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HomeMy WebLinkAboutPermits - Permits - (13) tAORT Town Of e over o m dover, Mass., 1 O'9'COCHICHE LAKEWICK zY^'` BOARD OF HEALTH Food/Kitchen PERMIT T Septic System BUILDING INSPECTOR CERTIFIES THAT �© 40-44 �.C�... 0'014A-5;�k:-.- ... ..�4THIS CE ---------------------- -- --•-. Qi ' Foundation ._ buildin s on Zd _. P.(. - �� Rough has permission tot Q` � 9 ...w ,v �,,. `141... to be occupied as ���i_. .....f.4--�............. ....... .. c�ev provided that the person accepting this permit shall in every respect conform to the terms of the application on fife inFinal this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of -Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough. Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION ST Rough service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No_ Smoke Dec. I CERTIFICATE OF USE & OCCUPANCY Town of North Andover Building Permit Number Date THIS CERTIFIES THAT THE BUILDING LOCATED ON MAY BE OCCUPIED AS IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY, ,�,,.,. •,�c CERTIFICATE ISSUED TO ADDRESSXV i b'SAC wud-.- � uildinglnspec i I E C Ed f Town of over No. r2.. 67 o rn * - LaKE over, Mass., 1 C 9A cacNicHEwicx �',"1. BOARD OF HEALTH Food/Kitchen . .. PERMIT T Septic System THIS CERTIFIES THAT................. DING INSPECT B�- OR has permission to Foundation p - ..... ......... buildings on....ZC� ......._ P �- to be occupied as.............. .. r .... �.. They Provided that the person accepting this permit shall in every respect conform to the terms of the application on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING IN ECTOR VIOLATION of the Zoning or Building.Regulabons Voids this Permit. Rough PERMIT EXPIRES IN 6 MONTHS Final UNLESS CONSTRUCTION ST f ELECTRICAL IlVSP R ........................................ Service BUILDING INSPECTOR f F' Occupancy Permit Required to Occupy Building GAS INSPECTOR Display in a Conspicuous Place on the Premises -- Do Not Remove Rough No Lathing or Dry Wall To Be Donenal Until Inspected and Approved by the Building Inspector. DEPARTMENT Burner fi Street No. Smoke r)er_ / [ Commonwealth of Massachusetts Official Use Only Department of Fire Services Permit No. Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 1/071 leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT LV INK OR TYPE ALL INFORMATION) Dade: ll O City or Tower of: NORTH ANDOVER To the Inspor•of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) 203U/ Ste e-11 ' q® 4L0 Owner or Tenant (' : c�crS Telephone No. (,117.Pi0- ya Owner's Address Is this permit in conjunction with a building permit? Yes No ❑ (Check Appropriate Box) Purpose of Building i! t� c ev, Utility Authorization No. Existing Service `f10 Amps p La CJ / -To Volts Overhead ❑ Undgrd ❑ No.of Meters / New Service Amps / Volts Overhead ❑ Undgrd ❑ No,of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: Completion of the follawln table may be waived 6 the In ector of Wires. No.of Recessed Luminaires 1/,5 No. of Ceil.-Susp.(Paddle)Fans Na,of 'Iota! Transformers KVA No.of Lundnaire Outlets No.of Hot Tubs Generators KVA No.of Luminaires /p Swimming Pool Above n- a. o mergency ig g rnd. .❑ rnd. ❑ Batte Units No,of Receptacle Outlets S No. of Oil Burners FIRE ALARMS No. of Zones ot No.of Switches No. of Gas Burners No.o Detection and Initiating Devices i No.of Ranges No. of Air Cond. TotaTons! No. of Alerting Devices ! Na.of Waste Disposers �. Beat Purnp umber Tons KW Na,ofSelf-Contained 1 Totals: _............................................................ Detection/ erdt Devices No,of Dishwashers Space/Area Heating KW Local unie ti ❑ Other Connection No,of Dryers Heating Appliances KW Security S stems:* No,of Water No,of evices or E uivalent Kj�4' a of Ba,of Data Wiring: Heaters Si ens Ballasts No.of Devices or Equivalent No.Hydromassage Bathtubs No. of Motors Total HP G TelecommunicationsWiring: No.of Devices or Equivalent OTHER: ' Attach additional detail if desired, or as required b Estimated Value o El ctrical Work: .3 lW— 9 the Inspector of Wires. .(When required by municipal policy.) Work to Start: f t OB Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE C RAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such cove a is m force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE [BOND ❑ OTHER ❑ (Specify:) I certify,under thepains andpenalties ofperjury, that the information on this application is true and complete. FIRM NAME: C S 1<Z to rl' l( 66r4. LIC.NO., Licensee: -6 Signature �'" LIC.NO.: 1�3 71O (f applicable, p number line.) ?"Pus. Tel.No.- *Per a !:cable, ente t t 'to the license Sca 4 -L Z O2 ��/A� Address' LI r....._�.r��. r � (.� _ L� qI� Alt.Tel.No.: Per M.G.L� .57-61, security work requires Department o€Pu* t3' blic Safety"S"License: Lic.No. OWNERS INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I hereby waive this requirement. I am the(check one) ❑owner ❑owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE. $`' r The Commonwealth of Massachusetts k� Department of Industricd Accidents Office of Investigations • 600 YEashington Street Boston, MA 02111 www.nuus.gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers A �licant Iinformation Please Print Le 'bl Nau ie(Business/Organization/IndiA dual): IiF s LO M z tv 1 Address: l C C c�z r� e c l �°�^ 200 CitylStatelZip: Phone#: . 761-3 z 1 ci':1`t ------------- Are you an employer?Check the appropriate box. Typt .af project(required): 1.❑ 1-am a employer with 4. 111 am a general contractor and I employees(full and/or part-time).*. have hired the sub-contractors b ❑New construatioh 2.❑ I am.a.sole proprietor.or partner- listed on the attached sheet.t 7. ❑Remodeiing ship and have no empioyees These sub-contractors have 8. Q Demolition` working for the.in any capacity, ,.,Workers, comp,insurance, g ❑Building addition [No workers' comp,insuran Ece 5. We are a corporation and its Mquired.] officers have exercised their 10.0 Electrical repairs or additions 3.❑ 1 am a homeowner doing ail work right of exemption per MOL I I.❑ Plumbing repairs or additions myself,[No•workers'comp. c, 152, §1(4),'and we have no 12,Q Roof repairs insurance required,)t ,employees, [No workers' comp. insurancorequired.) 13•Q.Other "Any applicant that cheeks I)M #i must also fill out the section below showing their workers'b6mponsatian policy information. t HomeownM who submit this eftidavit indioadrig they are doing all wort;and then hire outside contractors must submit a new affidavit indicating such. lCantrnotors that check this box muatattached an additional sheet showing-the name of the sub*contxactom and their workers'camp,policy information. I am an employer that is prgviding:workers'compensation irrsurancefor MY employees: Below is-the and fob site information, ' Insurance Company Name- ' o� 6 Policy#or Self-ins,Lie, P /t((a Expiration Date; 3d tJ r7. Job Site Address, 2O pTt,,.,t �t' �� �r�tl City/Statelzip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required.under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine tip to$4500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day againstthe violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. f I do,hereby certi y under`thee palm and penalties of perjury that