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Home My WebLink AboutPermits - Permits - 203 TURNPIKE STREET 125 711 312 01 7 CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Permit Number: 23357 Date: July 13, 2017 CO Permit Number: 26574 THIS CERTIFIES THAT THE BUILDING LOCATED ON: 203 TURNPIKE STREET MAY BE OCCUPIED AS Interior Fit-Up of Existing Dental Office IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: Dr. Emma Wu lZ� Building Insp for This is an e-permit.To[earn more,scan this barcode or visit northandoverma.viewpointcloud.coml#/records/26574 w"r , 111 } t l r � O 1bfn rd BUILDING PERMIT ? TOWN OF NORTH ANDOVER ,✓ /1 APPLICATION FOR PLAN EXAMINATION Permit NO: Date Received 01 F,Y / ACF1 �i�� Date Issued: Us IMPORTANT: Applicant must complete all items on this page LOCATION 20 Turnpike Street - unit 125 P..tint PROPEFM OWNER 125 N�op MAP NO 24/26: PARCE4 ZONING DISTRICT. His#oric'District :Yetn IVlachine Shop Village y s no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential 11 New Building F One family Addition Two or more family n Industrial 'XAlteration No. of units: i_XCommercial i...1 Repair, replacement Assessory Bldg Ll Others: I l Demolition i Other 43 Septic ©11VelI Q FloodpI Q Wetlands © Wa#ershed District Q Wa#erlSewer Interior Fit-Up of Existing Condo Suite Construct Dental Office ~ r � Idwititicatiott Please,type or Print Clearly) OWNER: Name: 125 NAOP LLC Phone: 97€3-1.321-7167 Address: CONTRACTOR Name; Phone, 97$- �1-9200 Address 1 fiD L©rum Street:Tewksbury,i�A [)1 ti76 Supervisor's Constrttction'Llcense Exp Date: 400 .2122101. ' Home improvement License Exp. .Date. ARCH ITECTIENGINEER rJim Tozokos Phone: 978--985-1813 Address: 1147 Main Street Tewksbury,MA 01876 Reg. No. FEE SCHEDULE;BULDING PERMIT;$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ 102,000.00 FEE: $ Check No.: Receipt No.: NOTE: Persotis coltti'actiiig r,ttlt iiiti•egistei•ed contractors rlo trot h(ti,e Access to the guar-ttitty fund Signature of Agent/Owner Signature of contractor 1 Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/Massage/Body Art ❑ Swimming Pools Well ❑ Tobacco Sales ] Food Packaging/Sales Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMENTS CONSERVATION ❑ ❑ COMMENTS DATE REJECTED DATE APPROVED HEALTH ❑ ❑ COMMENTS Zoning Board of Appeals:Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Con nectionisignature &Date Driveway Permit Located at 384 Osgood Street FIIRE:DEPARTMENT Temp 0..t�lnpster on site yes no i_ocated at 124 Main Strut Fire D+eparEmient sgrt tt; reldate COMMENTS q, i The Commonlvealth.of Massachusetts Departinent of ZitdustrialAccidents s 1 Congress Street,suite 100 ap s n Boston,MA 02114-20I7 ww .mass.gov/flirt NVorkers' Compensation Insurance Affidavit:Builders/Contractors/IJlectricians/Plumbers. TO BE FILE,D WITH THE PERAUTT ING AUMORITY. Applicant Information _ Please Print Legit Nalne(Business/Organization/Individual): Pinnacle Construction Company, Inc. Address: 160 Lorum Street. City/State/Zip: Tewksbury, MA 01 876 pllono#: 978-851 —9200 Are you an employer?Cheek the appropriate box: Type of project(required): 1.®I ant a employer with 14 employees(full and/or part-time).* 7. New construction 2.[I I am a sole proprietor or partnership acid have no employees worlang for me in 8. ❑Remodeling arty capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.EJ I am a homeowner doing all work-myself.[No workers'comp.insurance required,]s 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will i 0 E]Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.[]Electrical repairs or additions proprietors with no employees' 12.[]Plumbing repairs or additions S.Q I am a general contractor acid I have hired the sub-contractors listed on the attached sheet. 13,❑Roof repairs These sub-contractors have employees and have wvorkers'comp.insurance.t 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.E]Othet' 152,§1(4),and we have no employees.[No workers'comp.insurance required.] *Any applicant that checks box#i must also fill out the section below showing their workers'compensation policy inromration, t Homeowners who submit tills affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box most attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees, if the sub-contractors have employees,they must provide their workers'comp,policy number. I ant air employer that is proviriing workers'conrpetsallort Insrtrance for Lazy etzployees. Below is the policy cold fob site in•forraratiort. Insurance Company Name: Citizens Insurance Company Policy#or Self ins.Lie.#: WBND0 01 1 5 2 0 0 Expiration Date: 8/2/1 7 Job Site Address:� City/State/Zip: Attach a copy of the workers' c ipe a#ion policy declaration Rage(showing the policy number and expir tion date).. Failure to secure coverage as required under MGL a 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250M a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cerltfyjouler the palys,0r rLpetl llies a erjmy that the Infortztation provided above 's tr e a0 correct, Si nature Date: Phone#: Official use only. Do not write in this area,to be completed by city or town offzcrai. City or Town: Permit/License H Issuing Authority(circle one): 1.Board of Health Z. Building Department 3. City/Town Cleric 4. Electrical Inspector S.Plumbing Inspector 6,Other Contact Person: 1'ltbne#: Y r III f �L ��Q f , ca d'st'caia gC bildi'll Pgffaic jMt $raYelthl &am tw..work shall bg ��s` a .fly 1fa a� d��g by OL ill Tho dgbCsg Mll bgMq J � don i I �...,.....�..-.,,..-.,...err'^�' .' Sip�g�r �iN Initial Construction Control Document = w To be submitted with the building permit application by a M d Registered Design Professional w for work per the 8"' edition of the �b Massachusetts State Building Code, 780 CMR, Section 107.6.2 Project Title: Tenant Fit-up For Dr. Wu (Dentist) Date: February 27, 2017 Property Address, 203 Turnpike Street,Unit#125,North Andover,MA Project: Check (x) one or both as applicable: ( }New construction ( X ) Existing Construction Project description: Renovations to change an existing Doctors Office Into a Denist Office(Same Use Group). I, James J. Jozokos Jr., MA Registration Number: 20190 Expiration date: August 31,2017, ant a registered clesign professional, and hereby certify that 1 prepared or directly supervised the preparation of all design plans, computations and specifications concerning: (X )Architectural ( } Structural ( )Mechanical ( ) Fire Protection ( j Electrical ( )Other: for the above named project and that to the best of my knowledge, information, and belief such plans, computations and specifications meet the applicable provisions of the Massachusetts State Building Code, (780 CMR), and accepted engineering practices for the proposed project. I understand and agree that I (or my designee)shall perform the necessary professional services and be present on the construction site on a regular and periodic basis to: 1. Review, for conformance to this code and the design concept, shop drawings, samples and other submittals by the contractor in accordance with the requirements of the construction documents, 2. Perform the dirties for registered design professionals in 780 CMR Chapter 17, as applicable. 3. Be present at intervals appropriate to the stage of construction to become generally familiar with the progress and quality of the work and to determine if the work is being performed in a manner consistent with the approved construction documents and this code. Nothing in this document relieves the contractor of their responsibility regarding the provisions of 780 CMR 107. When required by the building official, I shall submit field/progress reports (see item 3.)together with pertinent comments, in a form acceptable to the building official. Upon completion of the work, I shall submit to the building official a `Final Construction Control Document'. ARc Enter in the space to the right a "wet"or electronic signature and seal: �0.� C� fly o. ASS. Phone number: 1 (978) 985-1813 Email: ozokos@comcast.net comcast.net OF �� PG Building Official Use Only Building Official Name: Perinit No.: Date: Note 1, Indica€e with an`x' proicct design plans,computations and specifications that you prepared or directly supervised. If`other' is chosen, provide a description. i Version 06 I 1 2013 W&ORTH Town 2 :' aT; 6 O "'" 0% No. Z � n �.K. h ver, Mass, � � � t OC MI CIiC.K ��' _ �.�go�'ETEA S BOARD OF HEALTH Food/Kitchen PER Septic System THIS CERTIFIES THAT ..., ..... IT T L mumaL '...Ew ..Wv.—04`. �.u..:" .. .. ...... ... ...... BUILDING INSPECTOR .... .... TLV .......... ... . ...... has permission to erect... ................... buildings on 3... . �.... ...... Foundation to be occupied as . I . ... .......... Rough p� ......... .. . . ........ ...... ... . . ................... Chimney provided that the person accepting this per all in a ry respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and Construction of Buildings in the Town of North Andover, PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT I E IN 6 MONTHS ELECTRICAL INSPECTOR . UNLESS CON U I Rough Service . .. ..,........, .....,...,.. Final BUILDINf 06PECTIR GASINSPECTOR Occupancy.hermit REquired t® Occupy Bu Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. q MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK '' I MA DATE PERMIT# - � . CITY tom; � -��_ _ � .� _.._.—.-_.._ .. •--�-- � JOBSITE ADDRESS ( "s1 OWNER'S NAME POWNER ADDRESS TEL1FAX TYPE OR OCCUPANCY TYPE COMMERCIAL EDUCATIONAL © RESIDENTIAL�]I PRINT CLEARLY NEW: ® RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES © NO FIXTURES"I FLOOR- BSM 1 2 3 4 5 6 7 S 1 9 10 11 12 13 14 Q. BATHTU6 ,I -_ _ - .! m�� I I . _.__. I -- CROSS CONNECTION DEVICE 1 y_.. f�_-_1 ..f ._._1 I J DEDICATED SPECIAL WASTE SYSTEM DEDICATED GASIOILISAND SYSTEM 1 - _( DE�,ICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM hICATED WATER RECYCLE SYSTEM 1 _ J � _ _J :1 . _ f _-,-_.t ----! .__f= _ 1�.�.f= —A DIS�,JIIASHER I _..._. IE. f __-- f DRINKING FOUNTAIN -J — �._..-=- ---I -- _f ._.... -f - ; .. . ._! ..__....I _ .....1 ._...__.I . - t -.--...... FOOD DISPOSER 1 I - I I --J ^_ f -f ._.__.-1 FLOOR/AREADRAIN INTERCEPTOR(INTERIOR) KITCHEN SINK f - J — t .._= ( .. -._1 J _ ,J _f _..J _. f ____j _. . .I _._J ._._.J —] LAVATORY ROOF DRAIN SHOWER STALL —f .,___J _I ----_ _I ____f __ -_ ____.1 -._ -. ._ f I .- -_ I -•_-- _.._J - I __ SERVICE/MOP SINK TOILET URINAL @� I . f ----1 WASHING MACHINE CONNECTION i WATER HEATER ALL TYPES WATER PIPING - I ---'` =-- i I I .._.._ -< (-,' I OTHER f -.1 .�. J .. _ 1 ��_�_( __ J - - f - -f _ I _...