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HomeMy WebLinkAboutMiscellaneous - Foster Street (3)Y Date ....1.1... .. `................ TOWN OF NORTH ANDOVER PERMIT FOR WIRING PCC ... This certifies that ......... ..................... �,:�,:..........�............................................... i has permission to perform .......................... . wiring m the building of.../.y ................�.....--�.............:........... ................... ,� P le'e , "t -c.-... North Andover, Mass. at ....:......:T ` , ...................................l. f Lic. No. ` �' f .............................................. Fee ...........:. .............................TRI.. ELECTRICAL INSPECTOR 1 f�q(/) Check # � Commonwealth of Massachusetts Department of Fire Services 0 a BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. ICj� 3 6 Occupancy and Fee Checked [Rev. 1/071 (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (NIEC), 5Z�22 MR 12.00 (PLEASE PRINT W INK OR TYPE ALL NFORMATION) Date: p o/'� City or Town of: NORTH ANDOVER To the Insp ctor 6f Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street & Number) ��•o p,,� 'fe—y- r'C-G-t Owner or Tenant t\ Telephone No. Q`19 . lo 93 -31:L32 Owner's Address i C,e,o Is this permit in Utility conjun tion with a buildi permit? Yes ❑ No KY (Check Appropriate Box) Purpose of Building �ll0 UX ,L�i� G.�► � 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: Completion o the followin table may be waived by the Inspector of Wires. No. of Recessed Luminaires No. of CeR. Susp. (Paddle) Fans No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires Swimming Pool Above ❑In- [Io. of Emergency Lighting rnd. grnd. Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS I No. of Zones No. of Switches No. of Gas Burners No. of Detection and Initiating Devices No. of Ranges g No. of Air Cond. Total Tons No. of Alerting Devices No. of Waste Disposers p Heat Pump Totals: Number ]**­ Tons *.......... "' KW No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Securitio o De ilc : or Equivalent No. of Water KW No. of No. of Data Wiring: Heaters Signs Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of lectr'cal Work: �U� (When required by municipal policy.) Work to Start: ?U Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE C VE GE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under the pans and penaltiecs,of perjury, that the information on this application is true and complete FIRM NAMES .l -C , jj ✓' t.IPGkY'i G LIC. NO.: Licensee: 'jrju ex E j1kX rSVQkk1 Signature LIC. NO.: (ff 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 law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent PERMIT FEE: $ Signature Telephone No. 3 ❑ 2012 Massachusetts Electrical Code Amendments 527 CMR 12.00 § Rule 8: In accordance with the provisions of M.G.L. c. 143, § 3L, the A 71- permit application form to provide notice of installation of wiring shall be uniform throughout the Commonwealth, and applications shall be filed ' on the prescribed form. After a permit application has been accepted by an Inspector of Wires appointed pursuant to M. G.L c. 166, § 32, an electrical permit shall be issued to the person, firm or corporation stated on the permit application. Such entity shall be responsible for the _ notification of completion of the work as required in M.G.L. c. 143, § 3L. Permits shall.be limited as to the time of ongoing construction activity, and may be deemed by the Inspector of Wires abandoned and invalid if he or she has determined that the authorized work has not commenced or has not progressed during the preceding 12 -month period. Upon written application, an extension of time for completion of work shall be permitted for reasonable cause. A permit shall be terminated upon the written request of either the owner or the installing entity stated on the permit application. ❑ The Permit Extension Act was created by Section 173 of Chapter 240 of the Acts of 2010 and extended by Sections 74 and 75 of Chapter 238 of the Acts of 2012. The purpose of this act is to promote job growth and long-term