SEWER / WATER CONNECTIONS DRIVEWAY -3:z FIRE DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED %✓ SI I d -o DATE APPROVED DATE REJECTED CONffyiENTS RECEIVED BY BUILDING INSPECTOR The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Massa 02111 Workers' Compensation Insurance Affidavit Please Print Name: Location: City Phone F7am a homeowner performing all work myself. 01 am a sole proprietor and have no one working in any capacity I am an employer providing workers' compensation for my employees working on this job. Company name RooUtc- Lr,!j 4Q C- - Address 2 © Cp� - 1 S Cites �A-"Ve C -S Phone #: %7 7Sd "-C o? 7 Insurance Co. (�Y� P9,T �M� �Cr��v Policy # )10% W CP1 V-(),107 Company name: Address City Phone #: Insurance Co Policy # Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one years' imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of ($100.00) a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do herby certify under the Print and penalties of perjuryt the information provided above is true and correct. !//'IT Date Official use only do not write in this area to be completed by city or town official' []Check if immediate response is required Building Dept Contact person: Phone A FORM WORKMAN'S COMPENSATION ❑ Building Dept ❑ Licensing Board ❑ Selectman's Office ❑ Health Department ❑ Other Town of North Andover o� tAORTH qti • o �, a Building Department 0 y � 27 Charles Street North Andover, Massachusetts 01845 OQ cocwcww.c• �. (978) 688-9545 Fax (978) 688-9542 9SSACHUS�� DEBRIS DISPOSAL FORM In accordance with the provisions of MGL c 40 s 54, and a condition of Building permit # the debris resulting from the work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL cl 1, s150a. The debris will be disposed of in /at: 0 Isp s/yU (i k -- '-hyo -Too Facility location ��Iature of Applicant 5/0/00 Date NOTE: A demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector. AFFIDAVIT FOR ARCHITECT AND ENGINEER THE COMMONWEALTH OF MASSACHUSETTS COMMONWEALTH OF MASSACHUSETTS ) SS: COUNTY OF ESSEX ) O his 28th dayof A ril A.D. 2000, before me, 1-io 11-112 P f— Linda S. Smiley, who, being duly sworn, deposes and says that she will review the preparation of drawings for Groupe Schneider tenant fit -out remodeling on the second floor of Building 36 at North Andover Mills in North Andover, Massachusetts; and that she will review and/or provide for the proper checking of all the working drawings and shop drawings for construction; and all modifications to the existing structures will be designed for construction in accordance with applicable provisions of Chapter 1, Section 116, Massachusetts State Building Code, and that such plans conform to all the applicable provisions of the Massachusetts State Building Code, and that all the materials used in the construction will be selected by specification by her or her registered professional Designee in accordance with the Controlled Materials Procedure therein defined. ' No. 10080 ' HAVERHILL, MASS. , Linda SLA, Subscribed and sworn to before me thi,,-. day of l ii A.D. 2. 30 Iid-lrne Or '` .�MAINotary Public My commission expires on O'G� \\Advfs0l\Projects\Projects\Affidavits, Bldg. Insp. Letters\G.S. BLDG 36 2ND FL. AFFIDAVIT.DOC May 10, 2000 Mr. Robert Nicetta Building Commissioner Town of North Andover 27 Charles Street North Andover, MA 01845 Dear Mr. Nicetta, This letter will serve as my approval as the representative of Yale Properties, Building Engineer for North Andover Mills, that the attached construction document as specified below, for the additions / alterations to Building No.36 Auditorium and Offices (Second Floor Partition Plan) is hereby `approved' based on the scope of work indicated per Bert, Hill, Kosar and Rittleman (Architects) Attached please find a `signed' copy of this document and initialed approvals of the following documents — BUILDING NO.36 — SECOND FLOOR PARTITION PLAN If you should have any questions, please do not hesitate to call me at (978) 682-9494 Many thanks for your help in advance. Sincerely, Arthur Boujoukos Building Engineer North Andover Mills One High Street, North Andover, Massachusetts 01845 Tel.: (978) 682-8708 Fax: (978) 682-8713 GOLDSMITH, PREST & RIN ID:19787721591 AUG 10104 10:30 No.003 P.02 "v f Civil & Structural Engineering a Land Planning a Land Surveying for Land ;& 8buctures Ft CONSTRUCTION CONTROL AFFIDAVIT IN ACCORDANCE WITH 780 CMR 116 of THE MASSACHUSETTS STATE BUILDING CODE, 6`" Ed. FINAL INSPECTION of STRUCTURAL WORK PROJECT NUMBER: 042104 PROJECT TITLE: Converse Shoe Roof Deck PROJECT LOCATION: North Andover, MA NATURE OF PROJECT: New Roof Deck Construction Please find attached the separate "Notarial Acknowledgment" required by the Commonwealth of Massachusetts. It attests to the authenticity of this document that states Scott Nelson and/or one of his designated engineers has inspected the structural foundation and framing for the PROJECT noted above. Intermittent inspections of this work were conducted by Sebastian Rizzon of this office two times during July 29, 2004 through August 6, 2004. The Final Inspection was done by Sebastian Rizzon on August 6, 2004. THE SCOPE OF WORK REFLECTED IN THIS AFFIDAVIT IS FOR THE STRUCTURAL DESIGN/ CONSTRUCTION OF THE ROOF DECK FOR THE BUILDING. I, as the Affidavited Structural Engineer of Record (SER), hereby certify that I and/or my engineers have conducted the aforesaid structural inspections of the above stated PROJECT and find that the framing has been properly installed in accordance with our original structural design drawings, revisions thereto and the Building Code of the Commonwealth of Massachusetts and is functioning as intended. U, tom"' c k4 4'e 5315 /Uq �QM M ( SS [PVA r)Lr(/6 �. 26e' Z6()r7 Goldsmith, Prest & Ringwall, Inc. 39 Main Street, Suite 301, Ayer, MA 01432 • (978) 772-1590 • Fax (978) 772-1591 • info@gpr-inc.com • www.gpr-inc.com GOLDSMITH, PREST & RIN ID:19787721591 a AUG 10104 10:31 No.003 P.03 NOTARIAL ACKNOWLEDGEMENT Commonwealth of Massachusetts County of A,(+ dM'A& t_ On this the day of before me, Day/ AA ,, M h Year uc'(�'Qc- [- lu� , the undersigned Notary Public, Name of Notary Public pp � personally appeared Name(s) of Signor(s) proved to me through satisfactory evidence of identity, which was/were to be the person(s) whose name(s) is/are signed on the preceding or attached document, and acknowledged to me that he/she/they signed it voluntarily for its stated purpose. ortw C. kap Signature of Notary Public U, -'(." 6-1 ((A.,p Printed Name of Notary My Commission Expires xc, 20', eam-7 GOLDSMITH, PREST & RIN ID:19787721591 AUG 10'04 10:29 No.003 P.01 r- GOLDSMITH, PMT & RINGWALL, INC. �p Engineering Solutions civil & Suwuual mower* • Land S.meying & Lend planning for Land & Structures StrwaurolEngineeringGroup 39 Main Street, Suite 301, Ayer, MA 01432 Phone: (978) 772-1590 • fax: (978) 772-1591 FAX0 : To: MikQ N. Andover 8Wdina Inspector From: Sebastian Rizzon Fax: 978-668-9542 Pages: 3 including this cover sheet Phone: teterence: Converse Sime Co. ❑ Urgent I ❑ Comments: Mike, 0 Date: 10 -Aug -04 CC: 11 is Frank Heidnrich of Osterville Builders asked me to fax you the final affadavit of construction for the Converse Shoe Building in North Andover, MA. The original document has been sent to Frank. Please call if you have any questions. IN CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Permit Number 273 (10/6/2009) Date: December 8. 2009 THIS CERTIFIES THAT THE BUILDING LOCATED ON One High Street Bldg #36 MAY BE OCCUPIED AS Interior Fit Up (3 Show Room) Disnlay Area IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY, Certificate Issued to: Converse Company One High Street North Andover MA 01845 /% Building Inspector CA m m C X CA mm y CD� Z CD O ar n� CD .o � o o p CL Q %<sm_ CD O .. .. O _ to = CD _ CO) 'O CD O v A, d _ d O _ CO) c 0 c CO) n CD O _ CD CD y. CD CO) 0 O CD O CCD 0 O r cn n O cn J O cn cn tv G G'1 b• C 0 0 Z 0 O 0 m O C CL m m 0 a: N CA 60 c =r, O d X11 So mfA � ::t— 71 "JO w _2 y n yma� m 3, Cl) = -CD =r-C N H x a. 0 ._► = .d.► O =rCL�*a = T m y -4Ooy O�m o = Ce mCD 0 t m O ti CO2 CD =r= N a =� a .... 0?C - O m H CL m fA CL Cr - �. a O H N �C, 0 0 �o � o CD �y 0 ted: Ci IO (n cn b7 z ?1 jJ w X11 (n gj A• ata ' K7 71 "JO w n gi 'S7 = oGa cn al a r �' x a. 0 a9 r x Q c� It z 0 H 0 9 1 Y 4 6 1 FROM ROAD SECOND FLOOR PARAMUS, NJ 07652 973.253.9393 T 973.253.9390 F WWW.SARGAP,CH.COM November 12, 2009 Town of North Andover Building Department 1600 Osgood Street North Andover, MA 01845 RE: Converse Display Areas Construction Affidavit One High Street Building #36 North Andover, MA 01845 To Whom It May Concern, This letter is to verify that the Converse display areas in the Building #36, to the best of my knowledge, have been built in accordance to the plans and specifications prepared by Sargenti Architects. The A104, E100 and E200 --sheet have been revised during the course of construction due to field conditions and client changes therefore revised signed and sealed sheets have been included with this submission. If there are any further questions please feel free to contact me. F Principal SARGENTI ARCHITECTS Page 1 11/9/2009 Gerald A. Brown Inspector of Buildings TOWN OF NORTH ANDOVER OFFICE OF BUILDING DEPARTMENT 1600 Osgood Street Building 20 Suite 2-36 North Andover, Massachusetts 01845 Telephone (978) 688-9545 Fax (978)688-9542 AFFIDAVIT FOR FINAL COST OF CONSTRUCTION In accordance with the provisions o the Massachusetts State Building Code, Article 1, Section 110.4 and 114.2, the total estimated cost of the construction including all related construction costs* of the building located at ©UE W (AN STET , 34,. 