- _.J _.._.. .! �f - S ..J f _ - -� - - E_]JL i INSURANCE COVERAGE; I haveµa current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES NO 0 IF YOU CHECKED YES,PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY _' OTHER TYPE OF INDEMNITY ]_] BOND OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement. _ CHECK' NE ONLY: OWNER ] AGENT SIGNATURE OF OWNER OR AGENT I l B hereby certify that all of the details and Information I have submitted or entered regarding this application are ue, nd a cura to :e best of my knowledge and that all plumbing work and Installations performed under the permit issued for this application will be in co pl 4e !that e I ent prmAslon of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAM LICENSE# IG ATURE MP 59 JP[j ORPORATION Fj#[�PARTNERSHIP # LLC COMPANY NAME f); ,. i r.. c I�l�- ADDRESS {. ?- Cie I --- --- CITY ��r a iC.° _ __.. _..__...__.. STATE ZIP % - TEL FAX - _ ( CELL �.. ,.�„_._ J EMAIL 1 t {I cHARLES D. BAKER GOVERNOR Commonwealth of Massachusetts JOHN C.CHAPMAN UNDERSECRETARY OF 1 KARYN E. POLkTO Division of Professional Licensure CONS U MRAF AIRS R AND LIEUTENANT GOVERNOR BOARD OF STATE EXAMINERS OF PLUMBERS AND GAS FITTERS CHARLES BORSTEL JAY ASH DIRECTOR,DIVISION OF SECRETARY OF HOUSING AND 1000 Washington Street • Boston • Massachusetts • 02118 PROFESSIONAL LICENSURE ECONOMIC DEVELOPMENT March 20, 2015 J.D. LaGrasse &Associates Joseph D. LaGrasse, Principal One Elm Square Andover, MA 01810 Re: Variance ► DA PV219—Dr.Timothy Norton (Medical Office-203 Turnpike St.-North Andover Dear Mr. LaGrasse: The Board of State Examiners of Plumbers and Gas Fitters grants your request for a waiver from the requirement to provide drinking fountains, with condition, as follows; 1. Provide drinking water stations/dispensers for each set of restroom facilities. 2. Install rough plumbing for fiiture drinking fountain(s) as required by 248 CMR. Note: Failure to adhere to the above conditions will render this variance grant null and void. The granting of this request is applicable to this eyed user and this location only. All other plumbing and gas fitting work if applicable shall comply with 248 CMR 3.00 through 10.00 and all other applicable statutes and Codes. Your attendance at a Board meeting is not required. This waiver is in effect upon receipt. Sincerely; For the Board Wayne E. Thomas, Executive Director Board of State Examiners of Plumbers&Gas Fitters TEL: 617-727-9952 FAX: 617-727-6095 TTYITDD: 617.727.2099 http:l/www.mass.gov/dpilboards/pt/ The Commonwealth of.IV.I'assachusefts Department oflndtfstri(d Aecldd` is Office of fn vestigations 600 Washington Street Boston,MA.02.111 Uf www.mass.govIdia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please�'rlint�e ibl Name(Busiucss/organization/lndividual): ') ' '�? Lei Address: - '� c: i '/ f City/State/2zp: �'lr C Phore i#: � Are your nn omployerY Cheek e appropriate box: Type of project(required) 1. X am a employer with J 4. El am.a general confractor and T 6. E]Now constinction. (full employees full and/or * havo hired the sub-contraofors p y p listed on the attached sheet: 7• enr:odoling El T am a sole propriofor or partnex4 2. ship and'l�ava xxo employees. Theso sub-contractors have S. El Demolition working for me is any capacity. workers' comp.insurance. 9. []Building addition [No workers' comp.insuranco 5. Q We are a corporation and its lo.0 Electrical repairs or additions required.] officers have exercised then 3.[l I am a homeowner Aing all work right of exemption por MOl; l LEI Plumbing repairs or additions mps elf.[No workers'comp. c. 1.52, §1(4),and we have no 12.0 goof,repairs insurancerequired.]t omployees. [No workers' ME] Other comp.insurancorequireal.j !Any applicant that checks box Of must also fill out the section belaw showing their workers'eompensation.policy information. t-Hemeowners who submit#his afFldavit indicatingthey a're doing all work and then hire outside contraotors rnustsubmit a new affCdavitindloating such. tCoutraotors that cheolcthis box must attached au ddditional sheet showing the name ofthe sub-contractors and their workers'comp.polloy fi formatlon. X am an employer that isprovidirig worirem,compensation hisurance for my employees Below is thepolley and kb 81te information. Tnsuranco CompanyName:. } ' r' - --`Z SZA 2 <� '1 i2-0A11C 6- polloy#or SON i ,Die.0: Expiration Date: A,/Z 211f.�" Job Site Address: .C)� TV L k2,al�� - City/Statelzip: AL!� lj h) )o v ef= A.tfiach a copy of tiro workers'compensation p olicy ileelarafio-n page(showing the policy)number and expiration dato). Failure to secure coverage as requiredundox Section 25A ofMGL o. 152 can lead to the imposition,of criminal penaltzes of a fine up to$:1,500,60 and/ox one-year huprisonment,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 maybe forwarded to the Offtoo of Investigations of the IA for insuranco coverage verification. I do Hereby et! i rtrt 7 alms and penalties of fret;wy that tree informatlonpr'ovideZ1,61e, ove s frue and eorrect. Date' &1/5- Phone Official use only. Do not wale in Ellis Ma,to be Completed by city or torvrc official City or Town: Permit/License 1# Issuing A.uthority(circle one): x.Board of Health 2.13uildingDepartment 3.ChoTown Clerk 4.Electrical Imp ector 5.Plumbing Inspector 6.Other - J - Coniact Derson: P11one 9: 7 q h i a I March 09, 2015 Mr. Jim Hurley Town of North Andover Plumbing Inspector 1600 Osgood Street Building 201 Suite 2035 North Andover, MA 01845 Re: 203 Turnpike Street I Suite 125 Shower Variance Mr. Hurley, In addition to seeking a plumbing variance regarding the shower requirement in a medical use facility (previous letter dated 2/25/2015) we are submitting a request for a variance from 248 CMR, Section 10.10, Table 1 requiring the installation of a drinking fountain for each set of toilet facilities in medical use buildings. Aside from a single convenience toilet facility within my client's lease area, the primary men's and woman's toilet facilities are located in the common core area of the building. There is no common drinking fountain in this area. After discussing with the client we have decided to seek a variance from the State Plumbing Board for the installation of the drinking fountain and instead, for compliance with the spirit of the code, propose the utilization of a bottled water cooler/dispenser located within the lease unit Waiting Room in lieu of the code specified drinking fountain. If you have any comments regarding this issue please call me at your earliest convenience. Sincerely, ��pEo ARph� 4 CwFC,N No.4153 Joseph D. LaGrasse, AIA ""°A One Elm Square T 97B,470,3675 1420 Celebration Blvd Andover,MA 01810 1 978.470.3670 Celebration,FL 34747 it" €. AA26001333 February 25, 2015 Mr. Jim Hurley Town of North Andover Plumbing Inspector 1600 Osgood Street Building 201 Suite 2035 North Andover, MA 01845 Re. 203 Turnpike Street 1 Suite 125 Shower Variance Mr. Hurley, 248 CMR, Section 10.10, Table 1 requires the installation of a shower for all medical use facilities. Unit 125 will be a vascular physician and would require the installation of a shower. After discussing with the owner we have decided to seek a variance from the State Plumbing Board for the installation of the shower. We would like to move forward with construction while waiting for our hearing and the decision of the Board. We understand we would be moving forward at our own risk and that we may be required to install the shower if the Board denies our variance. We will abide by the.decision of the Plumbing Board whether it is favorable or.. not. If you have any comments regarding this issue please call me at your earliest convenience. Sincerely, �� eD Aucy�r Ek Jo eph D. L.aGrass ,_A A o s Aaov� , MA U P ot rH o>=MPy�G One Ellin Square T 978.470.3675 1420 Celebration Blvd Andover,AIA O1810 F 978.4,70.3670 Celebration,FL 34747 a1'M'N 't,-'tI'A e-,u 11 i 101;Iy,g!I)III AA26001333 z s { _ t I11l: a WIT i1 Of #, ...: s .-. . 5son r it t LLJ MAM Why k' • top All I t s� >r <C/v � : A[.VKL, CERTIFICATE OF LIABILITY INSURANUL 2/24/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION'ONLY AND CONFERS NO RIGHTS OFON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND TkE CERTIFICATE HOLDER. lM PORTANT: IF the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsements, PRODUCER CONTACT E• PG Genatt GroupLLC l4S P ME'. _ 3333 NEW HYDE PARK RD f IdAIL 706489-1 SUITE 409 ADDRess: NEW HYDE PARK NY 11042 INSURERS AFFORDING COVERAGE NAW0 INSURER A INSURED 114SURERS:8 8 G CO AFAMASSACHUSEfTS INC.,SUBSIDIARY INSURERc-.13hiladeipbla Indemnity OF AFA PROTECTIVE S' fEMS,INC. INs6neRD: eG 'o any Insurance- Company 200 HIGH STREET BOSTON MA 02110 INSURER E: INSURER P COVERAGE$ CERTIFICATE NUMBER:608676608 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLECIES:LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IRS TYPEOFINSURA1iCE ADDLSUBR POLIC EFF POUGYEXP NSR LNVb POLICYNUMBIER MOM MMIDD UmTS C GENERALLIABILITY P14PK4293749 1212015 012J2016 EACH OCCURRENCE $1.000,000 X COMMERCIALGENERALLMSILITY PRA M5ESO[aoNxup ee 57A00,000 CLAIMS-MADE �OCCUR MEDEXP An one essan 55.000 PERSONAL&ADV INJURY $1.000000 GENERALAGGREGATE I 55,000.000 GEN'LAGGREGATELIMiTAPPUESPt:M PRODUCT&-cohmopAes I 55.QO 000 POLIGY X RO- IOG 5 B AUTTOMOBILELIAUILITY SISIPCA08202315 1712015 1212016 Eas dent 1.000.000 X ANYAUTO ROAILYINJURY{Perperson) 5 AUIOOWNEO 41CIIEOS SULFD BODILY INJURY(Perecddeno 5 NOR-OWNED ROPER�YDAMAGE 5 X HKEDAVID X AUTOS P¢raaet enl A X UMBRELLALIA13 X cc CUR 014550196 1212615 1212016 EACHOCCURRENCE„- $25.000.000 EXCESSLIAS CLAIMS-MADE AGGREGATE S25000.00D DEL) X REEIMONS10a00 $ 0 wORssERscaMPraEsnYtaN. T�VC3464077 12f2015 1212016 X +Gsr su- DTH• AND EMPLOYERSILIABILITY —--°° ANYPROPREETORIPARTNIRIExECtmvE YIN E.L.EACHACCIOEIVC $1.000.00D OFFICER[MEMSF.RE XCLUDE07 H[A , {MandataryinNll E3..DISEASE-E.AEMPLOYE 31.00g000 'bawler1[yyes.desc L7ESCRIPTIONOFOPERATIONSbelow E-L_DISEASE-POLICY LIMIT 31,060.000 DESCRIPTION OF OPERATIONS ILOCAl1ONSIVEHICLES(AUachACORb101,Additional Remaftschedule,ttmorespaceisrequited) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE A13OVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL 13E DELIVERED IN EVIDENCE OF INSURANCE ACCORDANCE WITH THE POLICY PROVISIONS. s •x* AUTHOIUmo REPRESENTATWE I I a &-I— ©Igoe;ZI?10 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) i The ACORD name and logo are registered harks of ACORD �� lttt; t,vrrttnvnrvt:ttttn v�irlusaut:reu.�Cei� ' Department of Industrial Accidents Office oflnvestigations 600 Washington Street Boston,MA 02111 wipmntass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/ElectricianslPlumbers Applicant Information Please Print Legibly NaMe(&tsiness/Organizationfindividual): AFA Protective Systems,Inc. Address: 200 High Street City/State/Zip: Boston,MA 02110 Phone#: 617-772-5900 Are you an employer?Check the appropriate box: Type of project(required): 1. 