the information provided above is true and correct { Si ature; `-�--- t Date: C Phone#: Of vial use only, Do not write in/his area,to be completed by city or town official, City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector5, Plumbing inspector 6.Other Contact Person: Phone#• Office Use Only Permit No /0 ' �' e071r?71117 lI�rF.c'"1 057 714455,4r4UJ12M occupancy&Fee Checx� Ole,'Dot�P�5�ry BOARD OF FIRE PREVENTION REGULATIONS 527 C APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code 5277 CMR 12:00 (Please Print In ink or type all informadon) Data [U To the at ester Wires: I Town of North Andover The undersigned applies for a permit to perform the electrical work described below. Location(Street&Number v u r �� j� Su, Z owner or Tenant Owner's Address Is this permit in conjunction with a building permit Yes No ❑ {C'rteck Appropriate Box) Purpose of Building. olC UUJity Authorization No. Existing Service Amps Volts Overhead ❑ Undgmd ❑ No.of Meters New Seance Amps Voits Overhead ❑ Undgmd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work S U��_ /Gam© l�. 19�I] i� ' Q u'® r , Total No.of Lighl8ng Outlets No.of Hot fuse No.of Transformers KVA I Above No.of nting Fixtures Swimmin Pool m I d ❑ lJmd ❑ Generators KVA No,of Emergency Lighting No.of Receptacles Outlets No.of Oil Burners Battery Units No.of SwgCh Outlets No of Gas Burners FIRE ALARMS No.of Zane —d Total No.of oelection and No of Ranges No of Air Cond Tons Initiating 6evtces Heat Total Total Nc� of Di sal No, Pumps Tons KW No.of Sounding Devices No.1 of Self Contained No of Dishwashers Space/Area Heating KW DetectiorvSounding DavIC85 ❑ Municipal ❑ Other No.of ODnrs Heating Devices KW Locat Connection No,of No.of tow VoJtaga No,of Water Heaters KW Signs Bailases WInn No.Hyoro Massage Tuds No.of Motors Total HP OTHER: INSURANCE COVERAGE, Pursuant to the requiremen8ls of Massachusetts General Laws I have a current Lability Insurance Policy including Completed Operations Coverage or its substantial equlvalent YES= NO have submitted valid proof of same to the Office Y>y4��NO = H you have checked YES please indfcate the type of coverage by checking the appropriate box INSURANCE = BOND = OTHER -- (PPlleaasseeSSpecify) o (Expiration Date) Estlmated Value�ol !e I 5 � �✓ G� p Rough FInal Worts to Start lD Inspection Date Resqueated 9 Signed undofr os f po 1&7- LIC.NO. FIRM NAME �J LJcansoo �� c7 lG � SEgneture T LIG.NO. (, 1a us.Tel No. Address 75 �Z�� � �� /'_r/'4 cya, y AJt Toi.No. OWNF-RIS INSURANCE WAJVER: I am aware that the Licenses duos not have the Insuranc coverage or Its subatantlal equivalent as required by Massachusetts General Laws.And that my signature on this permit application waives this requirement. Owner Agent (Please Check one► Telephone No. PERMIT FEE 5�-- (Slgnaturo of Owner or Agent) ! MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER,MASSACHUSETrS Date // /4 4' Building Locatio e) w Owners Name Permit# ( Amount tr f C iao-t�� Type of occupancy New Renovation Replacement ' Plans Submitted Yes ❑ Na FIXTURES r a w � a Ib'iv FLOCK �)CIi0d2 41H MOOR 5IH P� 6M �lClit SIHROCI (Print or type) Check one: Certificate Installing Company Name 64!", C� � �WAP ® Cow a5 � Address � �� �tl � Partner. � � r usuness Telephone -- 3 97S" S El Firm/co. Name of Licensed Plumber: Z-6e-e ao , . Z C r Insurance Coverage. Indicate the typo of insurance coverage by checy ng the appropriate box: Liability insurance policy Other e of indemnit Bond ❑ Insurance Waiver: I, the undersigned,have been made aware that the licensee of this application does not have any one of the above three insurance Signature. Owner Agent I hereby certify that all of the details and information I have submitted (or entered)in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State plumbin Code�and Chapter 142 of the General Laws. By, igna urea icense um er Type of Plumbing License Title CitylTown 1cense um er Master Journeyman ❑ APPROVED take usB ONLY BUILDING PERMIT O°oT 6'�ti TOWN OF NORTH ANDOVER ­�'',6 ° APPLICATION FOR PLAN EXAMINATION Permit NO: e d ' Date Received � R y �ssA US��� Date Issued: I PORTANT: Applicant must complete all items on this page UOAITIQVMN f y I -.