34p, u AkhaQ amounts to $ I, 126fter being the person referred to as the owner identified below, do solemnly swear that the statements made herein are strictly true and correct and made in good faith. *Related construction costs included all work done with or concurrently with the work contemplated by the Building Permit including demolition, plumbing, heating, electrical, air conditioning, painting, carpentry, landscaping, site improvement, etc. Furnishings and portable equipment are not part of the total construction. costs. COMMONWEALTH OF MASSACHUSETTS re f Own Pr 1156 ex S. S. %r 20 Qq Then personally appeared the able named 6 b r( -T and Made an oath that the above statement is true. JULIE A. BOB S- EIN efore, Me, Notary ( NoluOn, of Massachuse tfq I✓otrrrrission Expires r March S. �Dt3 / ttary Public OFFICIAL USE: Final Cost: Original Estimate cost of general work: Cost Difference: Additional Fee Required: TO AMEND FEE UNDER PERMIT NO.: Inspectional services Department 2005 FAfinalcostaffidavitfornn Strict code enforcement makes the town safer Before buying, renting, leasing check zoning BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 4 6 1 FROM ROAD SECOND FLOOR PARAMUS, NJ 07652 973.253.9393 T 973.253.9390 F WWW.SARGARCH.COM November 12, 2009 Town of North Andover Building Department 1600 Osgood Street North Andover, MA 01845 RE: Converse Display Areas Construction Affidavit One High Street Building #36 North Andover, MA 01845 To Whom It May Concern, This letter is to verify that the Converse display areas in the Building #36, to the best of my knowledge, have been built in accordance to the plans and specifications prepared by Sargenti Architects. The A104, E100 and E200 sheets have been revised during the course of construction due to field conditions and client changes therefore revised signed and sealed sheets have been included with this submission. If there are any further questions please feel free to contact me. Principal SARGENTI ARCHITECTS Pagel 11/9/2009 4 6 1 FROM ROAD SECOND FLOOR PARAMUS, NJ 07652 973.253.9393 T 973.253.9390 F WWW.SARGARCH.COM November 12, 2009 Town of North Andover Building Department 1600 Osgood Street North Andover, MA 01845 RE: Converse Display Areas Construction Affidavit One High Street Building #36 North Andover, MA 01845 To Whom It May Concern, This letter is to verify that the Converse display areas in the Building #36, to the best of my knowledge, have been built in accordance to the plans and specifications prepared by Sargenti Architects. The A104, E100 and E200 sheets have been revised during the course of construction due to field conditions and client changes therefore revised signed and sealed sheets have been included with this submission. If there are any further questions please feel free to contact me. Si Rc Principal SARGENTI ARCHITECTS Pagel 11/9/2009 4 6 1 FROM ROAD S E C O N D F L 0 0 R PARAMUS, NJ 07652 973.253.9393 T 973.253.9390 F WW W.SARGARCH.COM November 12, 2009 Town of North Andover Building Department 1600 Osgood Street North Andover, MA 01845 RE: Converse Display Areas Construction Affidavit One High Street Building #36 North Andover, MA 01845 To Whom It May Concern, This letter is to verify that the Converse display areas in the Building #36, to the best of my knowledge, have been built in accordance to the plans and specifications prepared by Sargenti Architects. The A104, E100 and E200 sheets have been revised during the course of construction due to field conditions and client changes therefore revised signed and sealed sheets have been included with this submission. If there are any further questions please feel free to contact me. S Principal SARGENTI ARCHITECTS Pagel 11/9/2009 f „aM f CERTIFICATE OF USE & OCCUPANCY TOWN OF NOR'T'H ANDOVER Permit # 193(9/10/09) Date: January 12.2010 THIS CERTIFIES THAT THE BUILDING LOCATED ON I High Street - MAY BE OCCUPIED AS Blde #36 — Tenant Fit up — Converse ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: Converse Co 1 Iiigh Street North Andover Ma 01845 / JBuilding Inspector O EMO • W t" O z W c o 94 o � �i O C H O C r-. O V V CL C MM w CD C w O i co 'Ea e =ts o. 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O: C de E c �! ... 0 . j Us o c a*. to O ' O O o fAI all ; 3 O J C c m 7 W 'd = C Cg) W �E m � LaILm 'CO2C v y Z a tiwc = m :mho CL. y W ev Z m c=:, CA E CO LU ca CM a CO2 m� O� z � h $ nmmO E Ag CA "oo O y C O 0 CD m cm C m `o cm c 0 IV CD t O Z 0 CD F. -0 M f u O "1 L ICDc 0 y CD CD CD mm = O � O i O d a. �a c c� c O Vca 'p C Z CL C.3 y C m c COD 0 D LU 0) W W W U) Location No. G� O� �3 Date NORTh TOWN OF NORTH ANDOVER AL •. • O 9 Certificate of Occupancy $ 0 �� Building/Frame Permit Fee $ s�cMus Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # avv/ 0 —�' 22666 `` Building Inspector � Nom CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Permit Number 273(10/6/2009) Date: December 8. 2009 THIS CERTIFIES THAT THE BUILDING LOCATED ON One High Street Bldg #36 MAY BE OCCUPIED AS Interior Fit Un ( 3 Show Room) -Display Area IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: Converse Company One High Street North. Andover MA 01845 Building Inspector U) m m C X CA v m CO) 10 CDZ CL Cp O CL n(o O CD Q Ov CL V w� `< W_ CD 0 ■ • Mlm co CD CA 10 CD O 10 d O CO) 10.0 C 0 CO) d C7 CD O CD CD a y. CD CO) O CCD O CD I I'M C 0 C O O1 S. y C tS N ® no m H W a C.) =. = d p7 O N CL 0 CO �'?so -4OON O =r m CD O C-3 ~' O � O1 O N COY a o' m ?='O nC', 5 = .,to CL CD to H G CD CL CLcr C CCD, _ CD N N 1 1 � CD CD d NI); w 0 0 ��- . CD CA CD CD CD W N Im r CK/ c' .o o.'O nom: 0 go C O CD c cn to � OQ n pd� z hd ^ CrJ n C" (^ w z Cn 7C tz `J z O I CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Permit # 193 9/10/09 Date: January 12 2010 THIS CERTIFIES THAT THE BUILDING LOCATED ON I High Street MAY BE OCCUPIED AS Blda #36 — Tenant Fit un — Converse ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: Building Inspector Converse Co 1 ffigh Street North Andover Ma 01845 015 �1 O H N. E U r! 6 z+ LU CL � c o 0 m c A C O y Q � � O� � � (�► � d � m � `� T ,� L��� �y O v P. cn O O ..0 C w U x O C a' w u2 cn x cn cn r! 6 z+ LU CL :i4 U 0 v O O .TIT P4 e --V 2 O co O co O Z Z 10. O y D C as CM I O Ww+ .� H O O 'E m m 0 CD CD t O � 3� O CD L _0 oco a �Q o Cc� C ca J O "a ca Z C.3 V y c C . tC R _02 0 � c o 0 m c C O y p 'O .22 C i pCD vlyi" C o a .V� E c your a m c mi Q• a:r E a m m H MA = C 3 Z Mo �c: : • m zipa �• t � � t C .t� y W y C � y c CD o aC3 i co y CD C: cm F C = •� v\ p� m /// C1 •y O : Cam i O r cc C I IL C Q i i .0 C Off„ •O = C m w a. IV o W C root- � 'fl Z . -.mow t w •y Cr •� .E acc z �. Z W cj m o®� 5 N a to o� 211 Cos CD H s $ aZm :i4 U 0 v O O .TIT P4 e --V 2 O co O co O Z Z 10. O y D C as CM I O Ww+ .� H O O 'E m m 0 CD CD t O � 3� O CD L _0 oco a �Q o Cc� C ca J O "a ca Z C.3 V y c C . tC R _02 0 4.. GENERAL BUILDING NOTES/CHECKLIST- NOT LIMITED TO ITEMS BELOW POST ALL LOT NUMBERS, ADDRESS, AND PERMIT (COPY OK)..or no inspections INSPECTIONS: (Minimum) Excavation, Footing, Foundation, Frame; Insulation, Final. FOOTINGS: Continuous Full 2x4 Keyway Continuous strip footings for interior columns FOUNDATION: Rebar as required Anchor bolts or straps Damproofing Foundation drain - pipelstonelfabric filter/cover and outlet connection. FRAME: Fireblock - over girts/plates between floor joist Penetrations for plumbing, heat, eiec, etc. Walls at stair stringers. Windbrace corners and center bearing partitions. Size ridge to provide full bearing at rafter cuts. ` Hip and Valley rafters - watch bearing at walls. Ridge & Hip - Provide proper connections. Cathedral roof rafters provide proper connections and use "HurricaneClips° ,tie to plate. Stair stringers - watch cuts and heal support. Joist hangers - fully nailed w/ hanger nails. Sill plates 2-2X6 (1 PT) w/sill seal. Girls - solid brick or steel plate bearing at foundations '/ " air space at sides in foundation pockets. _ Lateral bracing at ends. Certified calculations. required for Beams/LVUs Trusses. Solid bearing support for Headers/Beams etc. " Check headroom clearances - stairways, under beams Attic'Access. (min. 22x30 w/3' headroom above). Crawl space access. (min. 18x24). Bath exhaust fans to have metal duct to exterior (not in soffit). Firecode S/R wood frame of "0" clearance fireplaces & stoves Window Schedule or Every Habitable Room Must Have: Natural light equal to 8% of floor area. r of required glazing shall be openable. Bedrooms required min. 20x24 egress window or door. (5, t Vent attic spaces - "proper vent", soffit and required ridge vents. . Firecode under stairs if used for storage FIREPLACES: Separate permit required. s Inspections at Footing - Smoke Chamber - Finish Smooth parging, clean joints, 8" solid @ combust.QJ DECKS: Lag to house, provide flashing. �9 Rails min. 36" high, Baluster max space 5" on center. Over 8' above grade, use 6x6 posts w/lateral bracing. Lag all posts and rails. _ "i Pier footings down 48", Conc. pad at stair base. �KiM FINISH: Handrails returned to wall/newall post. l� Guardrails required alongside open cellar stairs. j Exterior grading complete. (= Certificate or occupancy required prior to occupying structure. Temporary Stairs required for inspection. Re -inspection fee - $30.00 (Be Ready). Certificate of occupancy required prior to occupying structure. Ar STRUBLE... G NEERI/VG, LLC 603 Main Street Reading, MA 01867-3002 (781)942-3845 (781)942-7083 Fax Final Construction Control Affidavit 780 CMR - Seventh Edition Project Title: Buildinq 36 — Converse Renovations Project Number: SE No. 2009-125 Building Permit No.: Project Location: One High Street, North Andover, MA 01845 Name of Building: Building 36 Nature of Project: Add new partial mezzanine to existing framing at second floor and frame out new skylight in existing roof. In accordance with Section 116.0 Registered Architectural and Professional Engineering Services - Construction Control of the Massachusetts State Building Code, I, Jeffrey W. Struble, Registration No. 32141, being a Registered Professional Engineer, hereby certify that I have prepared or directly supervised the preparation, of all the design plans, computations and specifications concerning the structural system for the above named project and that such plans, computations and specifications meet the applicable provisions of 780 CMR Massachusetts State Building Code, all acceptable engineering practices and applicable laws and ordinances for the proposed use and occupancy. I further certify that I have performed the necessary professional services and I have been present on the construction site on a regular and periodic basis to determine that the structural work has proceeded in accordance with the Contract Documents submitted