economic recovery and the Permit Extension Act furthers this purpose by establishing an automatic four-year extension to certain permits and licenses concerning the use or development of real property. With limited exceptions, the Act automatically extends, for four years beyond its otherwise applicable expiration date, any permit or approval that was "in effect or existence" during the qualifying period beginning on August 15, 2008 and extending'through August 15, 2012. ❑ Rule 8 — Permit/Date Closed: *** Note: Reapply for new permit ❑ ❑ Permit Extension Act — Permit/Date Closed: Trench Inspection Pass M Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: SERVICE INSPECTION: Pass 0 Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: PARTIAL ROUGH INSPECTION: Pass M Failed Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: ROUGH INSPECTION: Pass 0 Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: Date: FINAL INSP CTION: Pass 0 Failed 0 Re- Inspection Required ($.) ❑ Inspectors Comments: Inspectors Signature: — Date: DEB WEINHOLD ... TOWN OF MERRIMAC, MA........dweinhold@townofinerrimac.com I The Commonwealth of Massachusetts Department oflndustrialAccidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 W F sqe www mass.gov/dia M s Workers' Compensation Insurance Affidavit: Builders/Contractors/Elecinicians/Plumbers. TO BE FILED WITH THE PERMCTTING AUTHOR• please Print L 'bl A ' licant Information Name (Business/Organization/Individual):- Address: City/State/Zip:- Are you an employer? .eck the appropriate box: Phone 4: 1. ❑ lam a employer with employees (full andlor part-time).* 20 I am a sole proprietor or partnership and have no employees Working for me in any capacity. [No workers' comp. insurance required.] 3.E] I am a homeowner doing all work myself; [No workers' comp. insurance required.] t 4. QI am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5.❑I am a general contractor and I have hired the sub -contractors listed on the attached sheet. These sub -contractors have employees and have workers' comp. insurance.: 6. n We are a corporatig# and its officers have exercised their right of exemption per MGL c. 152 §1(4) and vne have no employees. [No workers' comp. insurance required.] Type of project ()required); 7. ❑ NBV d6nstt&tion 8. Remodeak 9. ❑ Demolition 10 ❑ Building addition 11.0 Electrical repairs or additions 12. n.PXnnbing repairs or additions 13% Roofrepairs 14.Other *Any applicant that check§ bbic #1_ must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and state whether or not those pntiges have emnlnvees. Hthe sub -contractors have employees, they must provide their workers' comp. policy number. I am an employer that is providing workers' information. Insurance Company Name:_ Policy # or Self -ins. MG. compensation insurance for my employees. Below is the polley and job site Expiration Date:- --- City/State/Zip: Job Site Address: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). required under MGL e.152, §25A is a criminal violation punishable by a fine up to $1,500.00 Failure to secure coverage as a and/or one-year imprisonment, qt well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a as ay be forwarded to the Office of Investigations of the DIA. for insurance day against the violator. A copy of this statement m coverage verification. coverage hereby certify under tlaepains and penalties of perjury that the information provided above is true and correct. Date: Signature: Phone #: official use only. Do not write in this area, to be completed by city or town officiaL City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Phone Contact Person: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their emiployees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is' defined as "an individual; partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enierpri'se, and including the legal representatives of a deceased employer, or the receiver'orr• trustee of an individual, partnership, association or other legal entity, employing employees. • However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment b6 deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or ,renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant'who has not produced -acceptable evidence of compliance with the insurance coverage iequiired." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance ofpublic work until acceptable evidence of compliance with the insurance requirements ofthis chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub=contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Acciderris. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. - City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (ifnecessary) and under "Job Site Address" the applicant should write •"all locations in (city or town)" A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-AIA.SSAFE Fax # 61.7-727-7749 Revised 02-23-15 wwwmass.gov/dia f' ACOROP OP ID: TD �- CERTIFICATE OF LIABILITY INSURANCEDATE(MM/DD/YYYY) 09/21/2015 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 policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT DeSanctis Insurance Agcy, Inc. NAME: 100 Unicorn Park Drive PHONE FAX Woburn, MA 01801 E ILC. Ext): A/C No CUSTOMER ID #: JUPIT-1 INSURERS AFFORDING COVERAGE NAIC # INSURED Jupiter Electric, Inc. INSURER A: Harleysville Insurance 26182 Salisbury, MA 011952 Lafayette RINSURER B: Technology Insurance Company42376 Sal INSURER C: INSURER D: INSURER E: INSURER F: CAVFRA[:FS n�nr,r,i. � �r . KtVIJIUN 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 D UB LTR TYPE OF INSURANCE POLICY NUMBERPOLIC/YYYY MOLICY XP LIMITS GENERAL LIABILITY A X EACH OCCURRENCE $ 11000,000 PREMISES Ea occu ante $ 100,00 COMMERCIAL GENERAL LIABILITY SPP00000076460P 12/23/2014 12/23/2015 CLAIMS-MADE1XI OCCUR MED EXP (Any one person) $ 5,00 X CCU Coverage PERSONAL & ADV INJURY $ 1,000,00 X Contract Liab GENERAL AGGREGATE $ 3,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS -COMP/OP AGG $ 3,000,00 17 POLICY X JPECj LOC DEDUCT. $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ 11000,00 BODILY INJURY (Per person) $ ALL OWNED AUTOS BODILY INJURY (Per accident) $ A X SCHEDULED AUTOS BA76461 P 12/23/2014 12/23/2015 PROPERTY DAMAGE $ X HIRED AUTOS (PER ACCIDENT) X NON-OWNEDAUTOS $ $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 10,000,00 A EXCESS LIAB CLAIMS -MADE CMB00000078286P 12/23/2014 12/23/2015 AGGREGATE $ 10,000,000 DEDUCTIBLE X RETENTION $ 0 $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY $ X X WRY TA IU- OER B OFFICER/MEMBER EXCLUDED? ECUTIVE Y� N / A TWC3442671 12/23/2014 12/23/2015 E.L. EACH ACCIDENT $ 1,000,00 E.L. DISEASE - EA EMPLOYEE $ 1,000,00 (Mandatory in NH) If yes, describe under MA,ME,NH DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) Replacement of Master Boxes at Four Sites Fountain Drive - -667-1 Bingham Way -667-2 Foulds Terrace -667-3 O'Conner Heights -667-4 North Andover MA 01845 DR, FISH #196040. "ADbITIOt INSUREDS LIMATS ARE NO GRtATER THAN THOSE REQUIRED BY WRITTEN CONTRACT." Town of North Andover, North Andover Housing Authority and the Department of Housina and Communi Develo men#... trANk;tLLAIIUN NORTA-1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Electrical Inspector ACCORDANCE WITH THE POLICY PROVISIONS. 1600 Osgood Street Bldg 20 Suite 2035 AUTHORIZED EPRESENTAT E North Andover, MA 01845 ©198 -2009 ACO T N. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD NQTEPAD: HOLDERCODE NORTA-1 JUPIT-1 PAGE 2 INSURED -S NAME Jupiter Electric, Inc. OP ID: TD Date 09/21/2015 (DHCD) are listed as Additional Insureds. TOWN OF NORTH ANDOVER BUILDING DEPARTMENT APPLICATION TO CONSTRUCT REPAIR, RENOVATE, CHANGE THE USE OR OCCUPANCY OF, OR DEMOLISH ANY BUILDING OTHER THAN A ONE OR TWO FAMILY DWELLING LORI` � ����� � r„ � � �� � �� � :This Section for Official Use Onl " BUILDING PERMIT NUMBER:1 DATE ISSUED: 1— I SIGNATURE: A i C Buildin Commissioner/I or of BuildingsDate SE;..: y 1.1 Property Address: 1.2 Assessors Map and Parcel Number: Map Number Parcel Number 1.3 Zoning Information: Zoning District Proposed Use 1.4 Property Dimensions: Lot Area Fronts ft 1.6 BUILDING SETBACKS (ft) Front Yard Side Yard