� MAF'S1aJfJPtC1=LDN1�1GST <ttT 31r storkz �Distrt.ra# +eso LLL ,...._'. ... :5Machinehrpl��llae es no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential New Building One family Addition Two or more family In striaL _ Alteration No. of units: Commercial Repair, replacement Assessory Bldg p Demolition Other peptic Weil ¢�Idoplam: letlards Insrs'hdQlsttct erlewer F � a DESCRIP ION OF WO K TO PREFORMED: C�► I E� -- ►� � c.�1 �' d ���y c a �- ,��v O 1 v r� �a ,r -,n __ / Identification Please Type Print Clearly) / c OWNER: Name: L.�i Z � - Phone: Address: f S� ��visvr�s�C�ns�r�tot�on L~�de�ee _ �° a Horne] rrlAo � 'eraticer�se . Exp Date,. ARCHITECT/ENGINEER) C r3ss .. i- k,s:—ex _—c-- Phone:9 7 P '-1 `?O 3 4 7 S-- Address:a-"e F-- ` yarn �c�ve�- �� oI � U Reg, No. �1 I S`^3 FEE SCHEDULE:BUL DING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMA TED COST BASED ON$125.00 PER SY, Total Project Cost: $ L� 1 7 L FEE: $ Check No.: /� Receipt No.: r NOTE: Persons contracting with unregistered contractors do not have access to a guaran(j)fund Signa#uref�9gt]Ownertgnattareof�ontraefo`r � Building Department The following is a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, Interior Rehabilitation Permits ❑ Building -Permit Application ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract ❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products V NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract ❑ Mass check Energy Compliance-Report ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doe;INSPECTIONAL SERVICES DEPARTMENT;BPI'ORM07 Revised 2.2008 N tTM C 11YY YY CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH AlOVER Temporary Permit Building Permit Number�272 (10/15/08) Date: January 9. 2009 THIS CERTIFIES THAT THE BUILDING LOCATED ON 203 Turn ike Street MAY BE OCCUPIED AS , Tenant Fit un-- Dentat Office IN �YwY wl ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY, Certificate Issued to. 3D Dental 203 Turnpike St North Andover MA 01845 f Building Inspector NORTfy TO" of Andover No. µ ra 0 dover, Mass., A_ CO CHIC HEWICK Y 7,q AORgrer� P'? BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System BUILDING INSPECTOR THIS CERTIFIES TI♦AT '�;t. o � - ......... ...� .r......... ....... ....................•... .... ....••.-.. ••. .'/.......................�.......................... ........ Foundation has permission to erect................. ..................... buildings ..G D i ri6i� , .. . . �.. .... Rough to be occupied as a �<��'f�S 11 r '1 � ... Chimney provided that the person accepting this permit shall in every respect conferms of the application on file in Final this office, and to the provisions of the Codes and By-Laws relating to the-Inspection, Alteration d Coristructign Buildings in the Town of North Andover. v frig-t /y���f~ PLUMBING INSPECTOR VIOLATION of the Zoningor Building Regulations Voids this Permit. Rough 9 9 Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION S ARTS Rough .r. jy---- --------•--......