1 am a employer with 40 4. E3 I am a general contractor and I 6. E]New construction _ employees(full and/or part-time).* have hired the sub-contractors 2.�] I am a sole proprietor or partner- listed on the attached sheet.t 7• Remodeling ship and have no employees These sub-contractors have 8. Demolition working for me in any capacity. workers'comp.insurance. 9. Building addition [No workers' comp.insurance 5. 0 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 I1.❑Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12.[0 Roof repairs insurance required.]t employees.[No workers' MUM Other Low Voltage Install comp.insurance required.] J ' *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. l ani aii etth to er tliat is rovirliit lvorlrers'coin ethsatloti itisihrance or nh eni to ees Below is the olio and job site P Y P � P f Y P Y policy I ithfbrfttatlpli. Insurance Company Name: Technology Insurance Company Policy#or Self-ins.Lic.M. 1WC3464077 Expiration Date: 2/12/2016 Job Site Address: City/State/Zip: OUP Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the,Office of Investigations of the DIA for insurance coverage verification. X do Hereby certify itisde thepaihis andpetialties of erfttry that die hiforuiation provided above is(hire a i i d eorh ect: Signature: Date: Phone#' fi17-772-5900 Official rise only. Do trot m ite in this area,to be completed by city or torvit official. City or Town: Permit/License# Issuing Authority(circle one): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: i Inn luunignunwettiin uJ trlu�aucnuaeie� Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 y wivit.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers A licant Information Please Print Legibly Name(Business/Organization/individual): AFA Protective Systems,Inc. Adch'ess: 1200 Nigh Street City/State/Zip: Boston,MA 02110 phone#: 617-772-5900 Are you an employer?Check the appropriate box: Type of project(required): 1.IM 1 am a employer with 40 4. [0 1 am a general contractor and I 6 New construction _ employees(full and/or part-time).* have hired the sub-contractors 2.( 31 am a sole proprietor or partner- listed on the attached sheet.t Remodeling ship and have no employees These sub-contractors have S. Demolition working for me in any capacity. workers' comp.insurance. 9. Building addition [No workers' comp.insurance 5. EJ We are a corporation and its 10 U Electrical repairs or additions required.) officers have exercised their 3.El l am a homeowner doing all work right of exemption per MGL 11. Plumbing repairs or additions myself. [No workers' comp. c. 152,§1(4),and we have no 12. Roof repairs insurance required.]t employees. [No workers' 13 9@ Other Love Voltage Install comp,insurance required.] *Any applicant that checks box M must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. Ions an employer that is providing workers'cosrrpensation insurance far my employees. Relow Is the policy and job site ` irtforntatiott. Insurance Company Name: Technology insurance Company Policy#or Self=ins.Lic:M. TWC3464077 Expiration Date: 2/12/2016 Job Site Address:r-507fi(I.,vel J7 -n/[ City/State/Zip: ). P� Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do Hereby certtry trader Elie paitis silt!penalties of erfttry that the information provided above is true and correct. Signature- Date: Phone#: 617-772-5900 Official use only. Do not write its this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health Z.Building Department 3.CitylTo`Yn Clerk 4.Electrical Inspector 5.Plumbing Inspector b.Other Contact Person:. Phone#: Information and -Insfiruction S Massachusetts General Laws chapter 152 requites all employers to provide waxlcexs'compensation for theft'employees. Pursu ant to this statufe,an e�nroyee is defltzed as"...every poison iti ffie service of anathex under'any contract of frixa,• express or implied,oral ox-written.,, An,employ r is defmcd as"an iudividual,partnership,assooigtion,cot Oratxcn or other legal entiI o anytwo pxmore of the force oing engaged in,a joint enterprise,anal,inoluding the legalxepresentatives of a-deceased aanploysx,or the xedeiver or;6- tee of an individual,partnership,asso olatien,or other legal,entity,employing employees. )14wover the owner of a dweflixig house Having itotmaxe than three apartments and who xesidos therein,,or the occupant ofthe dwelling house of another who employs persons to do maintenance,construction or repair work' such dwelling lrauso or on the grounds orbuilding appuxtenant thereto shall not because of such employment be deemedto bo an employer." MQL chapter 152,§25C(6)also states that"every state Or local licensing agency shall withhold the issuance or renewal of license or permit to operate a business or to cons'iructbuildings in the commonwealth for any applicant wire has not produced-acceptable evidence of compliance Wide the insuraxrco coverage required" Additionally,M�OL chapter 152,§25C(7)states"Nezthe�r the commonwealth.Roy any of its political sub6VIslom shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this cJlaptor have beou presented to the contracting authority." Applicants Please 0 out the workers'compensaiion affidavit completely,by cheoHng the boxes that apply to your situation,aird,if ,supply sub-caritractax(s)name(s),acldress(es)and phony numbex(s)along with thei7r coitificate(s)of insurance. Limited Liability Companies(LLC)ox Lituited Liability partnerships(LLP)with no employees other than the members orpartnors,arenotrequiredto carxyworkors'compensation ffisurance. ffanLLC orLLP daeshave emp1oyeo9,apolicy:1.8.xccl€7ired. Do advised thati isafdavitmaybasubmitted,fotheDepai'tmentof Industrial Acoidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit, T'he affidavit should be xehrrr odto the city or town,that the application for the permit or Reenso is being xequoAoq,not the Dq�artin ent of � Wusf4al.A.coidenfs. Should you have any questions regarding the law or if you are r'equixed to obtain,a*orkers' compensationpofioy,pleasecalltheDepartmentatthenumberlistedbelow. Sal--iusurad.companiosshouldenterthoIL- selfinsurance fiCense number on the appxc riato line. City or'Jt'owu Officials Please be sure that the affidavit is complete and printed legibly. The Depaztmout has provided a space at the bottom ofthe atUdavit foryou.to fill out in file event fire Office afSnvesogations has to con-taotyouxegardingtho applicant, Please bo-suxe to rill in the permitllicensa number whicliwill be used as a refexenco Mmbor, fa addition,air applicant that must submitmultiplo pormitllioense applications itr any givoa yoar,need only submit one affidavit indioath2g current PORGY information(ifnecessaty)and udder"Yob Site Address"the applicant should write"all locations in .(city or tow).)"-A copy of the affidavit thathas been officially stamped or marked by Tie city or town maybe provided to the applicant as proof that avalid affidavit•is on file far future liexmits or licenses, Anew affidavitmu'st be Mqd out each Year.Whero a frame owner or citizen is obtaining a license ar�otmit not related to any business or commercial venture (1,e,a dog license orHermit to but-n leaves efe)said p erson is NOT required to complete this affidavit, The Office of I nvesvgations would life to thank you in advance fox your co op exation and slipuld you have any egaestions, ploasa do not he41tate to give us a call. The epaxtxment's address,teleplionc,aad fay,nuutber: Uo CQM- 0A RI&of MV mar uotN Me WAYON-agatims 6bQ Wasbtgtm Stmt )308toni,MA.02111 Revfsed 5 26.05 Fax I� 4 Commonwealth of Massachusetts official Use Clnly Permit No. Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS [Rev u/07Jy and Fee Checked 'a (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL 'WORK All work to be performed In accordance with the Massachusetts Electrical Code(MEC), 27 C 12.00 (PLEASE PRINT'ININK OR TYPE ALL INFORWTION) Date: City or Town of: NORTH,A.NDOV,R To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location(Street&Number) �(} � -TV2lJ P1 �� 7 Owner or Tenant l� fty �� L Cam? Telephone No. Owner's Address Ts this permit in conj unction with a building permit? Yes No ❑ (Check Appropriate)[3ox) Purpose of Building Utility Authorization No. Existing Service Amps / Volts Overhead❑ -Undgrd❑ No.of Meters ew Service Amps I Volts Overhead❑ Undgrd ❑ No.of Meters Number of li eeders and Ampacity Location and Nature of Proposed Electrical Work: Com letion of the following table may be waived by the Inspector of Wires. No. of Recessed Luminaires No.of Cell.-Susp.(Paddle)Fans TransTotal Trsformers XVA _ No.of Luminaire Outlets No.of Hot Tubs Generators XVA Above In- o. a mergency ig t ng No.of Luminaires Swimming Pool rnd. ❑ rnd. ❑ Battery Units No. of Receptacle Outlets No.of Oil Burners FM ALARMS No, of Zones p �e No.of Switches No. of Gas burners No. of Detection and / Initiating Devices No. of Ranges No.of Air Cond. Total No,of Alerting Devices g Tons No. of Waste Disposers Heat rag Number Tons IOW No.of Self-Contained Totals Detection/Alerting Devices No,of Dishwashers S acelArea Heating IOW Local❑ Municipal ❑ Other p g Connection No. of Dryers Heating Appliances gW Security Systems. 3' No.of Devices or Equivalent No. of Water KW No.of No. of Data Wiring: Heaters Si ns Ballasts . No,of Devices o•E uivalent No.Hydromassage Batlitubs No.of Motors Total HP Telecommunications Wiring: No,of Devices or I; uivalent OTHER: Attach additional detail if desired,or as regadred by the Inspector of Wires. Estimated'Value of Electrical Work; (When required by municipal p olicy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10,and upon completion, INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability ins ranee including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such cover is in force,and has exhibited proof of same to the pormit issuing office. URA CHECK ONE: INSNCE EOND [] OTHER ❑ (Specify:) I cei-tify, under tit pants and peMa'-1 s o peijwy,that the in orntation oil this application is trice and complete. FIRM NAME: t6C f(iL LIC.No.: aa' �• Licensee: Signatu a LTC.NO.: (If applicable,enter "exempt"in the license number line.) Bus.Tel.No.: Address: Alt.Tel.No.. *Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License; Lic.No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by lave. y n y sign ow,I hereby waive this requirement. I am the(check one)❑owner El owner's agent. ownerlAgent _ (pf7 --7TZ,-S�l3U .PPRMIT.�EE.- $\2 Signature Telephone No. t c,v�u CERTIFICATE of LIABILITY INSURANGF. 