for the Building Permit. I am submitting, therefore, this final report as to the satisfactory completion and readiness of the project's structure for final occupancy. N OF mss JE p FFREY W.STRUBLE STRUCTURAL „'Qy v No 32141 W �O Signatu an to �FG�STEFt�`�u FQ0NAI. V SUBSCRIBED AND SWORN TO BEFORE ME THIS /DAY OF 2010 MY COMMISSION EXPIRES /62 7 4-21) /S NOTARY PUBLIC ARCHITECTURAL FINAL AFFIDAVIT To the Building Inspector: I certify that I, or my authorized representative, have inspected the work associated with Permit No. 193, issued on September 10, 2009 to Converse, Inc, for Renovations to Building 36, One High Street, North Andover, MA, (on the dates given below during construction) and that to the best of my knowledge, information, and belief the work has been done in conformance* with the permit and plans approved by the Building Department and with the provisions of the Massachusetts State Building Code and all other pertinent laws and ordinances. (* Subject to completion of all final punch list Items) Inspection Dates: September 1, 2009 — January 5, 2010 Carolyn Hendrie - 4823 Architect - Mass. Reg. No. Bargmann Hendrie +Archetype, Inc. Company 300 A Street, Boston, MA 02210 Address 617-350-0450 Phone Then personally appeared the above-named Carolyn Hendrie and made the oath that the above statement made by him/her is true. Before me, k", G` 0/ My Commission Expires q4�A 2 20 1 D P. 12904_Converse_36RenolcadminO ffidavitsl ARCHAFFI_final-010510. DOC MASSACHUSETTS - 780 CMR 112 CONSTRUCTION CONTROL FINAL AFFIDAVIT MECHANICAL & FIRE PROTECTION To the Inspector of Buildings, Re: Converse Renovation Project I certify that I have observed the work associated with permit no. 193 for One High Street, North Andover, Massachusetts 01845 To the best of my knowledge, information and belief, the work is complete and in conformance with the approved plans and the provisions of the Commonwealth of Massachusetts State Building Code and all other pertinent laws and ordinances. A b C. FMq� ENGINEER —MASS. REG. NO. a ABBE E. Hyl. nc WND m Sebesta Blomberg & Associates fA�lICAL + COMPANY 343 TEP�° 150 Presidential Way, Suite 330, Woburn, MA 01801 \svo AI ADDRESS 781-721-7220 PHONE .� !�. ►. v (w20 0 Then personally appeared the above-named i"S/�5 `' C 1 a Ile n and made oath that the above statement is true. Before me, My Co mission expires: SEBESTA BLOMBERG MASSACHUSETTS - 780 CMR 112 CONSTRUCTION CONTROL FINAL AFFIDAVIT ELECTRICAL To the Inspector of Buildings, Re: Converse Renovation Project I certify that I have observed the work associated with permit no. 193 for One High Street, North Andover, Massachusetts 01845 To the best of my knowledge, information and belief, the work is complete and in conformance with the approved plans and the provisions of the Commonwealth of Massachusetts State Building Code and all other pertinent laws and ordinances. .A b4,JV,') WIV L �'o >� ,� 4-7773 _ ENGINEER —MASS. REG. NO. Sebesta Blomberg & Associates COMPANY 150 Presidential Way, Suite 330, Woburn, MA 01801 ADDRESS 781-721-7220 PHONE 0 20W Then personally appeared the above-named - and made oath that the above statement is true. Before me, Y - My CIMIssion expires: 20 / m m m m N m C) y d C � SCOD CM) d 'C O Z y 0.O C. O CL y a� v� CD CDCL c o Cr c =r� m cD CD o 00 00 � C. CD CO) CD CLO CO) CO CD I 5 v CO) O O CD C CD z r cn V J n O cn m �l I 65 � I=MC90 -*30 z s � toto a� Q• y O gord� ~• ?a a o T • ..« = m . y O� o CD o S' 0mm m a > > yco • < d o y n W O m \�� d �C-34om O A m m y 1 CCOL • : � IL. N .� 0 01 y . � C. CLU: cr _� g 2 a C CCCDCg C/1 I WQ' 1�1 �► CES o Z y moo: CD .••� ^D �Il "�m c� v mx cn s.100 m d fa M ate. No c o cn oT T co M z nzj to cn x O � 7d 7d )mq 0 9 No. Date �� "1,-2 �aRTM TOWN OF NORTH ANDOVER 41 � 9 Certificate of Occupancy $ SSA Building/Frame Permit Fee $ s�CHU Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Alf-, Check # '7 -Pf ---Building Inspector v CERTIFICATE OF USE &OCCUPANCY Town of (North Andover Building Permit Number /' Date THE BUILDING LOCATED ON THIS CERTIFIES THAT V- V MAY BE OCCUPIED AS O i C e- `� �`e IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. CERTIFICATE ISSUED TO '= ADDRESS S419 17 Ik� 'S CHUSBuilding Inspector 0 4 C O O Z 0 m 0 m O W O. ca CD to n* O CA C O a CO) m u Od cr -i y W n C', m co d C LTJ N -1 ._► � et y T ^. a- S m O OC. O 4 CO) CA �mm0 m a ©' CD -4 CD O y C9 ;A • m :� eta � CL �.�% 7 o?a; CD ` :O CL CA dIV CL �o W 5 a SCD:to CA H 1 � : 0) y �r Ab CO C: o co o CD ..: C: CD. D =y u CD cu : 0 oma: c� m "AA CL Z c C=3 =CD :A C/) (n X OX,O ~ °� o�c A c w cn -n �^ a n cp H rA n Z y CCD O 'v _ _ c Cl) C. CM m ^�M� < 21= v cD m Z CD C/) M CD 7u c E5 CD CD m G w oo 2 C� CD C. v y y C O y10 O CD Cl) CD o C CD C O O Z 0 m 0 m O W O. ca CD to n* O CA C O a CO) m u Od cr -i y W n C', m co d C LTJ N -1 ._► � et y T ^. a- S m O OC. O 4 CO) CA �mm0 m a ©' CD -4 CD O y C9 ;A • m :� eta � CL �.�% 7 o?a; CD ` :O CL CA dIV CL �o W 5 a SCD:to CA H 1 � : 0) y �r Ab CO C: o co o CD ..: C: CD. D =y u CD cu : 0 oma: c� m "AA CL Z c C=3 =CD :A C/) (n X OX,O ~ °� o�c A w � w cn -n �^ a n cp C O O Z 0 m 0 m O W O. ca CD to n* O CA C O a CO) m u Od cr -i y W n C', m co d C LTJ N -1 ._► � et y T ^. a- S m O OC. O 4 CO) CA �mm0 m a ©' CD -4 CD O y C9 ;A • m :� eta � CL �.�% 7 o?a; CD ` :O CL CA dIV CL �o W 5 a SCD:to CA H 1 � : 0) y �r Ab CO C: o co o CD ..: C: CD. D =y u CD cu : 0 oma: c� m "AA CL Z c C=3 =CD :A C/) (n X OX,O ~ °� o�c Cr1 w � ?7 n 'JJ 'rf w x GL cn -n �^ a n cp rA z on BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR NUmt)ji: CS 089712 Birthdate 1=lf2611961 Expires' 11/26/2007 Restritfed OQ � r'� STEVEN J LOEPU - k 15 RICKER CIRCLE-'.7-.,-- So IRCLE ".':.--SO HAMILTON, MA -'01982 Tr. no: 89712 commissioner i q Location No. / Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ /l Building/Frame Permit Fee $ lz,� GU Foundation Permit Fee $ Other Permit Fee TOTAL Check #�/ .J 17642 $ Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAI RENOVATI, OR DEMOLISH A ONE OR TWO FAMILY DWELLING 3 f6:... BUILDING PERMIT NUMBER: / DATE ISSUED: SIGNATURE:eg 7" Building Commissioner/I for of Buildings Date SECTION 1- SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map and Parcel Number: Map Number Parcel Number 1.3 Zoning Information: Zoning DisUid Proposed Use 1.4 Property Dimensions: Lot Area (sf) Frontage ft 1.6 BUILDING SETBACKS ft Front Yard Side Yard Rear Yard Required Provide ReqWred Provided Reqdired Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Infomatioa: Public 0 Private 0 Zone Outside Flood Zone ❑ 1.8 Sewerage Disposal System: Municipal ❑ On Site Disposal System ❑ SECTION 2 - PROPERTY OWNERSHIP/AUTHORIZED AGENT histuric District 2.1 Inr of Record N e (Print) Address for Service: gnature Telephone 2.2 Owner of Record: Name Print Address for Service: 1 Signature Telephone SECTION 3 - CONSTRUCTION SERVICES 3.1 Licensed Construction Supervisor: Licensed Construction Supervisor: Address Signature Telephone Not Applicable ❑ r License Number Expiration Date 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name If Registration Number Address 16 Expiration Date Signature Telephone T M Z O v n m O z M- 90 O ic r v M r r ^Z V♦ v SECTION 4 - WORKERS COMPENSATION (M.G.L. C 152 § 25c(6) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yes .......0 No ....... 0 SECTION 5 Description of Proposed Work check all applicable) New Construction ❑ Existing Building ❑ Repair(s) ❑ Alterations(s) . ❑ Addition ❑ /: Ala , � s % .�'i,-i- Accessory Bldg. ❑ Demolition ❑ Other ❑ Specify 1 t "i A Brief Description of Proposed Work: c -A 0 -. t `1 2-604. I SF,CTION 6 - RSTIMATI2il C0NCTR1TVT1nN CncTc 1 Item Estimated Cost (Dollar) to be Com leted by permit applicant OFFICIAL USE ONLY 1. Building (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of Construction 3 Plumbing Building Permit fee (a) X (b) 4 Mechanical HVAC 5 Fire Protection 6 Total 1+2+3+4+5 Check Number Or.O,iiUIN IaUWive,KAU1riUKIZAILU1N JUBEUUMPL>TEDWHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, S C-+aTy —t^, g�<<'" , as Owner/Authorized Agent of subject property Hereby authorize � dei, V 'JC- + to act on My beh lf, in all matters rel ive.,to work authorized by this building permit application. • C' e of Owner Date SECTION 7b OWNER/AUTHORIZED AGENT DECLARATION 1, as Owner/Authorized Agent of subject property Hereby declare that the statements and information on the foregoing application are tnie and accurate, to the best of my knowledge and belief J Print Name Signature of Owner/Agent Date NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TINIBERS iST 2 ND 3 RD SPAN DIMENSIONS OF SILLS DIMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING X MATERIAL OF CHIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE SEP -`08-2004 WED 02:55 PM YALE PROPERTIES FAX NO. 19784546394. P. 02 September 8, 2004 Michael McGuire Building Inspector Town of North Andover 27 Charles Street North Andover, MA 01845 Re: Schneider Electric, One f'liigh Street, North Andover North Andover Mills- Dear ills Dear Mr. McGuire: Schneider Electric will be hosting their annual company outing at the North Andover Mills on Sunday, September 19, 2004. They have requested permission from Yale Properties to erect a tent which will be installed and removed on the day of the event. Yale Properties has granted permission, provided that Dig Safe has been contacted and that the area is restored to its original condition. Do not hesitate to contact me with any questions. Sincerely, YALE PROPERTIES USA Lauren M. Wallace Assistant Property Manager r Cross point, 900 Chelmsford Strcct, Lowcll, Massachusetts 01851 Tel.: (978) 453-6666 Fax: (978) 454-6394 SEP -08-2004 16:42 19784546394 95% P.02 CO) m m m CO) m CO) m v y d C � O O CO) C) CD C2 Z H C. O �� C CL y CD o p d� O Cr CD 0 C CP H• n0 CO) C C2 CO) O 'oCD Z O �CD CD 0 if VqJ� o� zz cn c O O Z o. 2r m m O EEc F G2 m m C O 0 a y h C Ma o m = dyCm y y elm FL"06 M oo �i y .* C =r- Mq w� 9L y ;i ^0 a rM Ir comm o CO) 10 -a IE m o. m a = y: �o = O O I mr� m � o_m oa^'= m m y� � Oa O N d y : _g: Q i IE CD: y R CO) _ O� m C41 'O m a� Ir o G, CA c ?: =m: 010- _� r 0 CLM _ _ cn, Cf)0 z zo w$ C o m �. '� Qa. '° cn y 7d q& z O omi No 1 U 5 Date......r�l...s.r...... TOWN OF NORTH ANDOVER PERMIT FOR WIRING -,; This certifies that .....