----•-. . service BUILDING INSPECTOR Fnal Occupancy Permit Required t0 Occupy Building GAS INSPECTOR Rough Display in a Conspicuous Place on the Premises -- Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. SEE REVERSE SIDE Smoke Det. Page 1 of 3 STRAIGHT UP BUILDERS INC. ---- --lProposal # 1121 WAN , 70: From: 3-0 Dental UpRight Builders hic, ff1r: Lirlia Scher 65 Central five. PO Pox 750001 Everett, ALL 021 49 ffr lingron Ifeights,11a 02476 Tel. 617-389-0400 Tel: 781-643-2758 Fax: 7,31 777-113 9 Pro'ecl Documents 3-1) Dental AH: Lidia,5eher 203 Turnpike Road No. Andover Ahr Tel: 781-643-2 758 Fax: 781-777-1139 7711e: New Dental Office Dale: 10-10-2008 Sc owe: )e: GENERAL CONDITIONS $ 20,325.00 Permit Project lavout Dumpsters for the removal of all construction related debris only Maintain accessible means of egress from 'obsite at all times'. supervision Qualifications; Any discrepancies between architect drawings and actual field dimensions will he reported to the owner and architect immediately upon discovery. Any cosequential aricc changes,leased on these discoveries,will be the responsibility ol'the owner. Removal of'any non-construction related debris,will be an additional charge to the owner! We are planning to stare dum Aster onsite, DEMOLITION 5,80.00 Coordinate all demo work with owner, Qualifications; Structural problems uncovered during the demolition phase are not euvered by this proposal ROUGII CARPENTRY $ 2,2c,a.0o Seal all penetrations,either new or existing discovered during demo. Provide blocking in walls at all casework,bath accessory and any other location deemed necessary, MASONRY A 1 t,2so.0o DOORS S WINDOWS $ s,3on.0o 10113r2008 Page 1 Wang 1121 Page 2 of 3 STRAIGHT UP BUILDERS INC. 1 STOREFRONT $ 'Fite above scope is not anticipated or carried in this pp•o posal 1 i "VAC 28,655.00 PLUMBING $ 49,900.00 Move existing HVAC return and surlily ducts. Prepare HVAC and all other piping for relocation to new location on plans. Remove existing toilet,prepare septic pipe and water lines to accept new toilet. Seal all penetrations,either new or exisfing discovered during demo. ELECTRICAL 55.300.00 Remove electrical wiring,lighting fixtures,piping and blocking to Finish wall and ceiling sur'faee, Landlord fire alarn►wiring,testing,programs ihi ,modules,devices ore ui pment are not included in this price. 1IVAC control conduit,wiring,devices or equipment are not included in this price, FIRE ALARM g The above scope is not anticipated or carried in this proposal SPRINKLER FIRE SUPPRESSION The above scope is not anticipated or carried in this proposal INSULATION � 21s.75 The above scope is not anticipated or carried m this proposal IMMALL& PLASTER g 26,940.00 Install new 5/8" GWB on existing hathrooln wall studs. Install new 5/8" GWB on all new wails Install new 5/8" GWB on existing walls in hall over wainscot. Install new 5/8" GWB on new bathroom ceiling, 'Pape,sand and make ready for new Finishes,all new wall GWB. Tape,sand and npalce ready for r►ew finishes,all new ceiling GWB. Qualifications; M ILLWORKWASE WORK $63,500.00 ceiling V4(p;rn.o0 FINISH CARPENTRY ' 5,140MO PAINTING&WALL COVERING S 11,600.00 10/13/2008 Page 2 Wang 1121 Page 3 STRAIGHT UP BUILDERS INC. Scram FLOORING $ 30.260.00 13AT11 ACCESSORIES g The above scope is not anticipated or carried in this proposal SICNACC The above scope is not auNci fated or carries{in this proposal ! i Quilifications&Assumptions: Items ordescriptions of work omitted Trout prints and specifications will not be carried in this proposal but will he estimated and proposed to the owner when evidence is presented that the work is necessary to be done io order to complete project as architect has intended it to be done.We will not be responsible