212 !20 5 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE'DOi_S NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED 13Y THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT 13ETWEEN THE ISSUING INSUREtt(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the pol(cy(tes)must be endorsed. if SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate hoiderin lieu of such endorsements. PRODUCER TT.CT PG Genatt Group LLC o ErI Womod-511fi-A648973333 NEW HYDE PARK RD a A SMITE 409 W Ids NEW HYDE PARK NY 11042 14U ER s AF ORDING COVERAGE HAICq INSURanAS INSURED iNsuRtut q0jarr Indamnity AFA MASSACHUSETTS,INC.,SUBSIDIARY INSURERce OF AFA PROTECTIVE SYSTEMS,INC. tN9u;mnD%Tech 'oTog1t InsuranceCompany_ 20D HIGH STREET BOSTON MA 02110 INSURE Et INSURE Fr COVERAGES CERTIFICATE NUM BER:608676608 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE.FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, gEXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. DI ILA NpoortusuRAuce ANSI SUBDR POLiCYHUMBER MMtpA P ht�fuDE1Y P LIMITS C GENERALLIABILITY PHPKI293749 U1212015 1212016 EACHOCCURRENCE $1000.000 x COMMERCIALGENERALMIBILRY P EES EaEacu SS,000000 CLANMS•MAOE OCCUR MEOEXP An One person S5000 PERSONAL&ADVINJURY 51000000 GENERALAGGREGATE 55.000000 GEN'LAGGREGATeL1MiTAPPLIESPER: PRODUCTS-COMPIOPAGG 55,000000 POLICY X O- too 1 IT S $ AUTOMOBILBIJAMUTY SISIPCAO$202316 1212015, 12laO16 Eaacdde 100000D x ANYppAyyUyyTO gg BODILY INJURY(Per penon) S Alh NED AICHEDULED BODILYINJURY(Pereeddenj S NON-0WNEO R PER�`f 7n GE S x HIREDAUTOS X AUTOS era o . S A X UM13RELLAUAR NCIAWS-MA OCCUR 614550196 1212015 121201B EACH OCCURRENCE'. $25,000,000 EXCESSUA9 D>± AGGREGATE 525000,000 DED X RL TENT[ON510.000 S D wonKERs cofdmsA'RotJ 112J2016 X V AND EMPLOYERS'UADILITY • ANY PROPRIETORIPARTHERMXFOUME YIN E.L.FACHACCIDENr $1.000000 OFFICERtMEMBEREXCLUOEDZ NIA (MandatorytnNH) F.L.OISFAse-1-AEMPLOYE 51.000000 fffyYmdesufbeun er DESCRIPTIONOFOPERA-noNswow E.L DISEASE-POUDYWIr $1,000000 DESCRIPTION OF OPERATIONS[LOCAMOHSIVEHICLE${AllaehACOR0101,AddlNonalRemarksScheduie,I[maraspacalsre�{utredl CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES of CANCELLED 1313FORE THE EXPIRATION DATE THEREOF, NOT;CE WILL HE DELIVERED IN EVIDENCE OF INSURANCE ACCORDANCE WITH THE POLICY PROVISIONS. *wt AUTHORIZED REPRESENTATIVE: !vW ©1988 2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD i � 1 anzmoarvea!!h a�Illa �arhtr�eLEd Official- Only 1JeParfinenL a�,�ira �ervice3 i BOARD Off' FIRE PREVENTION REGULATIONS. Occupancy and Fee Checked _ Rev. 111991 APPLICATION FOR PERMIT. TO PERFORM ELECTRICAL WORK All work to be perfarnznl in accordaric¢frith the Mlassarlluscits Mudrica]Code(t(Eq' 527 CNIR 12,00 (PLEASE PRINTININK OR TYPE.ILL ItV!'OR-A-L-fT10N) Date: Cit}' or Town of,' € oq&r— TO L1ie Ittspeclor of Mlles: By tltis'application die uzadersigned sees notice-ofhis.or her intentiou to perform the electrical work described below. Location (Street S itiurr�cr ' -- '� tativner or Tenatrt ., Telephone No. 1. Owner's Address Is this perzttit in conjunction witli n building permit? Yes1 ❑ No ❑ (Check Appro'date I3ox) . 'Purpose of Building utility Aufboriraiiorr No. xisting Service Amps ! Volts Overhead ❑ Uirdgrd ❑' No. of 11Ic(ers Sen-ice Atrtps I ti`ulis Overhead ❑ Undgrd ❑ No. of tlleters Number of Feeders and Anipacffi Latch ' and Nature cf ProposedElcctrir�al��Vark: _ , 1If1�- Ti Cara la on of the follr3+virrq table utal,be wairerl by the firs ctor•of lures. ` No. of Recessed F•t=lures. No,of Ceil.-Susp. (Paddle)Fans 14a, of Total 'I'rarrsfornzers I;.VA No, of Lighting Outlets No. of I•lot Tubs Generators KN'A tqo,. oFLighiing Fstures S�rinuning Pool Above ❑ In- ❑ a.o uzcrgeucy rg rturg rnd. rnd. Battery Units No, of Receptacle Outlets l O. No. of Oil Burners FIRE ALARMS No.of Zoues No, df switches No.of Gas Burners Na•nC Detection and Initiating Devices tal No. of Ranges No.of Air Cond. � No. of Alerting Devices ns No, of Waste Disposers Hcat pump tl�untber 'l azzs K1V No. of cif•-Contained Totals: DclectioulAlerting Devices ❑.Irlunicipal \ No. of Diihwashers SpacelAren Heating KW Local Connection ❑ Other No. of Dryers Heating Appliances lov Security Systems: No, of Deices or E uiva"le€tt `� Na, of!!rater XNY i4a,of Na.of Data Wiring: �J 1-lenter•s Signs Ballasts No.afDeviccs or E uMilent No.Bydrornassage Ratlrtubs No. of Motors Total HP I'clecomnttsuic::tions�1'iritrg: No:of.Devices orE ui�alent O THE R: ' ttrtacit additional derail if desirer� or as required by the Inspector of Wires, \ INSUR-4uNCE COVERAGE: llnlcss waived by the owner, no permit for the performance of electrical work may issue unless r the licensee provides proof'of liability insurance including"completed operation"coverage'or its substantial equivalent- T11e uudt�signcd certifies that srtch cov rage is in force, and has exhibited proof ofsatne to the permit issuing.office, .CHECK ONE: INSUR�INCE BOND ❑ O'1'IiER ❑ (Specify:) (Expiration Dole) Estimated Value of Electrical Work: '' (When required by municipal policy.) Work to Start: .,- ' Inspections to be'rcquested in accordance with MEC Rule 10,and upon completion. l I cerdfl•r undcr the Iiatrrs and penalties of perjury,dart the information an this application is trite trttd.completre. - FIR LTC.NO.: {. ,l L.tcensec: 5i° g�nature ' ;, haw w- LIC.NO.: (Ifappiicable, enter "emrrr t""in the ln_rnce muuber.litre_)} —_ IusTe l. a.:. LAddress: Alt Tel.`o 'MA"NER'S INSU"NCE WAIVER: I am-aware that the Licensee does not haste the liability insurance covcfage normally R' z required by Ia��. B zy s� ' tore below I hereb •xtmive this rc uircmcrtt I ant Ilse chcek one} q ( ) ❑o�s7�cr El a�llenl. OWncr/Abezlt . Sigtzatur P- Telcphonc.No. Pi?I�t�fIT.FEL: S ri The Commonwealth of Massachusetts i Department of Industrial Accidents Office of Investigations - _ 1 Congress Street, Suite 100 Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le k 'bl Nagle (Businessiorganization/IndividaaY�;� Address: City/State/Zip: `5 Phone Are you an employer? Check the appropriate box:' Type of project(required): 1.❑ I am a em la er with 4-❑ I am a general contractor and I �mployees(full and/or part-time).* have hired the sub-contractors 5 New construction 2.[ I am a sole proprietor or partner- ship listed on the attached sheet7. ❑ Remodeling ship and have no employees These sub-contractors have & ❑ Demolition working for me in any capacity. employees and have workers' 9 ❑ B ding addition [No workers' comp, insurance comp. insurance.# required] 5. El We are a corporation and its 10. lectrical repairs or additions officers have exercised their 11. Plumbing repairs or additions 3.❑ I am a homeowner doing all work ❑ g P myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] t c. 152, §1(4), and we have no employees, [No workers' 13.0 Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tCont,ractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp,policy number. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins. Lic.#: Expiration Date: Job Site Address: City/state/Zip; Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration(late). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby certify under the pa s and penalties of erjury that the information provided above is true and correct, 0 � Si : ature: - Phone#: Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2,Building Department 3, City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector d. Other { Contact Person: Phone#: Commonwealth of Massachusetts Official Use Only Department ®f Fire Services Permit No. 7,7-C"` Occupancy and pee Checked low BOARD OF )FIRE PREVENTION REGULATIONS [Rev.1/07] leaveblank APPLICATION[ FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed In accordance with the Massachusetts Electrical Code(MEC),527 CMR 12.00 (PLEASE PRINT INMK OR TYPE ALL INFOR1VfATION) Date: N13 - City or Taws of: NORTH ANDOVER To the Inspector of Wires, By this application the undersigned gives notice of his or hor intention to perform the electrical work described below, Location(Street&Number) o 3 1 Z, ,' t S'"T �t�✓ �" �� Owner or Tenant /V/�0 P Telephone No. Owner's Address ,�r'r�� _S - '{ 315- i Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check AppropriateBox) Purpose of Building ' '� Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd❑ No,of Meters New Service Amps / Volts Overhead❑ Undgrd ❑ No.of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: t,, p-s 3 Vey ,, /e 4 .�rv��, pu'j"(e'9' `,� �,`,�y- tn> t°rta-.t �'je3'e"a'", lC'c.+•� '0'S�>9'�- w,'r-z., �'�r4'> �� ,cj'' eJ„a��, r�er,�i. Completion of the following table may be waived by the Aspector of Wires, No.of Recessed Luminaires No.of Cell.-Susp.(Paddle)pans Trans Total sfor3€ners IS`VA No.of Luminaire Outlets No.of Hot Tttbs Generators ICVA No.of Luminaires 3 Swimming Pool Above ❑ In- ❑ o.o mergency Lighting rnd, tnd. Battery Units No. of Receptacle Outlets 3No.of Oil$urners FIRE ALARMS No, ai Zones No. of Svtitclres ,; No.of Gas Burners No.of Detection and InitiatingDevices No.of Ranges No.of Air Cond, 3 Tons1 No.of Alerting Devices HeatPump Number Tons KW No. of Self-Co ntained No. of Waste Disposers Totals: ` " os ............. Detection/Alerting Devices No, of Dishwashers S ace/Area Heating KW Local❑ Municipal ❑ Other p g Connection No.of Dryers Heating Appliances Kw SecN t o.o DeviSysteces or Equivalent No. of Water IOW No.of No. of Data Wiring: Heaters Signs Ballasts No.of Devices oir E uivalent ecommunicatNo.Hydromassage Bathtubs No.of Motors Total HP TeINo of Devices orsE a vwirinalent OTHER: GI)p iW c Attach additional detail ifdesired, or as required by the Inspector of Wares. Estimated'Value of Electrical Work: 0-0,0'6 (When required by municipal policy.) "Wolrk to Start: )-1-5--#3 Inspections to be requested in accordance with MEC Rule 10,and upon completion, INSURANCE COVERAGE: Unless waived by the owner,no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including"completed operation"coverage or its substantial equivalent. The undersigned certifies that such coverage is in force,and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE [A BOND ❑ OTHER ❑ (Specify:) ,I eeri fy, under the pains idol penalties of pelluly,ill at the intonation on tlti8 application is true and complete. FIRM NAME: . �. f��. f c ® =i��: LIC.NO.: ,-> l 2 f Si nature ;%' > r` �° r LTC.NO.: Licensee: 1 l� t g (If applicable,enter "exeinp "to the li ense nannber line.) � � Bus,Tel.No.: 7-9l"�d T I)y 7 Address: �;1 �'��d� j�/<1 u�,'r �r �f� ��>-� Alt.Tel.No.: "Per M.G.L c. 147,s.57-61,security work requires Department of Public Safety"S"License: Lin No.