`.� ) r'......."..f;.�........ �.....""`.:...... has permission to perform.............::. ............. wiring in the building of_... ...........:: ....................... / n -.................................. . North Andover, Mass. 1? �:.5... y... �� :?: �, ................................................................ �P.. 1 ee ., Lic. Nor � . LELECTRICAL INSPECTOR i a WHITE: Applicant CANARY: Building Dept. PINK: Treasurer 1 -LP Office Use Only ;. �., • RIC 0uaiuivuturid ll of MUBBLIC11115CHU Pooh No. I ! 1)(IlCltl t `� p 1 Ill U( j1UbIIC }�11(tl� Occupancy b Foo Checly dw/ BOARD OF FIRE PREVENTION REGULATIONS 527 CMA 12:00 19190 (loove blank) APPLICATION d ( ON FfORPERMIT TO PERFORM ELECTRICAL WORK All to bd p anco with Ileo Massacllusults Eluclrlcal Coda, 527 CMR.00 (PLEASE PnINT IN INK Oil TYP(= ALL INfO MATION) Data City r Tow of ,/t/mss To 1110 Ins �uclor of Wlrus: Tho udursignod uppilos for o porinll to porlorn► 1110 oloclrlcal work Joscribod bolow, Location (Strout 6 Numbor) Ownor or Tunant ' Ownor's Addruss la this pormlt In conjunction with n bulldlnpornllt: Yus� No ❑ (Chock Appropriato Oo Purpose of Building Utility Authorization No. Existing Survlcu Am61s Vulls Ovurhuad U Undsjrnd ❑ No, of Mu101* 4 Now Sorvlcu Amps _/ Volts Ovurhoud ❑ Undgrnd ❑ No, of Maim Numbor of Foodors and Afnpaclty Locallon and Nuluro of Proposod Eloctricut Work No, of Llphling outlets No, of Llat'nng Flr/utes No. of neceplacle Oullala No. of Switch Outlets No, of flanges .s No. of Disposals i a No. of Dishwasher* No, of Dryefa No. of Water Healers No, 01 Not Jlrbc `Z:f9'" Swimming Pool Aix" In- umd. ❑ umd. ❑ No. of Oil nurnare No, of Oas nurnera z5).- I No, of Air Cond. Total lune t" No, of Ilcnslortrwri"ulul KVA O+neralore KVA No. of En'aro*ncy UghUng Ilullety Unds FIf1C ALAnms No. of Zones No. of Dalacllon and In111a11ng Devlcee P aSr/. No.o1 1141411 Total Total ^- I un4ps lime KW No, of Sounding Devices No, of Sell Conjoined •� Space/Urea Ffealtng DslactIONSounding Device* treating Devices KW1• Local Municipal QOlhar ,'V �, Connscllun KNo. Lof No, of Low Voltage $IUns Ballasts IfV VV141t,� No. Hydro Message Ibbs —'' I No. of Motor*} Total HP OTIfEn: INSUIIANCE COVEr1AU1:: Pursuant to II'e roqulrements or Massrchusulls grnural Laws I Ilave a cutrenl Liability Ineurrnce Pollcy Including Comp sled plwrallone Covurallr or Its subalunllhl etlulvelsnl. YES� Choc auomlltad valid ptuol uI sun's to Ma 011lcu. YES NO U 11 you have chuckud YES, please (nulchls Iha 1 cwO r Oa b 1 chuckU'p the a rp oprluu box. NO u? U Y INSUnANCC UOND O OTHER 0 (Pious* Specify) P,..,p Estimated Vslw 1 a It�alWork S °+��� dullun Oalu) Work to Start 1� �:E Inspection Date noquesled: Ilough Signed undur 11, nalllaa of perlury: 1lyL J! FIfIM NAME Llcar'see LIC. NO. Slonrlure A UC. NO. ,�► ��—/ r Bus. Tul. No. All. Jul. No. OWNEWS INSUnANCE WAIV[n: I am aware that the Licensee doom no It's It's Inauronce covarape or 111 wbstuntlal crlulvalenl a ra q4& 1"Id by M&NsCheck husuns Ocnarsl Laws. and that my rlonclur0 un lids 114&111111 appllcullon waive• Ihu fullulrarnsr'1. Own+r Agcnl (Placa+ Check one) Tolophono No. PCr11dIT FCC it,' (5.gn.'luru 4&l Uwt4w 4&t A1.1,1111) " //�ldc.3� Location Yet � No. �� Date 4.� Check # TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee $ Other Permit Fee $ TOTAL $ /CSO 175-49 Ilk la / Building Inspector The Commonwealth of Massachusetts Not Applicable Q icensed Construction Supervisor: State Board of Building Regulations and Name (Print) TOWN OF NORTH ANDOVER Standards ON r-- l+ S A04V 1%l BUILDING DEPARTMENT Massachusetts State Building code 2.2 Airthorized Agent: � Registration Number 780 CMR Address TOM PAVM942— APPLICATION TO CONSTRUCT REPAIR, RENOVATE, CHANGE THE USE OF OCCUPANCY OF, OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING Building Permit Number: /_ Date Issued: 4 Signature: Building Commissioner/Inspector of Buildings Date 1.1 Property Address: 1.2 Assessors Map and Parcel Number. Map Number Parcel Number 1..3 Zoning Information: 1.4 Property Dimensions: Lot Area (sq) Frontage(ft) Zoning District _ProposedUse 1.6 B- ding Setback ft. Front Yard Side Yard Rear Yard Required I Provided Required I Provides Required Provided 107 Water Supply 9M.G.L.C.40.4 54 1.5. Flood Zone Information: 1.8 Sewer a Disposal System: Public a Private b Zone 1� Outside Flood Zone Q Municipal On Site Disposal System 2.1 Owner of Record Not Applicable Q icensed Construction Supervisor: N cNm cr Name (Print) Address: Signator Telephone q 32—Z37-2 ON r-- l+ S A04V 1%l Signa re Telephone rrAA 2.2 Airthorized Agent: � Registration Number Name (Print Address TOM PAVM942— C� T-- SignatureTelephone SECTION 3 CONSTRUCTION SERVICES FOR PROJECTS LESS THAN 35.000 CUBIC FEET OF ENCLOSED SPACE 3.1 Licensed Construction Supervisor: Not Applicable Q icensed Construction Supervisor: License Number 061717, Address Expiration Date Signator Telephone q 32—Z37-2 3.2 Registered Home Improvernelit Contractor: Not Applicable Q Company Name Registration Number Address a� Expiration Date ASt nature Telephone Revised 1997 JMC SECTION 6 -DESCRIPTION OF PROPOSED WORK (check all applicable) New Construction Q Existing Building Repairs Q Alterations Addition Q Accessory Bldg- Q 1 Demolition Q Other Q Specify Brief Description of Proposed : lr o r Sty 0 d LAIe ni R. NCw my behalf, in all matters relative to work authorized by this building permit application. 2A 2B 2C Q 0 Q E Educational Q Z Z2 L o, -- SC>� q,'�rae.Lce�b. �(Cc2��.iTS� /✓K,'r^��vv� /�}-,l�--L JC,l.11V1V / — VOl: Vl\V Vi A1�L Vvl.vlaw�iivi. USE GROUP Check as applicable) BUILDING AREA Existing if applicable) CONSTRUCTION TYPE A Assembly A-1 A-4 A-2 A-5 A-3 IA IB Q 0 B Business Total Height ft my behalf, in all matters relative to work authorized by this building permit application. 2A 2B 2C Q 0 Q E Educational Q F Facto F-1 F-2 H High Hazard Q 3A 3B 4 Q 0 0 I Institutional Q I-1 I-2 I-3 M Mercantile Cl R Residential 0 R-1 R-2 R-3 5A 5B 0 Q S Storage Q S-1 S-2 U utility Q Specify: M Mixed Use Q Specify: S S ecial Q Specify: COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS. ADDITIONS AND/OR CHANGE IN USE Existing Use Group: Existing Hazard Index 780 CMR 34 Proposed Use Group: Proposed Hazard Index 780 CMR 34 SECTION 8 - Building Height and Area BUILDING AREA Existing if applicable) Proposed Number of Floors or stories include basement levels SECTION 10a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN Floor Area per Floor (s Total Area s I, _ , As Owner of subject property Total Height ft my behalf, in all matters relative to work authorized by this building permit application. SECTION 9 - STRUCTURAL PEER REVIEW 780 CMR 110.11 Independent Structural Engineering Structural Peer Review Required Yes Q No Q SECTION 10a - OWNER AUTHORIZATION - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, _ , As Owner of subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date r revised bldg form/state JMC fed le -, 0-0 S�'{2by(Zc� t1�3,•�� SECTION 4 WORKERS' COMPENSATION INSURANCE AFFIDAVIT 1M.G.L. c. 152 § 25C(6)1 Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached Yes No SECTION 5 - PROFFESSIONAL DESIGN AND CONSTRUCTION SERVICES -FOR BUILDING AND STRUCTURES SUBJECT TO CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116 CONTAINING MORE THAN 35,000 C.F.OF ENCLOSED SPACE 5.1 Registered Architect: W. t No Applicable Name (Registrant): L11,q-PA s M Address --tExpiration Registration Number Signature v146Veiephon, Date 5.2 Registered Professional Engineer(s) Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name): Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date 53 Genera! Contractor Not Applicable 1 Company Name: AA%pm Y L Responsible in Charge of Construction Address t" ,l , 6t O Z Si ature (" Telephone lob - OWNER/AUTHORIZED AGENT DECLARATION 1 GJ -i�i'll -1-, Lorefy , as Owner/Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. Print N Sip -nature of Owner/Agents Date I J 0r?f11 ,r w, , , 0crrT1k A A I�Cn rnxTerror rrrrinV rnc'rc JLt.11V1� l i - Item Estimated Cost (Dollars) to be completed b permit applicant Official Use Only 1. Building (a) Building Permit Fee Multiplier 2. Electrical © (b) Estimated Total Cost of Construction from 6 3. Plumbing Building Permit Fee (a)x(b) / 4. Mechanical HVAC 5. Fire Protection 6. Total = 1+2+3+4+5 Check Number /y UJ d, cn Cf) Z D < m 0 0 < 0 0 LU m X UJ F- w m 0 z UJ cr, w 0 ul w CK U) cr < .3: m Li- w z ao- co 3: 00 1-- < < z < < a_ U) 0< Q Z 1: cn r < C? C ri z A 0 0 L) 0 Of 04 X 0QOi< "ZT �j � co __j I >- CL > uj z (D w Z z 0 0 Z m f--0 ty x z UJ 0 F- Ui + -i C) Cl) LU U) I— -T- U) -D > C) Lij :z C) F- F- 0 z Q? LL z ui LL 0 Z CO < LIJ < - mdM� 2 CO (n < m U- z z 0 0 L) X 0 C) Lu (D < 0 Z C? 1 0 < :E :e- �-1 0 U) 0 Z UJ < 0 -1 R LU UJ LU 0 Uj o 1 0 Lu Lj F- Lu LL(0 w -i Lij < :z Lij LUL-- C=�:E :D win C() Cl la- Co CL 3: m < C/) > cc 0 0 C) LU obw�-O-�<OF 0 r I-- LLI LLJ O� CC A a- 0 < CL Cf) co I-- < z (1) 0 LL M z C-4 04 W c)o < u U- J V �JO018800 M3N CY) . . . . . . . . . . J 3NI� MOM �O iltNil IL t December 2, 2004 Michael McGuire Building Inspector Town of North Andover 27 Charles Street North Andover, MA 01845 Re: Schneider Electric, One High Street, North Andover North Andover Mills Dear Mr. McGuire: We have reviewed the proposed construction documents for the new corridor and partition installation in Building 36, One High Street, in the North Andover Mills. for our tenant, Schneider Electric, and approved the following construction documents: Burt Hill Kosar Rittelmann Associates, Architects, Drawings ASK -2 dated October 21, 2004. Attached please find three (3) complete sets of plans along with affidavits from all necessary architects and engineers involved. If you should have any questions in do not hesitate to contact my office at 978-453-6666. We would like to thank you in advance for your time in reviewing these documents as quickly as possible in order that we may commence construction and realize critical time elements. Sincerely, IJ amE. Les I, RPA DI c or of Operations cc: Thomas A. Palmer, Schneider Electric (w/o enclosures) Cross Point, 900 