for intended work that is not clearly shown or explained on blueprints and specifications. Separate qualilicaiions are listed above Under each individual scope.Please review thoroughly and notify tts as to any discrepancies that you might recognize so that the propostl can be amended to reflect the mmus understanding oCalI wo€k heing perlonned. Material $ 20,903.75 Labor $ 24,055,00 Proposed By: 'Thomas A. Maloney Subcontract $ 275,535.00 Other $ 4,425,00 Accepted By: Subtotal $ 325,518.75 Overhead $ 32,551 M I)atc: Prolit $ 17.903.53 11AYNIFNT"1'E:RMS TO 13G DISCUSStill UPON ACCEPTANCE, Total $ 375,974,16 10/13/2008 Page 3 Wang 1121 The Commonwealtl t of Massaclausett Department of Industrial Accidents r Office of Investigations Vu 600 Washington Street Boston AM 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electridians/Plumbers Applicant Information Please Print Le 'bl Name (Business/organization/indivi dual): S Address: City/State/Zip: v e r el . ca a r L/ 7 Phone#:� of Are you an employer?Check the appropriate box: n Type of project(required): l.El am a employer with �� 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6' ❑New construction 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 1 7. (2-Remodeling ship and have no employees These sub-contractors have S. ❑ Demolition working for the in any capacity, workers' comp. insurance, 9, [] Building addition [No workers' comp, insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL I I,❑ Plumbing repairs or additions myself. [No workers' comp, c. 152, §1(4),and we have no 12.0 Roof repairs insurance required.] i employees. [No workers' comp. insurance required.] 13.❑ Other *Any applicant that checks box V I must also fill out the section below showing their workers'compensation policy information. I Homeowners who subinh.this affidavit indicating they a,t doing all work and thou hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp,policy information, /am an employer that is providing workers'compensation insurance for my empinyees. Belou,is the policy and job site information, Insurance Company Name: 4/vr�c9 A r s � Policy#or Self-ins. Lie. Expiration Date; I t 3 CJ Job Site Address. Z0 "3 T _ City/State/Zip: e Y �y _ 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 MOL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. 1 do hereby ce ifj, n er the pains and penallies of perjure=that the information provided above is true and correct Signature; ti Date: Phone#: ! r7 a Y Cyr Official use only, Do not write in this area, to be completed by cif},or town official: City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. electrical inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: i ACORD CERTIFICATE OF LIABILITY INSURANCE UPOP1 1 DATE 14�08 PRODUCER THIS CERTIFICATE 15 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Talbot Insurance Agency, Inc. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 221 Chelmsford Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Chelmsford MA 01824 Phone: 978-256-3367 Fax:978-256-8215 INSURERS AFFORDING COVERAGE NAIC fr ----- _-W INSURED INSURER A' Dartford Insurance Co. INSURERB: Colony Insurance Company Upright Builders, Inc. - Thomas Maloney INSURERC: 65 Central Aye. INSURERD: mm Everett MA 02149 INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDtCATEO.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH TH6 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. ILTR N R TYPE OF INSURANCE POLICY NUMBER DATE MMIDD>YY PDATE EXPIRATION LIMITS GENERAL LIABILITY EACH OCCURRENCE s 1,000,000 _ B COMMERCIAL GENERAL LIABtUTY GL 3643002 11/07/07 11/07/08 PREMISES(Eaoccarrence) S50,000 CLAIMS MADE �OCCUR MED EXP(Any one person) $ 1,000 _ PERSONAL&ADV INJURY S 1,000,000 GENERAL AGGREGATE s 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER. PRODUCTS-COMP/OP AGG s 2,000,000 POLICY PRO- ..