� OWNER'S INSURANCE'WANIsR: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below,I heroby waive this requirement. I am the(check one)❑owner ❑owner's agent. Owner/Agent pER2 Xfi 'EE: $ Signature Telephone No. The Commonwealth of 1Massachusetts _. _ Department of. ndustri(d AccW' is Office of Investigations 600 Washington►S`ireet Boston,MA 02111 UqF www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers App licant Information Please Print Le ibl Name(Business/Organization/Individual): Address: -7`7 A c_.�rG� l��' �_^ t 4_ C � City/State/Zip: /UJ r,--c ( ( , r F. Phone#: 787-.,7 i')6 0 31 5 Are ou an employer?Check the appropriate box: Type of project(required); �' yp p � 1.0.I am a employer with 3 4. ❑ I alit a general contractor and I S. ❑New construction employees(fail and/or part-time).* have hired the suit-contractors 2.El am a sole proprietor or partner- listed on,the attached sheet,* �• ❑Remodeling ship and'have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. ❑Building addition [No workers' comp.insurance 5, ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. Pgo workers' comp. c, 152,§1(4),and we have no 12,❑Roof repairs insurance required.]t employees. [No workers' nfl Other comp insurance required.] *Any applicant that checks box 01 must also fill out the section below showingtheir workers'compensation policy information. Nomeowners who submit this affidavit indicating tliey are doing all work and thenhiro outside contractors must submit a new affidavit indleating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp,policy information. fain an employer•that is providing worlters'compensation insurance for'tny employees. Below is the policy and job site infotrrtatlon. Insurance Company Name:; r._ - ' Policy#or Self ins.Lic.A, w C c--5-0 0 5-O 1 c Expiration Date Jab Site Address- City/State/Zip: Attach a copy of the workers'compensation-policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A ofMGL e. 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 t6$250.00 a day against the violator, Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA.for insurance coverage verification. I do tereby certo under ilge palnq and penat'tles ofperJury that the information provided above is trite and correct. Simature• '� .. � Dater hone 0: Dffrcial rise only. Do not ivrite in this area,to he completed by city or totvrz official City or Town: Permit/License# Issuing Authority(circle one): x.Board of Health 2.Building Department 3.City/Town Cleric 4.Electrical Inspector 5,Plumbing Inspector #.Other m - Contact Person: Phone#: (flinmonWeallh.DI Va44aclzu-4etb Official Use Only Pen-nit No. N-1 FU Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev, 1/07] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code 527 C IR 12.00 (Pl- 4 SE PRJ,-VT LY I-VK OR T�Y E.4 L Mr 4 TIO Date: To the Inspectv, of P�ices: Cih� or Town of: A. M2 1, 9 By Loca,llisflon ap(Streeplicatiton&thNumb,er)c Undcrsig(.�i ives 11 oti�,eof his or her iintpnpon to perfogni the electrical work described below,t l Oa%11 e r 0 1.Tena n I Telephone Niv�,/ (AN n e r's :Address Is Illis wn-mit in conjunction with a building permit? Yes Ej No 0 (Clieck Appropriate Box) Purpose ot'Building Utility Authorization No. Lxislinu Service Amps Volts Overhead El UndardEl No, 01'Meters NVNN,SVI-vice Amps Volts Overhead ❑ Und-rd ❑ No. of Meters N Nurnbet-of Feeders and Ampacitv Location and Nature ol'Proposed Electrical Work: Coinplefion of ihefiollowin�& able inai,be waived by the As2ecior of Trims. No.of Total No. of Recessed Luminaires No.of Ceil.-Susp.(Paddle)Fans Transformers KVA No, ofl-tnitinail-L Outlets No, of Hot Tubs Generators XVA /�111 Above In- I lo.of emergency Lighting No, of luminaires Swimming Pool fired. ❑ grnd. Battery Units No. ol'Recept-acle Outlets No. of Oil Burners FIRE ALARMS INo. of Zones D No.of-switches No.of Gas Burners No.of etection Initiating and Devices of R, Total Ranges No.of Air Cond. Tons No.of Alerting Devices Heat Pump U JKW No.of Self- ntalned No.of Waste Disposers 'Totals: ............ Detection/Alerting Devices 0 Mun No. Of Mshwashers Space/Area Heating KW Local "c'PP' 0 Other Connection No. ofDryers Heating Appliances KW Security Systems:y No.of bevices or Equivalent No.of 11'qter KW No. of No. of Data Wiring: beaters Ballasts Signs No.of Devices or Equivalent Telecommunications Wiring;No. Hydroniassage Bathtubs No. of Motors Total HP No,of Devices or Equivalle nt OTHER: 4ttocli additional derail if desired. or asrequiredbv Me Inspector of ff"ires. Lstimaied Vultle 'E.1ccu-1cal NVork: ff' hen required by municipal policy.) %Vork I Stu, Inspections to be requested in accordance with MEC Rule 10,and upon completion. INSURANCE V -/AhA: TUJnlcss waived by the owner,no permit for the performance of electrical work may issue unless d)o licensee provides proof of tiabilit) insurance including"completed operation"coverage or its substantial equivalent. The LIIAcI-Swiwd certifies that such coverage is in force, and has exhibited proof of same to the pen-nit issuing office. CHECK O\E: INI SUIRANCE 0 B011,71) El OTHER D (Specify:) I eej-(ijj,, under the pains and penalties qj'pejuq, Mal the information on this application is True and complete. F I 10 1 'N.VN I E:'4� LTC A- 1-n .NO.: Licensee: .Ae& —T—C, r14 L Signature IC.NO.: lfopp tic(Ible G1710, "C'"0 )f"1n f/?e liceffse tTIIt6e4l Tel "Bius.Tel.No (VEIP9 Alt,Tel.NO-(2 11106 Per\1.C),L. c. 147, s. 5 7-6 1,security workrequires Depard-nent of Public Safety"S" License: Lic,No. 011-'-,'FR'S INSUIUkNCE WAIVER: I any aware that the Licensee does not have the liability insurance coverage normally icquir(:d by 1;m% By nly Si.(gliaLUre below,I hereby waive this requirement. I am the (check one) El owner El owner's agont. 01% 'E $ Telephone No. tiUILUINV FtKMI I r a�:,'. •a o� ' TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINAT 0' Permit NO: ��' Date Received .= Date Issued: �`�, / SaCHus� IMPORTANT: Applicopt must complete all items on this page LOGA71T1 i 11lIAP NO; P� 1ONNO1i1+ . ,. „�Hla>4�1��lstr� t y ... . :" .. TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial Iteration No, of units: Commercial ❑ Repair, replacement ❑Assessory Bldg o Others: ❑ Demolition ❑ Other Q Septl Well t�Icntlpl �n Dflletlxtts D Wterhd 1sr� t Accc�'olnxA0 I a-YvA Ck-y1'2nI-V i-Y, 4- �) , 'm 1 f 0-A K)U � 6+wio n a.VA e- CIO t 4 (g TbCP Identification Please Type or Print Clearly) OWNER: Name: Phone: Address: 3 i k)e1JV ''-cY1 k Z4 1 r Addis. F upe�t 0--, Jr- S on tru kllD� I�1Ge11tI p Date Yf y HQm �rrtpt ouel�tel7t acer� gyp, I�ie I rr' l ARCHITE T/ENG,NEER W, d, �� I�,� �_ Phone: Address: Hnt : I Y) Reg, No. FEE SCHEDULE:BULDING PERMIT:MOO PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ Aq�QI bq , 00 FEE: Check No, Z®1 Receipt No.: NOTE: Persons contracling whir unregistered contractors do not have access to the guaranty fund agnal�re;of AgentlQwne _ lgnature of contract 1 , Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED PLANNING & DEVELOPMENT ❑ ❑ COMENTS CONSERVATION ❑ ❑ COMMENTS DATE REJECTED DATE APPROVED HEALTH ❑ ❑ COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature &Date Driveway Permit t Located at 384 Osgood Street ,l t,o�a#ed�i ��Mein Strut Flre D��a�m�ant�� lttrir�ld�i 1 NORT" Towe. of � : i _ �� . ndover Q � - 0 No. so h ver, Mass, Cxwicw�wKx 1' / � U BOARD OF HEALTH Food/Kitchen PERMIT T LD Septic System THIS CERTIFIES THAT BUILDING INSPECTOR has permission to erect .......................... buildings on ......o..,�.....� ..........f..�..�.'.� ..` '�� 2 Ffl , .�. j Rou to be occupied as ........... .. . . ..................Y..,'..�.............. °:..1..!; ... . ?...N�!7.�?eLl........... m y r provided that the person accepting this permit shall in every respect conform to the terms of the application I al ��--� on fife in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and , Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR Rough ��I VIOLATION of the Zoning or Building Regulations Voids this Permit. _Final -�5:5 PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTO UNLESS CONSTRUCTION TARTS (00i� / Service X-iIJILDI.NG-INSPECTOW _?_ZZ� GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Smoke Det. �— o x�oi�1H 6}g•Pre +,o F Mx an R y eta�CINSE'49 CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Permit Number 639-15 on 2f212015 Date: April 29, 2015 THIS CERTIFIES THAT THE BUILDING LOCATED ON 203 Turnpike Street— Suite 125 MAY BE OCCUPIED AS IN a doctor's office ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: NAOP LLC—Dr. Tim Norton 203 Turnpike Street North Andover,MA 01845 dui Building Inspector Fee: PreP aid$100.00 Receipt: 28471 Check : ........ t%ORTH own of 2 : s ndover 0 No. - _ na h ver, Mass, 7�A04ATED � U BOARD OF HEALTH Food/Kitchen PERMIT T L D��/ Septic System THIS CERTIFIES THAT f 7 , ....... BUILDING INSPECTOR ................ ... ................................................................................................ I 2 Fo , has permission to erect .......................... buildings on .......7J.....7!l-u�`....�.� f.?..... .�.C,...... Rou to be occupied as ...........,/.. ..`..'... ..,......, ✓./. ... d... L�.'7 (v,. ..... m y provided that the person accepting this permit shall in every respect conform to the terms of the application al ��- 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 INSPECT R ✓�� VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final �J PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTO UNLESS CONSTRUCTION STARTS &P�w ................ Service e iY / BUILDING INSPECTOR �nal ,� — r f GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Smoke Det. � � o � 4 0 f y t=s.C110E{ CERTIFICATE OF USE & OCCUPANCY TOWN OF NORTH ANDOVER Building Permit Number 639-15 on 2/2/2015 Date: Aprit 29, 2015 THIS CERTIFIES THAT THE BUILDING LOCATED ON 203 Turnpike Street-- Suite 125 MAY BE OCCUPIED AS IN a doctor's office ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: NAOP LLC--Dr. Tim Norton 203 Turnpike Street North Andover, MA 01845 Building Inspector Fee: PrePaid$100.00 Receipt: 28471 Check : I I h, ^ p' li 7 4 , I • € 5 March 09, 2015 Ms. Susan Sawyer Town of North Andover Health Director 1600 Osgood Street Building 201 Suite 2035 North Andover, MA 01845 Re: 203 Turnpike Street 1 Suite 125 Drinking Fountain Variance Ms. Sawyer, In addition to seeking a plumbing variance regarding the shower requirement in a medical use facility (previous letter dated 2/25/2015) we are submitting a request for a variance from 248 CMR, Section 10.10, Table 1 requiring the installation of a drinking fountain for each set of toilet facilities in medical use buildings. Aside from a single convenience toilet facility within my client's lease area, the primary men's and woman's toilet facilities are located in the common core area of the building. There is no common drinking fountain in this area. After discussing with the client we have decided to seek a variance from the State Plumbing Board for the installation of the drinking fountain and instead, for compliance with the spirit of the code, propose the utilization of a bottled water cooler/dispenser located within the lease unit Waiting Room in lieu of the code specified drinking fountain. If you have any comments regarding this issue please call me at your earliest convenience. �_D At? Sincerely, C��4 La rF�, 4153 `� N AND OVER, „f A sJ Joseph D. °� One Elnt Square T 978.470.3675 1420 Celebration Blvd Andover,AIA 01810 1+978.470.3670 Celebration,IT 34747 AA26001333 VV-1 February 25, 2015 Mr. Gerald Brown Town of North Andover Building Department 1600 Osgood Street Building 201 Suite 2035 North Andover, MA 01845 Re: 203 Turnpike Street/ Suite 125 Shower Variance Mr. Brown, 248 CMR, Section 10.10, Table 1 requires the installation of a shower for all medical use facilities. Unit 125 will be a vascular physician and would require the installation of a shower. After discussing with the owner we have decided to seek a variance from the State Plumbing Board for the installation of the shower. We would like to move forward with construction while waiting for our hearing and the decision of the Board. We understand we would be moving forward at our own risk and that we may be required to install the shower if the Board denies our variance. We w-lLabide by the decision of the Plumbing Board whether it_is favorable or not. If you have any comments regarding this issue please call me at your earliest convenience. Sincerely, ��D ARC&�T p, LaGR9�CA CAJ, o No.403 � )` oseph D. LaGrasse, AIA o ANpoVERI t MA a 2i0 p4� y�F L7H OF MPS One,Elm Square 'I'978,470.3675 1420 Celebration Blvd Andover,AIA 01810 P 978.470.3670 Celebration,FL 34747 ��°titii,.l�, i,'mt55rao <;lfataxtltimiot?, AA26001333 I I F F ,Z sA A NORTH ELEVATION B NORTH EAST ELEVATION I �� z � ts' i � c teas �z r � �s t�� •^ ��{ i�� w nn Z LOC fS PLAN C EAST ELEVATION 4 ... ... .. .......... .... ..... __.... ...... .. . . .. �AORTH own of � .At,, over 0 „ - to ver, Mass, Coc ai[He wc� v- �,q °RATF n S U BOARD OF HEALTH PERMIT T D' Food/Kitchen Septic System �// BUILDING INSPECTOR THISCERTIFIES THAT ........ ..O............................................................................................. /J�11Y Y / f j�f ,r� rc 1= S„�� Foundation has permission to erect .......................... buildings on .......{. �.[(. /�. .... . ... !.?. . ..... ��5- Rough to be occupied as ............/... . . ................. ............ ...r.l..!:� ....:!... ..��l..�n. � ........... Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION TARTS Rough Service ..... ......� ................................ INSPECTOR Dina[ X--�IJILDING GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final YY No Lathing or Dry all To Be Done FIRE DEPARTMENT Until Inspected and Approved by the Building Inspector. Burner Street No. Smoke Det. I Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost 196X5.0,0 m $ - $ 2,362.50 Plumbing Fee $ 295.31 Gas Fee 100 comm. $ '`100.00 Electrical Fee $ 295.31 Total fees collected $ 3,053.13 203 Turnpike Street Suite 125 Tenant Fit Up for Doctors Office BP#639-15 on 2/5/2015 Proposal Number: 7152 Project Proposal Date: 01/21/15 Revised:02/02/15 Prepared By: Office Hours: Monday- Friday 08:00arn — 04:00prn StarTbuch Property Services, Inc. Telephone: 978-548-6297 515 Lowell St., Suite 2 Fax: 978-548-4613 Peabody, MA 01960 HIC Ucense: #171532 Exp.: 3/27/16 Submitted To: Work Performed At, Dr.Tim Norton 203 Turnpike Rd, Suite 125 203 Turnpike Rd,Suite 125 North Andover, MA 01845 North Andover, MA 01845 I. WORK DESCRIPTION DEMOLMON o Remove approximately six walls o Remove existing kitchenette and cap plumbing o Remove any existing carpeting throughout the space Remove existing suspended coiling file system throughout Salvage all light fixtures which will be Installed in the newly constructed space Salvage hard duct work, diffusers and returns which will be used in the new constructed space Provide two 30 yard dumpsters during the course of the project GO N ST t RUC T ION Areas: 2 - exam rooms, 2 - treatment rooms, ultrasound room, MD office, business office, break/ conference room The walls In the above noted areas will be constructed out of 3 5/8"metal studs, 2 layers of 6/8"Type"C"GWB, 1/2" deep resilient furring channels place at 24"on center and insulated with 3" mineral wool batting Install blocking where upper cabinels will be installed Area: Bathroom * The walls in the water closet will be constructed using 3 5/81' metal studs,one layer of 5/8"moisture resistant GWB and Insulated with 3 1/2" batting * Install blocking for the grab bars Areas: Supply room. closet and one wall by the reception area The walls In the above notes areas will be constructed using 3 5/8" metal studs and one layer of 5/8" GWB on each side. These walls will not be Insulated, v, lnfo@startouchpropertyservices.com Page 1 of 7 ' S—f A n),' 0 U C R-1, 0 P E:IR 1,Ile E R vUC F Sp Ulim C" FLOORING VMVIK' ° All flooring wIP be installed|nthe areas as noted on the architectural plans dated Jarjuary7'2015 " Supply and install 1190 sq ydnof Mannington Commercial broadloom carpet with 4'variations ^ Co|ucTBO ^ Supply and install 100eqftof12VT Mmnnington[ommerchd " Style:Opacla » (]o|onTBD ° Supply and |Datad|8G0|nftnf Vinyl Wail BonnJnhnenD|ka ^ Cu|ocTBD ~ Minor floor prep included E L�'-�'iC,-911"I'UG A L U�f 0�� Install 88salvaged 2x4 light fixtures from the demolition Supply and Install one now 2x4light fixture 8o match the salvaged fixtures Install 4 salvaged 2x2light fixtures from the demolition � � Supply and Install twelve O" recess can lights � Supply and install white baffles and trims to the recessed can lighting � Supply and install twelve building standard light bulbs in the recess lighting All receptacles, switches and there covers will bowhite Replace VptoOU bulbs hl the salvaged fixtures |f any lenses need toba replaced onthe salvaged fixtures, K will benoadditional cost Supply and install three exist sign Supply and install three emergency lights Install mn outlet for one 10gn\|nn hot water heater uodoppnup/ia1eoafetk*o.,Lnonk|nnT8D Install two outlets for ejectionpumps. Location TBD Below is a description of the location of where the Items listed above will be installed: Area: Waiting RoC}Ul " Install approximately 8receptacles. « Install Four 2x4 light fixtupoawith single pole switch. ^ Install one wall mounted exit sign. " Install one emergency light. /\yeB: Reception ° Install 8receptacles. " Install Seven 6 Inch recess lights with single pole switch. * Install Four 2x2 light fixtures with single pole switch. Area: BU8iDeG8 Office v Install 3receptacles. ° Install one 2x4 light fixture with single pole switch. � Area: Break/Conference " mto0manoomhpmpnnyuaw/mm.com Page 2of7 � ZEr C nff o u c:',vyi PF, F,-�0 P ri',vrr Y Install 4 receptacles on the walls o Install 3 receptacles over the counter(GFCI) Install two 2x4 light fixture and one 6 Inch recess light. (with single pole switch) Install a receptacle for microwave Install receptacle for fridge. Area: Supply Room * Install 3 receptacles * Install one 2x4 light fixture with single pole switch Area: Nurse Station Install 4 receptacles Area: Treatment Room 1 * Install 5 receptacles around the walls. * Install a GFCI over the counter. * Install one 6 inch recess light with single pole switch * Install two 2x4 light fixture with single pole switch. Area: Treatment Room 2 * Install 6 receptacles around the walls. * Install a GFCI over the counter. Install two 2x4 light fixture with single pole switch Install one 6 inch recess light with single pole switch. Area: Ultrasound * Install 6 receptacles * Install Three W light fixture with single pole switch Area: Bathroom o Install a GFCI over the counter. Install one 2x4 light fixture. Install one exhaust fan. Area: Exam Room 1 Install 4 receptacles around the wall. Install a GFCI over the counter. Install two 2x4 light fixture with single pole switch. Install one 6 inch recess light with single pole switch. Area: Exam Room 2 Install 6 receptacles. Install two 2A light fixture with single pole switch. Install one 6!rich recess light with pole switch. ■ Into@startouchpropertyservices.com Page 3 of 7 Area: MID Office Install 5 receptacles. Install Three 2x4 light fixture with single pole switch. Area: Corridor Install 5 receptacles. Install eleven 2x4 light fixture With 3 way switch. Install two wall mounted exit sign. * Install 2 emergency lights. * All the lighting will be reused from the existing space F"LUMBING Remove plumbing from the MD Office Install hot and cold water supplies and drain lines for sinks in Exam Room 1,Treatment Rooms 1 &2, Bathroom Room and Break/Conference Room Install appropriate venting for the newly installed plumbing * Install water and drain line for one toilet * Install one 30 gallon hot water heater with appropriate safeties- Location to be determined install two ejections pumps- Locations to be determined Exam room sink with gooseneck faucet is included with the cabinet package An allowance of$200 has been given for the conferencelbreak room sink with faucet set Supply and install a wall mounted sink in the bathroom Supply and install an ADA toilet FWAG, * Installed salvaged hard duct work to suit the new layout * Installed the salvaged diffusers and returns Install new flexible duct 1i-,IEQ9K. Install a new 15116 suspended ceiling tile system throughout,with the except of the areas noted to have GWB ceiling Install Armstrong Commercial Grade, style 933, 24"x48"lay-in tiles over the Reception desk only * All other ceilings to be Armstrong Commercial Grade, style 933, 24"x 48", lay-in tiles * Install Armstrong Commercial Grade, style 933, 24'WBu, lay-in tiles ceiling in two closets * Install a GWB soffit above the reception area DO(M-0b HWS'T/,k1I—LKF10N Supply and install the following: * 25 Wood Door leafs, solid core PC-5 grade A, unfinished rotary birch. Prefit and pre machined for finish hardware. Architects types A, B, C. * KD hollow metal door frames.Architects Type 1, sized per door schedule * Complete sets of finish hardware, Commercial Home Depot in-stock or similar * Locks will be Schlage Commercial grade * All finished are assumed satin chrome finish Info@startouchpropertyservim.com Page 4 of 7 r"i i�t' �3 a ��_,�R-FS 2 ') �. ^� R,.a" n In =3 p a E t " T� Crfs1 11Y t .,� s��11a! , -j If1 