Chelmsford Street, Lowell, Massachusetts 01851 Tel.: (978) 453-6666 Fax: (978) 454-6394 FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. APPLICANT FILLS OUT THIS SECTION Tovh p,�cvn� APPLICANT YAu� Prco�nf S PHON q'18 PA(,Z_ - JS13 LOCATION: Assessors Map Number PARCEL SUBDIVISION LOT (S) STREET&Nf-- �k[Glk G1TLrz;B'r ST. NUMBER OFFICIAL USE ONL RECOMMENDATIONS OF TOWN AGENTS: CONSERVATION ADMINISTRATOR DATE APPROVED DATE REJECTED COMMENTS TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD INSPECTOR -HEALTH DATE APPROVED , DATE REJECTED SEPTIC INSPECTOR -HEALTH DATE APPROVED DATE REJECTED COMMENTS PUBLIC WORKS - SEWERIWATER CONNECTIONS FIRE DEPARTMEN' RECEIVED BY BUILWIMP Revised 9197 jm DATE DEC.22'2004 13:03 6177739920 TONRY #1949 P.001/002 "1a% www5fff t I,) AGORI , CERTIFICATE MJF LIABILITY 12/22/200 P 017)773+9200 (617)773-9920 THIS CERTIFICATE E OF INFORMATION Albert J. Tanry 8 Co. , Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE OCE$ NOT AMEND, EXPEND OR 300 Congress Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Quincy, MA 02169 INSURERS AFFORDING COVERAGE MAIC >I! ces, Jnc. P.O. sox 1154 Easton, MA 02334 THE FSO ANY REQUIREMENT; MAY PERTAIN, POLICIES. S OF INSURANCE LISTED BELOW BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING TERM OR CONDITION OF ANY CONTRACT OR OCHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH AGGREGATE LIMITS SHOWN MAY HAVE SEEN REDUCED BY PAID CLAIMS. IrwTYPE OF 1N:IURANOB POLICY NUMBER POY D I: M Mul I?A IIIMID LIMITS 0"ERALLIABILITY GL8E4831 04/02/2004 04/02/2045 EACH OCCURRENCE $ 1.0001OOt 7C OOMMEROIAI 6 MRA% UA91LnTY RU-$ loo ,001 CLAW MADE O OCCUR MED Ems' (" we Pte) 9 � 3001 A p PERSONAL & ADV INJMY $ 1,0001001 GENERAL AGGREGATE 9 2,000,00 OENIAGGREGATE LIMrrAPPLIESFE'fC PRODUM-COW10PAGG S 2IM01001 POLICYX JECi' LOC AVTOWMLE LIABILITY ANY AUTO BMA9015304 03/29/2004 5/29%2005 COM9wED SINGLE LIMrr (� a 11000.001 A ALL OWNED AUTOS �( SCHEDULED AUTOS X HIRED AUTOS X NON4 MeO ALM 110DBLY INJURY �—• RI Pm" ffi BODILY INJURY a (Pwftdmm ) ti�)L7AnA0.41E S "RAN LIABILITY AUTO ONLY -EA ACCIDENT 3 ANY AUTO OTHER THAN FA AGC $ AUTO ONLY: AGO I EICMUNIBRELLA LIABILITY BE130208 12/16/2004 12/16/ZOOS EACH OCCURRENCE s � ,000,001 X OCOLM CLAIMS MADE AGGRRGATE 3 11000, 001 A s DEDUCTIPLE 5 RETENTION ! a B MrORK@RBPBNSATIONAND EMPLOYERS' uABILr1Y OyFF�eIDaR£ROPMIRE�MSERF.XCLUDB EGtmvE WOOS 496101x004 04/02/2004 04/02/ZOOS TOR tmn s B? EL EACH ACCIDENT E Soo, 40, E.L. DISEASE - EA EMPLOYEE 9 500 OO, SPECIAL PROVISIONS bm" R.L. DftME -FOUCY LIMIT S 500.001 A =uIpment FLoater CISE4831 04/02/2004 04/02/2005 Equipnt Scheduled me (per schedule) p4p7m or WINNOW Lgg) 9XCLUSKINS ADM B 9 Project; Schneider Automtion cation: North Andover, MA dditional Insured: Structured Solutions, Inc. Structured Solutions, Inc. Ann: Steve Loeper 67 Faster Street Peabody , MA 01960 2612001=) FAX: $WOULD ANY OF THE ABOVE DE9DRIBED POLK= N CANCEL= MORE THE E)MRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO (NAIL –10_ DAYS WRIrMN NOTICE TO TWE CERrStATE HOLDER NAMED TO THE LEFT, BUT PAILURS TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR UACIUTY OP ANY MM UPON IMS INSVRSR, TM AGENn OR REQ &MOATIYEB. 12-21-2004 05:44 STRUCTURED SOLUTIONS 9788186370 PAGE:1 198 Location No. Date �► `� �Q �` NORTH TOWN OF NORTH ANDOVER 9 ° ;; Certificate of Occupancy $ 9 Buildin /Frame Permit Fee $ s�cMust Foundation Permit Fee $ Other Permit Fee $ TOTAL $ Check # 1176 40 17342 Building Inspector TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING ,- Y E e 0 MEN '� 2 01,0211 ..� - ~'"`5, s K SY "r This Section for Official Use Onl 6 BUILDING PERMIT NUMBER: DATE ISSUED: / SIGNATURE: Ae 62A� Buildin Commissioner/I or of Buildings Date E 1.1 , Property Address: 1.2 Assessors Map and Parcel Number: Map Number Parcel Number I.4 Property Dimensions: Lot. Area Frontage ft 1.3 Zoning Information: Zoning District Proposed Use 1.6 BUILDING SETBACKS (ft) Front Yard Side Yard Rear Yard Required Provide R ed Provided Re red Provided 1.7 Water Supply M.G.L.C.40. 54) 1.5. Flood Zone Information: Public ❑ Private ❑ Zone Outside Flood Zone ❑ 1.8 Sewerage Disposal System: Municipal On Site Disposal System ❑ ? ... �L r...�xi.,.x.. 75. 2.1 Owner o Record 4�.�I�(Print) Address for Service: Signature Telephone y�3-(I(I&� 2.2 Authorized Agent Name Print Address for Service: Signature Telephone 3.1Li `sod Construction Supervisor Not Applicable ❑ Address License Number % a00 Li nsed Construction Supervisor: i�9 , -3 73 Expiration Dat lgnature Telephone 3.2 Registered Home Improvement Contractor Not Applicable ❑ Company Name'. Registration Number Address Expiration Date Signature Telephone Ir Workers Compensation Insurance issuance of the building permit. Signed affidavit Attached Yea ... SEC ION 5 ~PROD. Uig CONSTRUCTIO e a �tza 5.1 Registered Architect: Name: Address Signature must be completed and No ....... ❑ with this application. Failure to provide this affidavit will result in the denial of the Telephone - 0 ALA A Not Applicable ❑ Company Name: Re' )onsible in Charge of Construction Area of Responsibility Registration Number Expiration Date ! Name: Address: Signature Total Not applicable ❑ Registration Number Expiration Date Name: Address Signature Telephone Area of Responsibility Registration Number Expiration Date ` Name A&�,�ress Signature Telephone Area of Responsibility Registration Number Expiration Date Name Address Signature Telephone - 0 ALA A Not Applicable ❑ Company Name: Re' )onsible in Charge of Construction �:`.4M., ivi'll's'75�M New Construction K Existing Building W Repairs) ❑ Alterations(s) F" Addition ❑ Accessory Bldg. ❑ Demolition ❑ A-1 ❑ A4 ❑ Other ❑ Specify Brief Description of Proposed Work: ❑ to Yl- v (. [ Ol m 01 ❑ ❑ B Business D/ BUILDING AREA EXISTING if applicable) PROPOSED Number of Floors or Stories Include Basement levels o2 Floor Area per Floors O+C Total Areas ado Total Height (ft) /-A r Independent Structural Engineering Structural Peer Review Required Yes ❑ No ❑ SECTION 10a Owner Authorization - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, as Owner of the subject property Hereby authorize to act on My behalf, in all matters relative two work authorized by this building permit application Signature of Owner Date USE GROUP Check as applicable) CONSTRUCTION TYPE A Assembly ❑ A-1 ❑ A4 ❑ A-2 A-5 ❑ A-3 ❑ ❑ 1A 113 ❑ ❑ B Business D/ 2A 2B 2C 0 0 ❑ C Educational ❑ F Factory ❑ F-1 0 F-2 ❑ H High Hazard ❑ 3A 3B ❑ ❑ IInstitutional 0 I-1 ❑ 1-2 ❑ I-3 0 M Mercantile 0 4 ❑ R residential ❑ R-1 0 R-2 ❑ R-3 0 5A 5B ❑ 0 S Storage ❑ S-1 ❑ S-2 ❑ U Utility M Mixed Use S Special Use ❑ ❑ ❑ Specify: Specify: Specify: COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS, ADDITIONS AND OR CHANGE IN USE Existing Use Group: -;3u-5/%J6 .SS Existing Hazard Index 780 CMR 34: Proposed Use Group: �ntJ--� /t*JA--SS Proposed Hazard Index 780 CMR 34: BUILDING AREA EXISTING if applicable) PROPOSED Number of Floors or Stories Include Basement levels o2 Floor Area per Floors O+C Total Areas ado Total Height (ft) /-A r Independent Structural Engineering Structural Peer Review Required Yes ❑ No ❑ SECTION 10a Owner Authorization - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, as Owner of the subject property Hereby authorize to act on My behalf, in all matters relative two work authorized by this building permit application Signature of Owner Date „. . 117M I, as Owner/Authorized Agent Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury Print Name Signature of Owner/Agent Date pq*.kWA Item Estimated Cost (Dollars) to be Completed by permit applicant L Building _ (a) Building Permit Fee S UV Multiplier 2 Electrical -19(b) (b) Estimated Total Cost of Construction from (6) 3 Plumbing ! . A Building Permit fee (a) X (b) 4 Mechanical (HVAC) /v 5 Fire Protection 6 Total (1+2+3+4+5)%U Check Number ➢ S.➢, af�5 .�>�,;n /r;u ax )).,-h J �.- dt ,elc"[J v ➢t `."r��.�; 4 SS R,k{S:., LL{{ zir .. ' tr fl "Fa iAk'` h�..9.w e',�'a n t➢J} 1i�: .A y�.K'TS�;Y"k` );{Y-r(�i �C Y(S1 i x^ 7���'.'4� t �t�iT. }'. � 4i art..: l�.�. 'h.��s�'"�i )'Sy{.�X. �'t tK. 5�`t�t.:� Ji rro � '�, �f��: K. 5;���`,jA ^�V t'1�'� � .::�? i 5� t .l Y 7�' t➢ ➢ i<: �\A .7 .' r,k�`i� b ” tt.i �W�2➢ � S� . t/]`�'�3 z" Yk j tY-f�� �4"�.Y..'{,4 f i+',C' S.V�R'� H t1.: 5�{Lff_ 1'k �J iYi .fit If�.F �tyY��JtI� kE. �SC�Y F � . 'i{i '7 'i. � M' � �,�,,+., i'e'. i�. NO. OF STORIES SME BASEMENT OR SLAB SIZE OF FLOOR TIMBERS 1sr Z ND 3RD SPAN DEMENSIONS OF SILLS DEMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING x MATERIAL OF CHRvINEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE - r FORM - U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that allmecessary approval/ permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and or landowner from compliance with any applicable requirements. ...r..ws...aw.■ssrss.esass.■ss.w.s.own ssr■u■sw.w.swoo ......a.......ar..s... APPLICANT —5//W"i 6f 14tlf- HONE ASSESSORS MAP NUMBER LOT NUMBER SUBDIVISION LOT NUMBER 1 -/ STREET -- / G' S T STREET NUs a a m ON �v ....•.....• ■.• ■■ss.■a.s.■s...-...s..wss.ss.sSTREEw...-MBER ss.ssss.s ■■ OFFICIAL USE ONLY ...............a................-...ssawwa.ar.s*memo memo ■- was s.s..................Weal ........a RECOItD&NDATIONS OF TOWN AGENTS .•w.■ws.s■swwas.sswsw■..■■.s■s.....ss.■ss..ssw•■m..■as.■...■.....s..s......w... CONSERVATION ADNHNISTRATOR COIVIIVINNTS 1"OWN PLANNER COMMEN-IS FOOD INSPECTOR - HEALTH SEPTIC INSPECTOR - HEALTH COMMENTS PUBLIC WORDS - SEWER / DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED DATE APPROVED DATE f COMMENTS RECEIVED BY BUILDING INSPECTOR Tl A 1 T> __..._-. North Andover Building Department Tel: 978-688-9545 DEBRIS DISPOSAL FORM In accordance with the provision of MGL c 40 S 54, a condition of, Building Permit Number is that the debris resulting from this work shall be ,d disposed of in a properly licensed solid waste disposal facility as defined by MGL c11,S150A. The debris will be disposed of in: w s ion of Fa ility) Signature of Permit Applicant - S %7 d Y Date NOTE: Demolition permit from the Town of North Andover must be obtained for this project through the Office of the Building Inspector ey CERTr�lA% �� �11R_A`N E.. _. ARSu CERTIFICATE NUMBER H 03-001021429-01 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS MARSH USA INC. NO RIGHTS UPON THE CERTIFICATE HOLDER OTHER THAN THOSE PROVIDED IN THE DONNA FENTRESS POLICY. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE FAX (877) 855-7274 AFFORDED BY THE POLICIES DESCRIBED HEREIN. 500 W. MONROE STREET CHICAGO, IL 60661 COMPANIES AFFORDING COVERAGE COMPANY 17953-BASC -ALL - A NATIONAL UNION FIRE INS.CO. INSURED COMPANY SQUARE D COMPANY SCHNEIDER ELECTRIC HOLDINGS B AMERICAN HOME ASSURANCE CO (AIG) COMPANY ATTN: CONNIE PONCE 1415 S. ROSELLE ROAD C ROYAL INSURANCE CO. OF AMERICA PALATINE, IL 60067 COMPANY D INSURANCE CO OF THE STATE OF PA CCIYERAGE5 T)us c fic a edea 2 i reptac ar►y preV)0i� i sWe_d_ �tl I'llit ' 1y� .. ....._P ..�, ] THIS IS TO CERTIFY THAT POLICIES OF INSURANCE DESCRIBED HEREIN HAVE BEEN ISSUED TO THE INSURED NAMED HEREIN FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THE CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, CONDITIONS AND EXCLUSIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. CO LTR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE (MM/DD/YY) POLICY EXPIRATION DATE (MM/DD/YY) LIMITS A GENERAL LIABILITY RMGL 4805615 06/30/03 06/30/04 BODILY INJURY OCC X COMPREHENSIVE FORM BODILY INJURY AGG PROPERTY DAMAGE OCC X PREMISES/OPERATIONS UNDERGROUND EXPLOSION & COLLAPSE HAZARD PROPERTY DAMAGE AGG X PRODUCTS/COMPLETED OPER BI & PO COMBINED OCC S 5,000,000 BI & PD COMBINED AGG X CONTRACTUAL PERSONAL INJURY AGG X INDEPENDENT CONTRACTORS X BROAD FORM PROPERTY DAMAGE x PERSONAL INJURY $ A AUTOMOBILE LIABILITY RMCA 661-2215 AOS 06/30/03 06/30/04 BODILY INJURY $ A X ANYAUTO RMCA 661-2216 TX 06/30/03 06/30/04 (Per person) B ALL OWNED AUTOS (Private Pass) RMCA 661-2218 VA 06/30/03 06/30/04 BODILY INJURY $ B ALL OWNED AUTOS (Other than Private Passenger) RMCA 661-2217 MA 06/30/03 06/30/04 (Per accident) PROPERTY DAMAGE $ HIREDAUTOS NON-OWNED AUTOS BODILY INJURY & $ 2,000,000 PROPERTY DAMAGE GARAGE LIABILITY COMBINED EXCESS LIABILITY EACH OCCURRENCE $ AGGREGATE $ UMBRELLA FORM $ OTHER THAN UMBRELLA FORM A EMPLOYERS' LIABILITY RMWC 5211502 AIDS RMWC 5211505 DAS 06/30/03 06/30/03 06/30/04 06/30/04 X We srnru- oTH- R T _-'d'. EL EACH ACCIDENT $ 2,000,000 THE PROPRIETOR/ X INCL PARTNERS/EXECUTIVE EL DISEASE-POLICY LIMIT $ 2,000,000 EL DISEASE-EACH EMPLOYEE $ 2,000,000 OFFICERS ARE: EXCL OTHER C AUTOMOBILE & P2HA 021500 06/30/03 06/30/04 EACH OCCURRENCE 3,000,000 EMPLOYERS' LIABILITY EXCESS DESCRIPTION OF OPERATIONS/LOCATION SIVE HICLESISPEC IAL ITEMS RE: SCHNEIDER AUTOMATION, INC. AND ITS SUBSIDIARIES INCLUDING QUANTRONIX, INC. AND SCHNEIDER ELECTRIC ASSEMBLY & TEST. CERTFICATE4HOLOER ' k CANCELLATION ' SHOULD ANY OF THE POLICIES DESCRIBED HEREIN BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE INSURER AFFORDING COVERAGE WILL ENDEAVOR TO MAIL -In DAYS WRITTEN NOTICE TO THE TO WHOM IT MAY CONCERN CERTIFICATE HOLDER NAMED HEREIN, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER AFFORDING COVERAGE, ITS AGENTS OR REPRESENTATIVES, OR THE ISSUER OF THIS CERTIFICATE, MARSH USA INC.9 ♦ �„ay, �� ✓L BY: Christy N. Phoebus Y1_11.117111lr Issued B WEB_ USER aaa°a`•' ......�. .»,. «,. ....moi 71 MM2(3�i12)VALID AS OF 06/27/03 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations Boston, Mass. 02111 Workers' Compensation Insurance Affidavit Name Please Print Name: Location: City Phone # I am a homeowner performing all work myself. I am a sole proprietor and have no one working in any capacity I am an employer providing workers' compensation for my employees working on this job. C:mmnanv name- C / e f C- Insurance Co. M Af.5h OS /9- :I Jc- • Policy # /c/"I W C 16oz//.S69 lq o S Company name: Address Citi Phone #: insurance -C6. Policv # Failure to secure coverage as required under Section 25A or MGL 152 can lead to the imposition of criminal penalties of,a fine up to $1,500.00 and/or one years' imprisonment_as weU_as_civil..penaftiesin thefnrmnfa_STOP WORK_ORGER_and_a fine -of .($1D.0.00)_a day against.me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby E ...s:F......b..{Ln n...n...,nd nnnfl/fisc of nnrinni iho► thn infnrmniinn nrnviliwi ahnva is Mlla anlirnTPCt. Print name /q� / • Z-/ 7 7 Phone # lam% �'- l�%� %a o Official use only do not write in this area to be completed by city or town official' City or Town Permit/Licensing ❑ Building Dept ❑Check if immediate response is required ❑ Licensing Board ❑ Selectman's Office Contact person: Phone #: ❑ Health Department ❑ Other AFFIDAVIT FOR ARCHITECT AND ENGINEER THE COMMONWEALTH OF MASSACHUSETTS COMMONWEALTH OF MASSACHUSETTS ) SS: COUNTY OF ESSEX ) On this 31" day of March, A.D. 2004, before me, 6V_0�40 OM019 Linda S. Smiley, who, being duly sworn, deposes and says that she will review the preparation of Tenant Fit -Out Documents for the Second Floor of Building 36 at North Andover Mills, in North Andover, Massachusetts; and that she will review and/or provide for the proper checking of all the working drawings and shop drawings for construction; and all modifications to the existing structures will be designed for construction in accordance with applicable provisions of Chapter 1, Section 116, Massachusetts State Building Code, and that such plans conform to all the applicable provisions of the Massachusetts State Building Code, and that all the materials used in the construction will be selected by specification by her or her registered professional Designee in accordance with the Controlled Materials Procedure therein defined. �' No. 10080 NEWBURYPORT ` MASS. o �J LindaS. S iley N Of MPSSP Subscribed and sworn to before met ik a� day of A. D. c� Notary Public My commission expires on SCG o�Uv� It • �' r � �� "'i00I77/I720%'CCI/CpU�lIO�✓(�LCIOQpCf'CUJP.�6 y $OARD OF BUILDING REGULATIONS °` icense. CONSTRUCTION SUPERVISOR a #' I1 Number SCS 06!#193 M1 Birthdate '07/19/1854 Expires:107/19/2004 Tr. no: 112 Resfncted 00 �'� � SHAWN D LITTLE`r 15 BURNHAM ST HAVERHILL, MA 830 '' I n `.� : X11Administrator ' e June 2, 2004 Michael McGuire Building Inspector Town of North Andover 27 Charles Street North Andover, MA 01845 Re: Schneider Electric, One High Street, North Andover North Andover Mills Dear Mr. McGuire We have reviewed the proposed construction documents for the renovations to Building No. 36, One High Street, North Andover Mills Complex for our tenant, Schneider Electric, and approved the following construction documents — Burt Hill Kosar Rittelman Associates, Architects, Drawings A-200, A-300 and A-400 dated March 31, 2004. Attached please find three (3) complete sets of plans along with affidavits from all necessary architects and engineers involved. If you should have any questions in regard to these construction documents, please do not hesitate to contact my office at any time. We would like to thank you in advance for your time in reviewing these documents as quickly as possible in order that we may commence construction and realize critical time elements. USA Stephen K. Smith Senior Property Manager cc: James E. Lesko III, Regional Director of Operations, Yale Properties USA (w/o enclosures) Thomas A. Palmer, Schneider Electric (w/o enclosures) Cross Point, 900 Chelmsford Street, Lowell, Massachusetts 01851 Tel.: (978) 453-6666 Fax: (978) 454-6394 U) m m m y m C2 H C � d 'fl O CD n ZH o.O 0• r c C. = N! o C-) 00 CD CDCL C o cr ? �dCD CD o CD C CD W CD CO y CDD I � c CO) O 1CD Z o CD CD0 •C c -*, o d S H O CfA d0:10CL y y Cao 3 T C2 Z -PC y o. � a =a fA 'TI �Q..a o CD �OmH O y 0 O =r S > m O O m 0' O = O ZC•A .� � O N A W O- Itm R C ay = :,_� (iJ M� : cry o'� � o m O � M. 02 cr Cn eo O O O Z O � �,:� �� Z CA 7 H N M O us eW � //�nj CD y cn ca � � •C dam: O CD ? O d o 'AL ftftft . Lo w o 9*11. omq 0 0 d ° M a' O m p " Poo'X� O a- Com" n p EL O r- O n O O o' � r C O L Location No. � i o 1 Date TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ Foundation Permit Fee Other Permit Fee ti TOTAL Check #� 18026 H Building Inspector i The Commonwealth of Massachusetts 1.2 Assessors Map and Parcel Number. Yat.� PRo TIES State Board of Building Regulations and 1..3 Zoning Information: TOWN OF NORTH ANDOVER Standards Lot Area (sq) Frontage(R) BUILDING DEPARTMENT Massachusetts State Building code 2.2 Authorized Agent: Company Name 780 CMR Z32 bio Name (Print APPLICATION TO CONSTRUCT REPAIR, RENOVATE, CHANGE THE USE OF OCCUPANCY OF, OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TO FAMILY DWELLING W0 Building Permit Number: � Date Issued: OZ j Signature: / % 0 Building Comrnissiouetlnspecit din Date CFr�t7nN 1_ C1TC iNLY\DMATTf�N LI Propel : G 1.2 Assessors Map and Parcel Number. Yat.� PRo TIES Map Number 53 Parcel Number �- 1..3 Zoning Information: 1.4 Property Dimensions: Zoning District sed Use Lot Area (sq) Frontage(R) 1.6 Building Setback ft. Front Yard Side Yard Rear Yard Required Provided Required Provides Required Provided 107 Water Supply 9MG.L.C.40.4 . 54 1.5. Flood Zone Information: 1.8 Sewerage Disposal System: Public Private b �e n Outside Flood Zone 13 Municipal 0 On Site Disposal System 2.1 Owner of Record Not Applicable Q v Yat.� PRo TIES SL'IOI tL Name (Print) Address: Signature A^ oN !-tt s 1z Signature Telephone 2.2 Authorized Agent: Company Name Registration Number Z32 bio Name (Print Address SignatureAj Telephone Cvf^ nN 2 rnNamD.r — — nn--- • — —.—'..........,,.....,......