__. JECT LOC AUTOMOBILE LIABILITY ' ANY AUTO a acc dent)SINGLE LIMITI S ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HEREDAUTOS BODILY INJURY S NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE S (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCOENT $ ANY AUTO EA ACC S - OTHER THAN AUTOONLY: AGG s EXCESSfUMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE S DEDUCTIBLE _ S RETENTION $ —�—� S WORKERS COMPENSATION AND TORY LIMITS JOTH- ER EMPLOYERS'LIABILITY ------- A ANY PROPRIETORfPARTNERIEXECUTIVE 6S60UB-0964L35-8-07 11/03/07 11/03/08 FL EACH ACCIDENT $ 100000 OFFICERIMEMBEREXCLUDED? E.L.DISEASE-EA EMPLOYEE $ 100000 It yes,describe under ---- SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT S 500000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES!EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS Re: work performed at 203 Turnpike Rd. N Andover, MA. CERTIFICATE HOLDER CANCELLATION 3—DDENT SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO$0 SHALL 3-D DENTAL PC IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR 11 CHESTNUT ST ANDOVER MA 01810 REPRESENTATIVES. ACOftD2S(2DQ1IQ8) ORATION 1988 I i 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 at: i 4��- is that the debris resulting from this work shall be disposed of in a properly licensed solid waste disposal facility as defined by MGL c 11, S 150 A. Also, note Permits are required under Fire Prevention laws Chapter 148 Section I OA. The debris will be disposed of in: Cj ICU (Location of Facility) Signature of Permit Applicant Date .�rcl eels ss z rrl , l Gr CONSTRUCTION CONTROL AFFIDAVIT PROJECT NUMBER: 2175 PROJECT TITLE; 3-D Dental Office Suite 100& 120 PROJECT LOCATION: 203 Turnpike Stree,First Floor,North Andover,MA NAME OF BUILDING: North Andover,MA 01845 SCOPE OF PROJECT: Interior Dental Office Build Out In accordance with Section 116.0 of the Massachusetts State Building Code, 1, Joseph D. LaGrasse, MA. Reg. # 4153 being a registered professional engineer/architect hereby certify that I have prepared or directly supervised the preparation of all design plans, computations as specifications concerning: Entire Project Architectural X Structural X Mechanical Fire Protection Electrical Other For the above named project and that, to the best of my knowledge, such plans, computations and specifications meet the applicable provisions of the Massachusetts State Building Code, all acceptable engineering practices and all applicable laws for the proposed project. I further certify that I shall perform the necessary professional services and be present on the constriction site on a regular and periodic basis to determine that the work is proceeding in accordance with the documents approved for the building permit and sliall be responsible for the following as specified in Section 116,2,2: 1. Review of shop drawings, samples, and other submittals of the contractor as required by the construction contract documents as submitted for building permit,and approval for conformance to the design concept. 2. Review and approval of the quality control procedures for all code-required controlled materials. 3. Special architectural or engineering professional inspection of critical construction components requiring controlled materials or construction specified in the accepted engineering practice standards listed in Appendix 1. Pursuant to Section 1 16.4,1 shall submit periodically,a progress report together with pertinent comments to the Building Inspector. Upon completion of the work,I shall submit a final report as to the satisfactory completion and readiness of the project for occupancy. 