o Supply and install the follow items: Plastic laminate counters and cabinets @ Rooms 09,10,13&14 * Cabinet and counter in the above mentioned room will be chosen from the Ritter Best Value Exam Room Casework. The counters have no seam, self cooing backsplash and rounded front edge. The cabinets are heavy-gauge(18 and 20 gauge)cold rolled steel shelf with powder-coated finish Seamless 12 mil polymer covered drawer and door fronts Side mounted drawer runners on all drawers and writing surface have a 100 lb, capacity. German-engineered 110 degree door hinges Manufacture warranty is three years. Dimensions: Overhead Cabinet is 48"wide x 14"deep x 24"high. Base Cabinet is 48"wide x 18"deep x 36"high to top of counter. Height to top of backsplash:39". Sink inside dimensions: 12"wide x 10"deep x 5"high. Sink outside dimensions: 15"wide x 15"deep. Plastic laminate counters and cabinets @ Break/Conference- Which will be chosen from Nome Depot in-stock cabinet and laminate counter selection Plastic laminate counters, knee walls,and ranks brackets @ Nurses station 08* Granite counters(not to exceed$33 per sq ft) , Maple knee wall, and Rakks Brackets @ Reception Desk 03* > Maple(stained)wall panels with reveals in Waiting 01 per Elevations A, B, C, D&F on A3.1 Maple Tdm for Existing Entry Unit at Door 01 (Shop pre-finished) F_''A Ng8H 64 — Apply 1 coat of primer to the all walls, hard ceilings and metal frames Apply 2 coats of finish paint to the all walls, hard ceilings and metal frames n A Benjamin Moore or California interior commercial grade product will be used 3 All wood work installed will be factory finished H11AARM U Relocated the existing fire alarm devices to suit the new layout Permit fees are included A one time cleaning of the space will be performed at the end of the project Supply and install two fire extinguishers * Replace the existing 12 exterior windows Total cost for labor and materials is: $6,300(Not included in the final pricing below) a info@startouchpropertyservices.com Page 5 of 7 II. EXCEPTIONS All data which includes phone, cable and internet will be done by others. Please note the according to the IBC, an electrical permit will need to be obtained to perform this work. III. TERMS * Interior Painting: Price Includes to match the existing color; additional colors will be an additional cost to be determined by the size of the building. Exterior Painting: Price includes to match the existing•color; additional colors will be an additional cost to be determined by the size of the building. Exterior projects are always weather permitting. * We allow one punch list at the completion of the project to accommodate necessary touch-ups. Color/material selections are final; any changes made may result in additional charges. Any necessary materials will be stored in an orderly fashion. All debris will be removed on a nightly basis. StarTouch Property Services, Inc. is not responsible for any cracks resulting from the expansion&contraction of wood. All StarTouch Property Services, Inc. proposals include a one-year warranty on all labor performed. Any alteration or deviation from the above specifications Involving extra costs will be executed only upon written order, and will become an extra charge over and above this proposal. All agreements contingent upon strikes, accidents, or delays beyond our control. This proposal may be withdrawn by StarTouch Property Services, Inc. if not accepted within 30 days. Workwill be accomplished between the hours of 7 a.m. to 5 p.m.Work performed outside of this time frame may result in an additional charge. Quality and workmanship standard for this contract are defined by the National Association of Home Builders, Residential Construction Performance Guidelines for Professional Builders and Remodelers. 8th Edition. IV. BUDGET All materials are guaranteed to be as specified, and the above work is to be performed in accordance with the drawings and specifications submitted for the above work, and completed in a substantial workmanlike manner for the sum of: _� ' 11"�_'I "N� r y _ �,- �� x ,. _ og"g 'm MEMO- "I y ey . . RK- Demolition, including the dumpsters Construction, including electrical, plumbing, HVAC, Millwork Fire Alarm Misc. - Permit fee, cleaning, fire extinguishers --------------------------- ....... . ... Total cost of Construction $ 196,875.00 Total $ 196,875.00 1. Payments to be made as follows: 1/3 deposit at proposal signing, 1/3 work-in-progress, 1/3 at project completion. 11. We accept all major credit card companies, but there is a surcharge fee of 2.75% up to 3.5%to cover the cost. 111. A 12.0% annual late fee will be charged for payments not received within 15 days of project completion. info@startouchpropertyservices.com Page 6 of 7 / !� �� y�� G ��, ' � Respectfully Submitted Frank 8on1on. Project Manager On behalf ofGtorTbuoh Property Services, Inc. The above 'o�a. 00en8oat|onammdoondiUnnnanana1n��hJ�mn�an*henobvacoep�md. | —� specifications ^ | StarTbuch Property Services, is Kied. Payments will Uo made ea outlined above. ` Signature Dm1m ) (, � .�.�l---.._.............—...........--~^^^^^^^^^—^^^~~^—^~'~~^^—'' � ' � � ' | ! " Page 7uY7 I I 10» Massachusetts -DepartMef f Of Public Safety ) Board of Building Reguiatio is and Standards C'fsttgtrttetii;�t 5ttltrt•�ia<<� �! � License: CS-104350 LISA M GOMES t 40 HIGHLAND ST PBABODY MA 071964 s i„ xpiration 0910112016 C�mrrtissiarter i I Initial Construction Control Document To be submitted with the building permit application by a A d Registered Design Professional a F� for work per the 8"'edition of the Massachusetts State Building Code, 780 CMR, Section 107 Project Title: Suite 125 Date: 03 February 2015 Property Address: Suite 125,203 Turnpike Street,N.Andover,MA 01845 Project: Check(x) one or both as applicable: X New construction X Existing Construction Project description: Fit-out of roughly 3,000 /- square-feet of the first floor space at 203 Turnpike St. I Joseph D. LaGrasse,AIA MA Registration Number: 4153 Expiration date: 08/31/2015 ,am a registered design professional, and I have prepared or directly supervised the preparation of all design plans, computations and specifications concerningl: X Architectural Structural Mechanical Fire Protection Electrical Other: for the above named project and that to the best of my knowledge,information,and belief such plans,computations and specifications meet the applicable provisions of the Massachusetts State Building Code, (780 CMR), and accepted engineering practices for the proposed project. I understand and agree that I (or my designee) shall perform the necessary professional services and be present on the construction site on a regular and periodic basis to: 1. Review, for conformance to this code and the design concept, shop drawings,samples and other submittals by the contractor in accordance with the requirements of the construction documents. 2. Perform the duties for registered design professionals in 780 CMR Chapter 17,as applicable. 3. Be present at intervals appropriate to the stage of construction to become generally familiar with the progress and quality of the work and to determine if the work is being performea in a manner consistent with the approved construction documents and this code. Nothing in this document relieves the contractor of its responsibility regarding the provisions of 780 CMR 107. When required by the building official, I shall submit field/progress reports(see item 3.)together with pertinent comments, in a form acceptable to the building official. Upon completion of the work,I shall submit to the b ' ' a `Final Construction Control Document'. D, LaG��F� Enter in the space to the right a"wet"or No.a15s electronic signature and seal: n AN oov>r€t, v OHO ar MRS� Phone number: 978.470.3675 Email:jlagr•a architects.com Building Official Use Only Building Official Name: Permit No.: Date: Note 1.Indicate with an `x'project design plans,computations and specifications that you prepared or directly supervised.If`ollier' is chosen, provide a description. Version 06 11 2013 iSTART-1 OP ID: RR CORD DATE(MMIDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 02/03/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING iNSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the pollcy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsements. PRODUCER CONTACT John Dussault Foster Sullivan Insurance NAME; 163 Main St, PHONE o Ext:978-686-2266 FAX No): 978-686-6410 North Andover,MA 01845 E-MAIL dusseultCfostersullivan rou aom Michael Lescord ADOREss��_ ult@_� ersu._..___.._.gr �. INSURER(S)AFFORDING COVERAGE NAIC If _ INSURER A:SAFETY INSURANCE CO 39454 INSURED Star Touch Property Services _ INsunm B:AMTRUST NORTH AMERICA 15954 ]no 515 Lowell St INSURER 0: Peabody, MA 01960 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPEOFINSURANCE DDL UBR POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER MM/DD/YYY MM/DD/YYY GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY BMA0020187 00/02/2014 08/02/2015 D AGF TO Rt NTED 500,000 PREMISES Ea occurrence $ CLAIMS-MADE X OCCUR MED EXP(Any one person) $ 10,000 Business Owners PER80NAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN3.AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 2,000,000 X POUCY PRO- I $ AUTOMOBILE LIABILITY CC a?! crid D nt)SINGLE LIMIT $ 1,000,000 A ANY AUTO 6224552 08/02(2014 08/02/2015 BODILY INJURY(Per person) $ 100,000 ALLOW'NED X SCHEDULED AUTOS AUTOS BODILY INJURY(Per acddent) $ 300000 .Y P PROPERTY DAiAAGE X MIRED AUTOS X AUTOSNONOWNFD ER ACCIDENT) $ S UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED RETENTION $ WORKERS COMPENSATION WC STATU- X OTH- AND EMPLOYERS'LIABILITY CRY LIMITS ER B ANY PROPRIETOR/PARTNERIEXECUTIV£Y/N W WC3066969 08/02/2014 08/02/2015 F.L.FAGH ACCIDENT $ 500,000 OFFICERIMEMBEREXCLUDED? ❑ NIA ..._.__., _.._._.._��..........._............... ._,.... (Mandatory In NH) EL.DISEASE-EA EMPLOYEE $ 500,000 IF yes,describe under 50n OOn DESCRIPTION OF OPERATIONS below EL.DISEASE-POLICY LIMIT $ i DESCRIPTION OF OPERATIONS/LOCATIONS J VEHICLES (Attach ACORD 101,Addlllonel Remarks Schedule it more apace Is required) ,fob location: 203 Turnpike Rd, Suite 126 North Andover, MA 01845 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN NAOP LLC ACCORDANCE WITH THE POLICY PROVISIONS. and First General Realty Corp 93 Union Street AUTHORIZED REPRESENTATIVE Newton Center, MA 02459 01980-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of Industrial Accidents w Office of Investigations I Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl StarTouch Property Services, Inc Name (Business/Organization/Iiidividual): Address:515 Lowell St., Suite 2 Peabody, MA 01960 978-548-6297 City/State/Zip: Phone #: Are you an employer? Check the appropriate box: Type of project(required); 1.41 I am a employer with 9 4. C2 I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. New construction 2.0 I am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling ship and have no employees These sub-contractors have $. Demolition working for me in any capacity, employees and have workers' 9. Building addition [No workers' comp. insurance comp. insurance.t � We are a corporation required.] 