-- ---- ..... — 1 3.1 Licensed Construction Supervisor: Not Applicable Q v Licensed Construction Supervisor: smyw . L4fAL License Number G� 08 1 �I2 Address 1G G Expiration Date 7 Signature A^ cell � Telephone 43 Z? - 3.2 Registered Home Improveme t Contractor: Not Applicable Q Company Name Registration Number Address Expiration Date Signature Telephone -1- 1771 J1V SECTION 6 - DESCRIPTION OF PROPOSED WORK check all applicable) New Construction Q 1 Existing Building Repairs Q Alterations Addition Q Accessory Bldg. E3 I Demolition Q 1 Other Q Specify Brief Description of Proposed : (N W 19 GO(kiNt ONItMSrM (2 B/MIXuv"S. w1112ncrU C vNS 2B 2C Q Q Q E Educational 10 SECTION 7 - USE GROUP AND CONSTRUCTION TYPE USE GROUP Check as applicable BUILDING AREA Existing if applicable) Proposed CONSTRUCTION TYPE A Assembly A-1 A4 A-2 A-5 A-3 IA 1B Q Q B Business W2A 2B 2C Q Q Q E Educational 10 F Facto Q F-1 F-2 H High Hazard Q 3A 3B Q Q I Institutional Q I-1 1-2 1-3 M Mercantile Q 4 Q R Residential R -I R-2 R-3 5A 5B Q Q S Storage Q S-1 S-2 U utility Q Specify: M Mixed Use 0 Specify: S _Special Q Specif COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS. ADDITIONS AND/OR CHANGE IN USE Existing Use Group: Existing Hazard Index 780 CMR 34 Proposed Use Group: -Proposed Hazard Index 780 CMR 34 SECTION 8 - Building Height and Area BUILDING AREA Existing if applicable) Proposed Number of Floors or stories include basement levels SECTION 10a -OWNER AUTHORIZATION -TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT Floor Area per Floor s Signature of Owner Date Total Area s Total Height ft SECTION 9 - STRUCTURAL PEER REVIEW 780 CMR 110.11 Independent Structural Engineering Structural Peer Review Required Yes Q r No Q SECTION 10a -OWNER AUTHORIZATION -TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, , As Owner of subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date revised bldg form/state JMC Seg ����d � � ����� w► SECTION 4 WORKERS' COMPENSATION INSURANCE AFFIDAVIT IM.G.L. c.152 § 25C(6)1 Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached Yes 13 No SECTION 5 - PROFFESSIONAL DESIGN AND CONSTRUCTION SERVICES- FOR BUILDING AND STRUCTURES SUBJECT TO CONSTRUCTION CONTROL PURSUANT TO 780 CMR 116 CONTAINING MORE THAN 35,000 C.F.OF ENCLOSED SPACE 5.1 Registered Architect: No Applicable Name (Registrant): L nty Address Registration Number Signature Telephone Expiration Date 5.2 Registered Professional Engineer(s) Name Area of Responsibility Address Registration Number Sijznature Telephone Expiration Date Name): Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date Name Area of Responsibility Address Registration Number Signature Telephone Expiration Date 5.3 General Contractor Not Applicable Q Company Name: ww Responsible in Charge of Construction .1 . WVK Address V • Z3 Si ature Z� Z ZZ. Telephone c,t✓11 rhe_ SECTION 1 O - OWNER/AUTHORIZED AGENT DECLARATION 1, cl iytlll J ' MAX I 'as Owner/Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of perjury. Print Signature`of Owner/Agent I Date SECTION 11 - ESTIMATED CONSTRUCTION COSTS Item Estimated Cost (Dollars) to be completed b permit applicant Official Use Only 1. Building 000 (a) Building Permit Fee Multiplier 2. Electrical d (b) Estimated Total Cost of Construction from 6 3. Plumbing 0 Building Permit Fee (a)x(b) YS L9 4. Mechanical HVAC V 5. Fire Protection 19 6. Total = 1+2+3+4+5 Check Number `••`• �U✓J.IJII?•7L{R7 +^^ kvAriI/?'7.762 Albert 3. Tonry # Co., Inc. 300 Congress Street Quincy, MA 02169 .r'tnr♦•.,cw..r-.v e.■f ....wvw.,.+n v.nrrw.•..• nom. ..r....r,...... ONLY Amt CMFM NO RIC HT3 UPON CERTIFICATE HOLDER. THIS CER'CMATE OM NOT AMEND, LX ENO OR ALTER THE COVERAGe AFFORDED BY THE POLICIES BEi.OW. INSURERS AFFORDING COVERAGE NAIL Al mom xtiom s erut t on servAces. XnC. P.O. Brno 1154 Easton, MAA 02134 1ar a Insurance covany +N ummul Associated ers Insurance a Is�u�e o: e COVERAGE' TM POUM AWREWREMOff MAY PWAK POWES. OF MMM WM ttsTW MLOW MWOZEN I== TO THE Hifi, uRW NAIMW AMA Mr01.)G1' WMATM NO TERRY! CMZ OONQRM MANY CONTRACTOR OTHM ANT 1M M RESPW TO WfpCH TM$ CaMrAlt MAY goes= OR M WURAN X AFFC MW 8Y THE PMMIM Mr.M MO MWON 18 WWWT TO ALL THE TERMS. IMCLMM ANU COWMON$ OF OWN AGORWATE UMiTS ON" MAY HAVE 986N RMX=V BY PAID CiAR+IS. TYPE OF l PJRAMOi POub'y lO R Ulm" A Basra uA9WW X aCamb am <al MWAL %"t17Y CLAW MOM FRI CCm CLSSE4331 04/02/2004 04/02/MS MROOC%xmmx a 1 000 004 ii MWRa 300,001 MM IV (Af'CI an offmo a 5,0* PaRiONAtAAWftAW ': 1,00020* GWAMM AOMMUTa i 2,000, 001 FaiAr{ RGt i g t rA s t poucY x Loa A= s Z 000 001 A AVIVIMMULIANIM AWAM Ail AMS �( 8CM1fai MAWOO x WMAUTM X NON -ow eo Nffos WA9025304 05/29/2004 05/29/2005 � UW a 1.000.001 .7'lidUFtY a {PYrDers�ti BODURMURY (Pat*~) OMRAN4YAMM" R4W AUTO �tUTBONtY.E1A4C�B►�I i T BA ACC i �Y Aft a A M lanexrnr X OCCUR C{AWMAN rferd+now a SHAM 12/16%2004 s 11000,001 s 000 001 .. ,. a i PR �Q1�PA NSRT%@CUTNd r „ �,a� ��'�avM' W powg* �oNa bmw 04/02/2004 04/02/2005I INC MLOACHAOCIOW ! ' t.i.ware-fAeMPL ra s 500,001 I.L. -POLICY LI11iIT t _ ... _. 500 001 A Lorw pme�tt FLoator CI8F.411; l r 2 004 04!02!2005 Sc Et u pment {per sthlle) cc: 3chnelder Automation ion: North Andover, MA ional Insarad: Structured Wntions, Inc. Structured Solutions, Inc. Attm Steve Loeper 57 Foster Street P"body , MA 01960 FAX., CA"MumemonTm OMAYM UA'M TMEREF, TME MSUI i0kMM VfiLL VOR TD MAL _10— DAYS wmreN loom 7p 7m eswrw Tw w"m It moo TO "m im BUT AMLWW 7O MAIL SIM WIM WKU WpOft NO OW","ON OR 4utMUrl OR ANY MMWON "au e,TMAtiUM 12-21-2004 05:44 STRUCTURED SOLUTIONS 9785185370 PgGE;1 OFFICE OF BUILDING INSPECTOR • ~r + TOWN OF NORTH ANDOVER CO� NSTRUCTION CONTROL, PROJECT NUMBER: PROJECT T1TL.E: S&AAI EI P.J�. Et rcGT9 I C- 9 P N I Sl oAl S PRCWECT LOCATION_! N* - k4 I N„ T NAME OP N'IUILQINd: �"-f." i�41►1 �', l C)�, E L, *.aTy' 1 C - NATURE OFPROJEOT cIPGR ,(��N4 N'S AaaI) i`� (N0YJ116N .,. IN ACCORDANCE WI ARTICLE ARTICLE 116 OF 11-e MASSACHUSETTS STATE ��� p� L1/`+t.+Da 5 l�/6 - TI�i4,T RgGISION NO /cam � ■ BEING A REGISTERED PROFESSIONAL ENGNEER/ARCHITECH HEREBY CERTIFY THAT f HAVE PREPARED OR DIRECTLY SWEWSEDi THE PREPARATION OF ALL DESIGN FLANS, COWPJt'A'TIONS AND SPECIFICATIONS CONCERNING ENTIRE PROJECT n ARCtMTECTURAL)d STRUCTURAL O MECHANICALr O FIRE PRO rEC IONS 0 ELIr'CTRNCAL OTHER ( PECIFY) FOR 7ME ABOVE k4kMW PWlW=AN0 THAT, TO TW BEST OF My MWLEGE, SUCH COMPUTATIONS AND SPECIFICATIONS MEET THE APRJCAKE PRk>'VISION OF TIS MAS$ACH, STATE RMLO C3 CODE. ALL ACCEP rABEE FNGINWINC3 PRATE M AND APPIJCAM E LAWS AND ORDINANCES FOR THE PROROSSD US6. ANO O=IpANCY. I FURTMER +CERTIFY THAT 1 SHAM PERFORM THE NOCESSNtY PROFESSIONAL SMrA= Amb 8 RPR68ENT ON THE CONBTRWCTION SITE ON A REMJIR AND P't600DIC BOS TO DETERMINE THAT THE WORIC IR PkOCMMNG IN ACCORDANCE WITH THE DOCUMWM APPROVED FOR THE BUWNG } REKNIT AND SMALL 8S RESPONOME FOR TF16 Pb6LOW1140 A$ SPECW#t b IN SEOTION 116-o am !. i�9ViANK ':Oj" � � tNl9 deetBn f.1011t;.� lllOjt Citi OI'�IEY MW by titer =*OC orIn aoeordWMWNlh rice "*waft ofdopAmwft uwsftmmwwusmng 2. RmvkwandappmWofftquftcajjuvI praaedmW for SB nm6xials■ 3, Be p at IntetvWs approprio* b the stems cgwrdbmcsm to l"m mis generally iamular WW PVWWW 00 pe d In a=m er *Oft with #w mia Wd Burgon domtm'hoax +antailft pi sl, if w�erjc is bang PURSUANT TO SECTION 116.2 .2 1 GKU L SUBMIT WEMY . A PROGRESS IMPORT 7`OGETHER WLTH PERTINENT COWAMM TO THE NORTH ANWVER BUILtXNG INSPECTOR. UPON COMPLETION OF THE WORK I SHALL SUBMIT A FINAL REPORT AS TO THE SATISFACTORY COMPLETION AND READINESS OF THE PROJECT FOR OCCUPANCY. 3� E 3 RIBED AND SWORM TO6EMAC-ME-THIS ,, PAY OF 20 0 a .. 01-30-2005 05:10 STRUCTURED 9788186370 MY COMMISSION EXPIRES h� PAGE:1 -- —� ---- �— -- ..r..n v. r. �. .. .V. .�..• VVV JIV JGVJ 1 •Vim Vi January 11, 2005 Michael McGuire Railding Inspector Town of North Andover 27 (harles Strer( North Andover, MA 01845 Re: 5ellarider Efectrie, lvarth Andover NUIls, one Ingh Street, North Andover Ticar Mr. McGuire: We are submitting tlic followinb restroom renovation/conibudil,(, dMuments pertaining to the 7"S Fluor of Building 36 on bahalf of nur tenant, Schneider Electric, for your approval: Burt HIR K inar Rittelmau Amociates, A chilmis, Drawings ASK -1, ASK -2 and ASK -3 dated ADYe1,11rr 15, 2004, Enclosed are three (3) complefa sets of plsuls alOng With affidavits from at) iiwr iary architects and cnewcrrs involved. If you have any qucsinm in in"j tv these documents, do not hesitate to contact me. Your prnmjj( a(tLntion to this matter is apprcciated. Sincerol)r, YA E MOPFAtT ►tt4 i F.Tr ,III, A D' r of Operations T?nrlosures cc: Thomas A. PWmcr, %hncidcr Ficctric (w/o enclosures) CM33 Point, 900 C idumfiml Stn:r.1, Uweu, mj%Wtritsetts 01 g., t "L'ol.: (978) 453-6666 Pax: (97R) 454-a i94 TOTAL P.01 02-07-2005 01:34 STRUCTURED SOLUTIONS 9788186370 PACE:1 AFFIDAVIT FOR ARCHITECT AND ENGINEER THE COMMONWEALTH OF MASSACHUSETTS COMMONWEALTH OF MASSACHUSETTS ) SS: COUNTY OF ESSEX ) On this 7th day of February, A.D. 2005, before me, Linda S. Smiley, who, being duly sworn, deposes and says that she will review the preparation of construction documents for Renovation of Toilet Rooms on the second floor of Building No. 36, North Andover Mills, in North Andover, Massachusetts; and that she will review and/or provide for the proper checking of all the working drawings and shop drawings for construction; and all modifications to the existing structures will be designed for construction in accordance with applicable provisions of Chapter 1, Section 116, Massachusetts State Building Code, and that such plans conform to all the applicable provisions of the Massachusetts State Building Code, and that all the materials used in the construction will be selected by specification by her or her registered professional Designee in RED gjPq S. Fc accordance with the Controlled Materials Procedure therein Qw \aoa S�,� F� No. 10080 defined. o NEWSURYPORT MASS. , D � "�,L G� '��Af OF MPSgP Linda S. Vniley yah Subscribed and sworn to before me this / day of 00 Notary Public ` My commission expires on FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. """"""""APPLICANT FILLS OUT THIS SECTION ***+*** APPLICANT YArGJ�, t- c J bM FAL M E PHONE 9?8-q-7S -3S 73 LOCATION: Assessor's Map Number PARCEL SUBDIVISION LOT (S) STREET_ g3,NfG ST. NUMBER OFFICIAL USE ONL RECOMMENDATIONS OF TOWN AGENTS: CONSERVATION ADMINISTRATOR DATE APPROVED DATE REJECTED COMMENTS TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD INSPECTOR -HEALTH DATE APPROVED DATE REJECTED SEPTIC INSPECTOR -HEALTH DATE APPROVED DATE REJECTED COMMENTS PUBLIC WORKS - SEWERIWATER CONNECTIONS FIRE DEPARTMENT RECEIVED BY BUILDING ,TE Revised 9197 Jm BOARD OF BUILDING REGULATIONS; ' s License: CONSTRUCTION SUPERVISOR w n NumbWr,C�� S 089712 E .: 8i18t9. 