4tu Sign re of Architect Date H/constriction control affidavtt.doc (�Q Ciy�r� �8 Offices ' No.4153 � ANDOVER, One Elm Square �� MA T 978.470.3675 Andover,MA 01810 F 978.470.3670 �atnf Of,dA`'Sp 1420 Celebration Blvd. www.lagrassearchitects.com Celebration,FL 34747 AA26001333 Whyy CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Permit# 272 Data: Fqbnaa 20 2009 THIS CERTIFIES THAT THE BUILDING LOCATED ON 203 Turnpike StreetMAY PROMS ON ACCORDANCE WITH THE S OF THE 1VIASSACHUSETTS STATE BUICCUPIED AS Dental OfficeLDING . ILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY, Certificate Issued to: David W, Wang, DMD, PhD 203 Turnpike Street North Andover MA 01845 Building Inspector C NORTf-� q own of � Andover No. a 72o0 * - Cc,fldover, Mass. 'pq COC MIC IAEwIGlS`1' i ,9 °Rgre© Ae�` ,�G} S BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System THIS CERTIFIES THAT....... � . ...... �� ...:.... DING INSPECTOR BUILDING .... ...... ..... Foundatio has permission to erect................ . buildings __. ...�.�',�I.... .... A to be occupied as..................... .. . �'2'C3 f1 _.... ....... .e�`t '—f . .......1�. �` c provided that the person accepting this permit shall in every respect conform to the arms of the application on file in this office, and to the provisions of the Codes and By-Laws relating to a ins action, Final p Y 9 Alteration,�nd Co�Structi Buildings in the Town of North Andover. �sr=� /'�� ° PLUMBING INSPE TOR VIOLATION of the Zoning or Building Regulations Voids this Permit. PERMIT EXPIRES IN 6 MONTHS UNLESS CONSTRUCTION S ARTS ELECTRICAL IN5 QR x -r................................. ' ervice BUMDING INSPECTOR Occupancy Permit Required to Ocatpy .Building GAS INSPECTOR Display in a Conspicuous Place on the Premises — Do Not Remove Finch No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until inspected and Approved by the Building Inspector. Burner Street No. �y r SEE REVERSE SIDE�i Smoke Det. i :- �-- APPLICATION FOR PERMIT TO BUILD***** **NORTH ANDOVER, MA y� ; ;� / PER]`.�_T NO � A6 M Lr NO. p I.OT_NO_ 7 2. RECORI)OF OWNERSHIP v DATE BOOK PAGE ZONE SEIB DIV-LOT NO. l[)(:1'1I(7N -z"z.2 S PURPOSEOF BUR DIN(; OWNER'S NAMES d'V 'vt� _ NO.OF STORIES SIZE; u OWNER'S ADDRESS BASEMENT OR SLAB ARC'k Ill 'S NAME SIZE OF FLOOR TIMBERS I 3 BUILDER'S N 'c Cl ✓-1�4' �ti 4 SPAN DISTANCE TONEAREST BUIL.DING DiNIENSIONSOF SILLS i)IS LANCE FROM STREET' DIMENSIONS OF POST S DISTANCE FROM LOT LINES-SIDES REAR DIMENSIONS OF GIRDERS AREA OF LOT FRONTAGE I IOU Fr OF F(ELNDATIiNN THICKNESS IS BUILDING NEW SIZL?OF FOOTING X IS BUILDING ADDITION MATERIAI.OF CI UNINEY IS BUILDING ALTERATION S IS BUIH)ING ON SOLID OR FILLED LAND 6 r 1 V"�� W!I I.BUILDING CONFORM TO REQUI REMENTS OF CODE IS BUILDING CONNECTED-LO TOWN WATER BOARD OF APPEALS ACTION,IF ANY IS BUILDING CONNECTED TO TOWN SFWE:R IS BUILDING CONNECTED TO NATURAL GAS LINE INSI'tl('I-LON$ 3. PROPERTY INFO RNIATION LAND COST Est'.61.1xi.COST PAGE 1 Fill our SECTIONS 1-3 EST_BL.IX1 COST PER S(1_FT. EST.BLDU COST PER ROOIA ELECTRIC METERS MUST BE ON OUTSIDE OF BUILDING SEPTIC PERMIT NO. ATTACHED GARAGES MUST CONFORI-ITo STATE FIRE REGUATIONS $. APPROVED BY: PLANS MUST BE FILED AND APPROVED BY BUILDING INSPECTOR 11�BI II1 DING INSPF CiOR �/ [7 (� r (^ram DATE FIiFI) I f/ OWNERS 3'E`.L 7-?r- &? -- ��3 J CONI'R.TI=L#���J-�J � �� — CONTR.1_10CS SIG36URF.OF OWNFR OR ALJTIiOlVZEDA, PERMIT GRANTED Q� L 19 r t t inn , I • h • i f � r I , I c