5. oration and its 10.0 Electrical repairs or additions p 3. 1 am a homeowner doing all work officers have exercised their 1 LC] Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.0 Other camp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information, t Homeowners tvho submit this affidavit indicating they are doing all work and then 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 stib-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp,policy number. I am an employer that is providing workers'compensation insurance far my employees. Below is the policy rind,job site inforuaation. Insurance Company Name: Arrltrust North America Policy#or Self-ins. Lic. #:W WC3066969 Expiration Date:08/02/2015 515 Lowell st Peabody,MA 01960 Job Site Address: City/State/Zip; Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500,00 and/or one-year imprisonment, as well as civil penalties in the form of STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is trice and correct. l �� 02/04/2015 Si mature; Date; Phone#: 978-83 -1206 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other• Contact Person: Phone#: TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received Permit NO. a t Date Issued: "" IMP ORTANT: A licant rnrlst complete all items on this page LOCATION +�' � rr Pant , `�Print � y 10D Year-old Slruclrtre yes rao MAP NOPARCEI_ ZONING DISTRICT Historic'Dastrict yes no Machin ,„Shop VGllage yes ro TYPE OF IMPROVEMENT. PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family El Addition Li Two or more family ❑ Industrial Alteration No. of units: Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: ❑ Demolition ❑ Other ❑ Septic ❑Well I Floodplam fl 1Netlands ❑ Watershed District ❑Vliater..dwer > fDESCRIPTI N F WORK TO BE PERFORMED. ov 1- Ye iaL� ✓ L✓ 1N t S ✓� �e w"`��s, ,�� , �nece 55�.✓ Identification Please Type or Print Clearly) OWNER: Name: N O9 L.L C- Phone: Address: �.;�� S ✓L 5...; S Vt.1 0� Ct1, p CONTRA hone Address Wl Su P ervisous ConstructEon License Exp Date 1p I' 1 e Horne Improvement License Exp Date n ARCHITECT/ENGINEER L r�� e r`ISSfl G'o1 �5 _ Phone: G17 - Ll0 7 Address: Q+ic- }-1 SR�g✓� A oV�� IWA Reg. No. FEE SCHEDULE:BUL.DING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F. Total Project Cost: $ 7. 000, t90- FEE: $ �' �U. o e' Check No.: - Receipt No.:'- NOTE: Persons contracting with unregistered contractors do not have access Otto guaranty fut f2 Signature of AgentfOwner Signature of contract `" Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ S ped PI I Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. .Total land-area, sq, ft.: -ELECTRICAL: Movement-of.Maier,locatr on,Ymast or service drop requires approval of Electrical Inspector Yes No DANGER. ®NE LITERATURE: Yes No MGL-Chapter-166.Section 21A-F and G min.$100-$1000 fine NOTES and DATA-- wor department use al- 0. i r ® Notified for pickup - Date Dou.Building Permit Revised 2010 Initial Construction Control Document To be submitted with thebuilding permit application by a = a Registered Design Professional �< for work per the Wh edition of the eyr Massachusetts State Building Code, 780 CMR, Section 107 Project Title: Suite 125 Date: 03 Febr'uary2015 Property Address: Suite 125,203 Turnpike Street,N.Andover,MA 01845 Project: Check(x) one or both as applicable: X New construction X Existing Construction Project description:Fit-out of roughly 3,000+/-square-feet of the first floor space at 203 Turnpike St, I roseph D.LaGrasse,AIA MA Registration Number:4153 Expiration date: 08/31/2015 ,am a registered design professional, and I have prepared or directly supervised the preparation of all design plans, computations and specifications.coneerningr: X Architectural Structural Mechanical Fire Protection Electrical Other: for the above named project and that to the best of my knowledge,information,and belief such plans,computations and specifications meet the applicable provisions of the Massachusetts State Building Code,(780 CMR),and accepted engineering practices for the proposed project. I understand and agree that I(or my designee)shall perform the necessary professional services and be present on the construction site on a regular and periodic basis to: 1, Review, for conformance to this code and the design concept, shop drawings, samples and other submittals by the contractor in accordance with the requirements of the construction documents, 2, Perform'the duties for registered design professionals in 780 CMR Chapter 17, as applicable. 3. Be present at intervals appropriate to the stage of construction to become generally familiar with the progress and quality of the work and to determine if the work is being performea in a manner consistent with the approved construction documents and this code. Nothing in-this document relieves the contractor of its responsibility regarding the provisions of 780 CMR 107. When required by the building official,I shall submit field/progress reports (see item.3.)together with pertinent comments, in a form acceptable to the building official. Upon completion of the work,I shall submit to the b ' a`Final Construction Control Docurnent'. ARC Enter in the space to the right a"wet"or 12: No,M63 electronic signature and seal: a A novEtz, �t r 5 � r�ot:� s Phonenunrber: 978A70,3675 Email;jlagra architects.com. Building Official Use Only Building Official Nance: PermitNo.: Date: Note 1,Indicate with an`x.'project design plans,computations and specificntions that you prepared or directly supervised. If`other'is chosen, provide a description. Version 06112013 Initial Construction Control Document To be submitted with the building permit application by a a Registered Design Professional for work per the 8"'edition of the r �r Massachusetts State Building Code, 780 CMR, Section 107 Project Title. Suite 125 Date: 03 February 2015 Property Address: Suite 125,203 Turnpike Street,N. Andover,MA 01845 Project: Check(x)one or both as applicable: X New construction X Existing Construction Project description: Fit-out of roughly 3,000 +/-square-feet of the first floor space at 203 Turnpike St. I Joseph D.LaGrasse,AIA MA Registration Number:4153 Expiration date: 08/31/2015 ,am a registered design professional, and I have prepared or directly supervised the preparation of all design plans, computations and specifications concerning': X Architectural Structural Mechanical Fire Protection Electrical Other: for the above named project and that to the best of my knowledge,information,and belief such plans,computations and specifications meet the applicable provisions of the Massachusetts State Building Code,(780 CMR),and accepted engineering practices for the proposed project. I understand and agree that I(or my designee)shall perform the necessary professional services and be present on the construction site on a regular and periodic basis to: 1, Review, for conformance to this code and the design concept,strop drawings, samples and other submittals by the contractor in accordance with the requirements of the construction documents, 2. Perform the duties for registered design professionals in 780 CMR Chapter 17,as applicable. 3. Be present at intervals appropriate to the stage of construction to become generally familiar with the progress and quality�o f the work and to determine if the work is being performed—fin a manner consistent with the approved construction documents and this code. Nothing in this document relieves the contractor of its responsibility regarding the provisions of 780 CMR 107. When required by the building official,I shall submit field/progress reports (see item 3.)together with pertinent comments, in a form acceptable to the building official. Upon completion of the work,I shall submit to the b a `Final Construction Control Document', geD A&% �[�•y�Q�p. laG,��c'a Enter in the space to the right a"wet"or 4: o`' No.4163 electronic signature and seal: h 0 ANpoVER, y OH OF 0 Phone number; 978.470.3675 Email:jlagra, architects.com Building Official Use Only Building Official Narim Permit No.: Date: Note 1,indicate with an`x'project design Plans,coEnputations and specifications that you prepared or directly supervised,If'other'is chosen, provide a description. Version 061 t 20l3 -�� 7 a•, s t _ s � L� ,�,�� w � I �; � `s , } � .� a' ��x� t� -i5i � - a# ; t ��• � � att � � c � € � r y ! {{ �, �': €t,� aL, �� yt :€ '�'°.�`� ti �{fir :h �` � �- g 1• 1 `. ,qt �� -�. � rt � r t:. _,:,� g�,: � � � s �.- �,`.�`-`-�r..€" ,}�i � �r- ;' i•.'�-� � f-. r'`- r - 3"' -�"' v r - Sk g - AIL '� - 1� I � 1 i 3 1 Enter construction cost for fee cal - North Andover Fee Calculation Construction Cost $ 17,000.00 m $ - $ 408.00 Plumbing Fee $ 25.50 Gas Fee 100 comm. $ ' 100.00 Electrical Fee $ 25.50 Total fees collected $ 559.00 203 Turnpike Street 617-14 on 3/5/2014 Remove and Replace 3 new water source heat pumps N4RT1y i i w n 01z ��s ncluver ;yx ti c 0 4 rb_ b �xrrZ- 1 V Os ■i1Y - .- � T 1 }I�.�"r l � h ver, Mass, � � ' �S 'p CGCiiCf/R WICK : \ i AQ� 51 7' .9 � ED S U BOARD OF HEALTH f Food/Kitchen "Pv " Septic System ... �j BUILDING IN5PECTOR, - THIS CERTIFIES THAT ............NA0.P ..., ..,.. .......,.......... ...... .......,......... ........... has permission to erect.......................... buildings orC9 .. !!�P I a.................... ... Foundation k v � Rough to be occupied as .... .a ...%W43...VP.....HARI&...VA . .,�... .... Chimney provided that the person accepting this permit shall in eve respect conform to the terms of the a lication P P P g P every p P Final k on file in this office, and to the provisions of the Codes and By-Laws relating to the Inspection,Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR t 3 VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough ;y Final ti 1 ` PERMIT EXPIRES IN 6 MOTS ELECTRICAL INSPECTOFt `} Y UNLESS CONSTROTION S TS =,v Rough Service ... . ......... ....... ... ......................,... Final BUILDING INSPECTOR ; GAS INSPECTOR - 3 Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT v z Until Inspected and Approved by the Building Inspector. Burner yv Street No. Smoke Det. r l S yZl l