11/2$!1961 x� 11i28/2007 Tr. no: 89712 d STEVEN J 15 RICKER CIRCLE CL� SO.'tiA 'MIT ON, MA''D1B2'' Commissioner C� p mm m - A mX r. _V Wo im = o Vo .0 o � � �� CoA O� yx xm =m dna tnzm �m 02 y N O fny0i �N m z a T z m c D p ~ bCO O m O z C. r- z w v z =im -� m > to G7 z m o M W z Tz m Tz O 1 O n C r- 0 9>2m r?t C1320 �� r o Oo� Z N mm �z T C� V r z UO UO � m � r z 2i y 0 9cy�'Frrs 17�y Z Schneider Electric DrawingNo.: 270 Congress Street ASK -1 North Andover Mills Boston, MA 02210 T: 617.423.4252 Date: Projecth99827.15 Kusa RrtcMvm F: 617.423.4333 11-15-04 Scale: AS NOTED n=� FA 9cy�f173 1p�' Schneider Electric North Andover Mills Zo��noo�� �O 000 � CZ CZ:m mAz 0-0 W--_? m0 m Vu pG7 mO0 m Lj � O X m --I � $ m� 0O mZ � � m 5.10" —11, 115' _ 31-0" 115" ��� b b 0 0 0 0 0 N 0 O 5' b 0 0 3'-0" 1'-5' 3'-0" 1'-5" 5' 10 2W b H m 05 r- mzv -TZ OZ v A x m m v O�a—i� z 00 mmD=y Z p 4 P3�Z z �p p Z ocv_ C m 0 v O % zm i 7NE9- O mac.; %Z p (n O c�r-m ZnT o ;0 M 2!; m Wzn O 0 Bun Hill Kusm KlttGmann Aawciutw O9 01 Z m O o < zy A' O z oIZI My Z m fn rn c m Z b LA A O O < oFn mnv Z00TO Z m Z co V1 N = r Z m m = zzv z rc„ , m m 25 bj " o z m NMS NZo z O m D ; 270 Congress Street Boston, MA 02210 T: 617.423.4252 F: 617.423.4333 Drawing No.: ASK -2 Date: 11-15-04 CO) CD az CD CLw �P-0 a �CC3 .o 0 o� a� c CD® CD 0 CA su y 0 CA Ma CD CD CD a, ca CD CA 0 rig CD 0 CD On rr% EE cn V J n O cn e ao��g s = C to O Cr N aOSoS .o W 0300 a n cc CD Z y CL C2 m .o c 3 = .T= N Oi. Im O H T ,.� d 0'0 d ri1 O m N O y. fG �p = :I Il 01 W � O C =ry d = Om CL-" 0 0 C ' O m45 _ cc, o O go H ;� V' o. d :O w b G, o mcc� o C-8 •� O =01 ti CD O 0 CD O o d � o .M .A t-, 9, 1 H 0 0 o ►� "fid ;t7 9, 1 H 0 0 E ol �7 • /a x w o OE-( u z CD c R. a Cs: 2 � O O o H W � o w° D. cin a Cc: ro o w° Xrn wo' A U co w � � ao' w Ci W r.a W � a2 u U)w coo� d C7 ..0 Do ao' w w p: rr G4Q y C z cn a v x o cn R H z 0 U O O E � L O V Z a O CO) o � cm ,I C w+ Q 10 co y m m .CO2 � O O CL O.0 D O c O d CL cmQ c c ccc w �v CL. OD C Z CD u N2 c C C C . _O Q. H 0 0 U) LLI U) W W W U) o CD c O o � CH : O C �O CD V O. C ev ev s: D o o •' P' E a w_ :tea N z 0 C $ V CM mi � — o. CD o E a o Z' CA La m 3 m y .5 _m H O W `E= ..emo CLC.) L m VJ O cc S .� a4 • G7 N O �. O w CI •p = O O. "_•" p N "r h O OH Z CIO) LU C �' O+=.�t .y H . �.�C .y Z O UA L CO3 m� o� ~ CosCLO. y l0 O m:21, H z 0 U O O E � L O V Z a O CO) o � cm ,I C w+ Q 10 co y m m .CO2 � O O CL O.0 D O c O d CL cmQ c c ccc w �v CL. OD C Z CD u N2 c C C C . _O Q. H 0 0 U) LLI U) W W W U) The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02.111 www.mass.govAlia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual)' J. Calnan & Associates, Inc. Address: 1250 Hancock Street, Suite 302N Ci incy, MA 02169 Phone#: (617) 801-0200 Are ,you an employer? Check the appropriate box: 1.0 I am a employer with 5 5 4. ❑ 1 am a general contractor and I employees (full and/or part-time).* have hired the subcontractors 2. ❑ 1 am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These stib-contractors have working forme in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.t required] 5. ❑ Weare a corporation and its 3. ❑ I am a homeowner doing all work officers have exercised their myself (No workers' comp. right of exemption,per MGL insurance required.] t c. 152: §1(4), and we have no employees. [No workers' comp. insurance required.l Type of project (required): 6. ❑ New construction 7. ❑ .Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. El Electrical repairs or additions ILEI .❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other *Any applicant that checks box #] must also fill out the section below showing their workers' coinpensabon 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, xContractors that check this box must attached an additional sheet showing [lie 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. 1 a[it a[t employer ilitit is providing ivorkers' conipeiisatioit instirarace fnr i[[y employees. Below is the policy marl job site information. Insurance Company Name Ohio Casualty Insurance Policy # orSelf-ins. Lic. #: XW053119614 Expiration Date: 10 1 2010 Job Site Address: , A �0 �rl=Y`�+C�t�?_l Flo City/State/lip: �iVt Mh D J'Z 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. 1.52 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 ofa STOP WORK ORDER and a fine oftip to $250.00 a cla e ainst the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of th Dl for insurance. coverage verif cation. I do Itereby cern rad the [i[[ n[i[ c[oo]ties ofperjmy that the information provider] above is trite and correct. Sisnattu-e: nate• 1122/ WSIVAWOM Official use only. Do not write in this area, to be completed by city or town offcial. City or Town: Perinit/License # Issuing Authority (circle one): L Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing inspector 6. Other Contact Person: Phone M Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide. workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined, as "an individual, partnership, association, corporation or other legal entity, or any two or more ofthe foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments, and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer," MGL chapter 152, §25C(6) also states that "every state or local licensing, agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct. buildings in the commonwealth. for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neithex 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-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. if an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of.insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you .have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed. legibly. The D€partment has provided a. space at the bottom of die 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 niultipl.e permitilicense 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 afdavit 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 pen -nits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related. to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in. advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone -and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 021.11 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 4-24-07 Fax # 61.7-727-7749 www.mass.gov/dia IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIMER This Certificate of Insurance does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25 (2009/01) 'DF created with pdfFactory Pro trial version www.r)dffactory.com � ACC'MO CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDIYYYY) 10/2/2009 PRODUCER Phone: 781-681-6656 Fax: 781-681-6686 The Driscoll Agency, Inc. 93 Longwater Circle THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O. Box 9120 ADDT Norwell MA 02061 INSURERS AFFORDING COVERAGE NAIC # INSURED INSURERA:Nat' 1 Fire Ins Co of Hartford 20478 J. Calnan & Associates, Inc. President's Place, No.Tower 3 1250 Hancock Street INSURER B: Everest National Insurance Cc INSURERC:Ohlo Casualty Insurance Co. GENERAL LIABILITY Quincy MA 02169 INSURER D: INSURER E: EACH OCCURRENCE $1,000,000 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 LTR ADDT *SAMPLE* POLICY NUMBER POLICY EFFECTIVE DATE MMIDD/YYYY POLICY EXPIRATION DATE MM DD LIMITS A GENERAL LIABILITY INS2095325239 10/1/2009 10/1/2010 EACH OCCURRENCE $1,000,000 DAMAGE RENTED X COMMERCIAL GENERAL LIABILITY PREMISESS Ea occurrence) $ 100,000 ( CLAIMS MADE 1XI OCCUR MED EXP (Any one person) $ 5,000 PERSONAL &ADV INJURY $1,000,000 X Inc- (nnt.rarfual GENERAL AGGREGATE $2,000,000 X Iric. X, C, U GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $2,000,000 POLICYFX PRO- LOC A AUTOMOBILE LIABILITY SAP2095325225 10/1/2009 10/1/2010 COMBINED SINGLE LIMIT (Ea accident) $1000000 ANY AUTO BODILY INJURY $ X ALL OWNED AUTOS SCHEDULED AUTOS (Per person) BODILY INJURY $ X HIRED AUTOS X NON -OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY- EA ACCIDENT $ OTHER THAN EA ACC $ ANY AUTO AUTO ONLY: AGG $ B EXCESS I UMBRELLA LIABILITY 71C8000071-91 10/1/2009 10/1/2010 EACH OCCURRENCE $10,000,000 X I OCCUR F—I CLAIMS MADE AGGREGATE $10,000,000 $ DEDUCTIBLE $ RETENTION $ 0 C WORKERS COMPENSATION XW053119614 10/1/2009 10/1/2010 X oRYTIATU IT X OTH- ER MA RI CT N AND EMPLOYERS' LIABILITY EMPLOY EMPLOYERS' Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $500000 OFFICER/MEMBER EXCLUDED' ❑ (Mandatory in NH) E.L. DISEASE - EA EMPLOYE $500000 E.L. DISEASE - POLICY LIMIT 1 $500000 If yes, describe under SPECIAL PROVISIONS below A OTHER INS2095325239 10/1/2009 10/1/2010 Leased or Rented $100,000 Conractor Equipment DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS Evidence of insurance for work performed within the Insureds scope of normal business operations. Notice of cancellation provision is 30 days, except 10 days applies for non-payment of premium. CERTIFICATE HOLDER CANCELLATION 30 ACORD 25 (2009101) © 1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD IDF created with pdfFactory Pro trial version www.pdffactory.com SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE *SAMPLE* CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO USA SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE ACORD 25 (2009101) © 1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD IDF created with pdfFactory Pro trial version www.pdffactory.com ,Milssachusetts - Department of Pufific SafetN Beard of Building Regulations and Standards Construction Supervisor License License: GS 56087 Restricted to: 00 STEPHEN ISA TERRENZI. 12 ENDICO. T STREET NORWOOD, ,INA 120.62 Expiration: 3/5/2011 ( m,mmii sbPact' Tr#: 12500 "ORTH TOWN OF NORTH ANDOVER OFFICE OF BUILDING DEPARTMENT 400 Osgood Street North Andover, Massachusetts 01845 D. Robert Nicetta, Building Commissioner Telephone (978) 688-95454 Fax (978)688-9542 CONTROL CONSTRUCTION —SECTION 116.0 M.S.B.C. CERTIFICATE OF ENGINEERING/ARCHITECTURE BULDING INSPECTOR TOWN OF NORTH ANDOVER 400 OSGOOD STREET NORTH ANDOVER MA 01 845 I, Carolyn Hendrie HEREBY CERTIFY THAT THE BUILDING CONSTRUCTED AT 1 High Street DOES CONFORM IN ALL RESPECTS TO THE MASSACHUSETTS STATE BUILDING, CODE AND APPLICABLE FEDERAL REGULATIONS FOR THE FOLLOWING: Building 36, New Stair for Converse, Inc. AUTHORIZED SIGNATURE: DATE: January 21, 2010 REGISTRATION: 4823 NOTE: ENGINEER "WET STAMP" MUST BE AFFIXED TO THIS FORM Control Construction Form revised 11.15.2004 BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 11EALT11 698-9540 PLANNING 688-9535