Rear Yard Required Provide Required Provided Required Provided 1.7 Water Supply M.G.L.C.40. § 54) 1.5. Flood Zone Information: Public 0 Private 0 Zona Outside Flood Zone ❑ 1.8 Sewerage Disposal System: Municipal On Site Disposal System ❑ 2.1 er of Record Herat /gird o ✓tK l�i%S,�UIr TNo�e�7``t' du.lal s %�� Name (Pri t) Address for S .ce Signa re Telephone 2.2 Authorized Agent ft CH4E-L �. "Ie90owS %l(e4dawl Cotir�, S Fvti lel S. "i`er�.p e e _ Name Pri Address for Service: -Y 7 3 Sign re Telephone /"I12i�/iGc 7 3.1 Licensed Construction Supervisor N Not Applicable ❑ Address // N ! �1 a 9 y2 �i , �►• 7P i 9ivt /Vl f o 3 `7 G, License Number Licensed Construction Su r: j3jen�- �/%r %78 �lS 7/y�i Eviration Date , Signature Telephone 3.2 Registered Home Improvement Contractor Not Applicable Company Name_ Registration Number Address Expiration Date Signature Telephone v n M / n©� O TM N Z O Z M 90 O a r v M r r ZZ . G) Kxckc,� ` 7), Rec'CkOL'n 14e0d06JS (�Af-)r. 0g, L— as Owner/Authorized Agent Hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and belief. Signed under the pains and penalties of pi 0- C6 C-:) Print Name Signa ofer/X#ent Date Item Estimated Cost (Dollars) to be 0,10"OP r 5"On Completed by permit applicant 11F 2- 1. Building -3 to, 337 (a) Building Permit Fee Multiplier 2 Electrical (b) Estimated Total Cost of L4 -7 Construction from (6) 3 Plumbing -7/ Building Permit fee (a) x (b) 4 Mechanical (HVAC) 5 Fire Protection 6 Total (1+2+3+4+5) 5 0/1 3 g Check Number 21 211� g" MT V �ih A"N tv kp MY; W NO. OF STORIES SIZE BASEMENT OR SLAB SIZE OF FLOOR TIMBERS iST 2ND 3RD SPAN DEMENSIONS OF SILLS DEMENSIONS OF POSTS DIMENSIONS OF GIRDERS HEIGHT OF FOUNDATION THICKNESS SIZE OF FOOTING x MATERIAL OF CIIIMNEY IS BUILDING ON SOLID OR FILLED LAND IS BUILDING CONNECTED TO NATURAL GAS LINE ECTIUN 4 #)Ii)tlfAf!> +Cx Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Signed affidavit Attached Yea ...... No ....... ❑ ( SECTi()Pt S P)t$USIONAi.1&IG i; �St+C°JCIONR'1'1CClt€S't?$DtS Alm �USt` fit) 5.1 Registered Architect: Name: MED /�TfG"� (` No. 4663A COHASSET, Address MA V Signature Telephone SCF:)1'0CSSI9�l l cv� J�`C°L" Area of Responsibility �y Regis tion Number Expira on 15 e Address: S afore Total Not applicable ❑ Name: Registration Number Expiration Date Address Signature Telephone Area of Responsibility Registration Number Expiration Date Name Address Signature Telephone Area of Responsibility Registration Number Expiration Date Name Address Signature Telephone SLS %" tl #iii' �OsG1I' C–oo r✓1r�:;Y—, +'N- Not Applicable ❑ Company Maime�-6 p Responsible in Charge of Construction �w�, 0��,���T��1�';.' 1�'i%�Q)'.�iit�:L+ak:�ll.�t►ritxca`M�� .;.,. New Construction ❑ Existing Building Y- Repair(s) ❑ Alterations(s) Addition 0 Accessory Bldg. ❑ Demolition ❑ Other 0 Specify Brief Description of Proposed Work: IA IB ❑ ❑ B Business Existing Use Group: I/ / Proposed Use Group: IV Z�� Existing Hazard Index 780 CMR 34: ��%% Proposed Hazard Index 780 CMR 34:- A)/ JQ BUILDING AREA EXISTING if applicable) PROPOSED Number of Floors or Stories Include Basement levels_ 3 . Floor Area per Floorst) - Total Areas Total Height (ft) e i Independent Structural Engineering Structural Peer Review R Yes ❑ No SECTION 10a Owner Authorization - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, - IT -6V -!f- /L Owner of the subject property Hereby authorize A,�-a AOX1,91gs, � li7djS ( � to act on My behalf, in all matters relative two work authorized by this building permit application Signai4e Owner Date USE GROUP Check as applicable) CONSTRUCTION TYPE A Assembly ❑ A-1 ,C A-4 ❑ A-2 0 A-3 ❑ A-5 ❑ IA IB ❑ ❑ B Business ❑ 2A 2B 2C 0 0 ❑ C Educational ❑ F Factory ❑ F-1 0 F-2 ❑ H High Hazard ❑ 3A 3B ❑ ❑ IInstitutional ❑ I-1 ❑ I-2 ❑ 1-3 ❑ M Mercantile R residential ❑ ❑ R-1 ❑ R-2 ❑ R-3 0 4 5A 5B fig' ❑ ❑ S Storage ❑ S-1 ❑ S-2 ❑ U Utility ❑ Specify: M Mixed Use ❑ Specify: S Special Use ❑ Specify: COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATIONS, ADDITIONS AND OR CHANGE IN USE Existing Use Group: I/ / Proposed Use Group: IV Z�� Existing Hazard Index 780 CMR 34: ��%% Proposed Hazard Index 780 CMR 34:- A)/ JQ BUILDING AREA EXISTING if applicable) PROPOSED Number of Floors or Stories Include Basement levels_ 3 . Floor Area per Floorst) - Total Areas Total Height (ft) e i Independent Structural Engineering Structural Peer Review R Yes ❑ No SECTION 10a Owner Authorization - TO BE COMPLETED WHEN OWNERS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, - IT -6V -!f- /L Owner of the subject property Hereby authorize A,�-a AOX1,91gs, � li7djS ( � to act on My behalf, in all matters relative two work authorized by this building permit application Signai4e Owner Date •°" OFFICE OF BUILDING INSPECTOR + TOWN OF NORTH ANDOVER CONSTRUCTION CONTROL PROJECT NUMBER: dnf�' PROJECT TITLE: J VIA 14 PROJECT LOCATION: a NAME OF BUILDING: NATURE OF PROJEC IN ACCORDANCE WITH ARTICLE 116 OF THE MASSACHUSETTS STATE BUILDIN CODE, I _ i.�`I 1 -,,,^ eD t li �'�_ REGISTRATION NO. BEING A REGISTERED PROFESSIONAL ENG1NEER/ARCHITECH HEREBY CERTIFY THAT I HAVE PREPARED OR DIRECTLY SUPERVISED THE PREPARATION OF ALL DESIGN PLANS, COMPUTATIONS AND SPECIFICATIONS CONCERNING: ENTIRE PROJECT X ARCHITECTURAL ❑ STRUCTURAL ❑- MECHANICAL ❑ FIRE PROTECTION ❑ ELECTRICAL ❑ OTHER (SPECIFY) FOR THE ABOVE NAMED PROJECT AND THAT, TO THE BEST OF MY KNOWLEGE, SUCH PLANS, COMPUTATIONS AND SPECIFICATIONS MEET THE APPLICABLE PROVISION OF THE MASSACHUSETTS STATE BUILDING CODE, ALL ACCEPTABLE ENGINEERING PRATICES. AND APPLICABLE LAWS AND ORDINANCES FOR THE PROPOSED USE AND OCCUPANCY. I FURTHER CERTIFY THAT I SHALL PERFORM THE NECESSARY PROFESSIONAL SERVICES AND BE PRESENT ON THE CONSTRUCTION SITE ON A REGULAR AND' PERIODIC BASIS TO DETERMINE THAT THE WORK IS PROCEEEDING IN ACdt�Ri DANCE WITH THE DOCUMENTS APPROVED FOR THE BUILDING PERMIT AND SHALL BE RESPONSIBLE FOR THE FOLLOWING AS SPECIFIED IN SECTION 116.0 1. Review, for conformance to the design concept, shop drawings, samples and other submittals which are submitted by the contractor in accordance with the requirements of the construction documents. -� 2. Review and apprcvat of the quality control procedures for all code -required controlled materials. 3. Be present at intervals appropriate tc the:.stage of construction to become, generally familiar with the progress and quality of the worts and to determine, in general, if the work is being performed in a manner consistent with the construction documents. ED Aft PURSUANT TO SECTION 116.2 .2 1 SHALL SUBMIT WEEKLY, A PROGRESS REPORT ��` 6• MED�N FCJ TOGETHER WITH PERTINENT COMMENTS TO THE NORTH ANDOVER BUILDING INSP No. 4663 O COHASSET, UPON COMPLETION OF THE WORK, I SHALL SUBMIT A FINAL REPORT AS TO THE 5 Mn SATISFACTORY COMPLETION AND READINESS OF THE PROJECT FOR OCCUP NGY. -4 E tt' SIGNATURE SUBSCRIBED AND SWORN TO BEFORE ME THIS DAY OF 19 NOTARY PUBLIC MY COMMISSION EXPIRES ACOFDCERTIFICATE OF LIABILITY INSURANCE X0126/2000 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Byfield Insurance Agency Inc ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 57 Main St. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR Byfield, MA 01922 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P:978-462-0833 F:978-462-2880 INSURERS AFFORDING COVERAGE INSURED INSURER A: PREFERRED MUTUAL INS. CO. MEADOWS CONSTRUCTION AND MICHAEL MEADOWS 166 MIDDLE RD. INSURERB: ARBELLA PROTECTION INS CO INSURER C: LEGION INS CO NEWBURY MA 01922- INSURER D: INSURER E: rnveoer_ee THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IL NSR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION I LIMITS A GENERALLIABILITY ® COMMERCIAL GENERAL_ LIABILITY 1--- CPP130532102 EACH OCCURRENCE is 1,000,000 11/22/1999 11/22/2000 1 FIRE DAMAGE IS 50,000 � IM CLAIMS MADE Is OCCUR (Any one fire) ❑ CPP140532102 MED EXP (Any one person) E 5,000 11/22/2000 11/22/2001 — _ PERSONAL BADV INJURY $ 11000,000 ❑� __— ; GENERAL AGGREGATE $ 3,000,000 _______ GEN'L AGGREGATE LIMIT APPLIES PER: ®I POLICY F❑l PRO• ❑I LOC PRODUCTS •COMP/OP AGG j$ 3,000,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT I$ 1,000,000 ❑j ANY AUTO (Ea accident) ❑� ALL OWNED AUTOS B 65361400000 04/08/2000 04/08/2001 1 BODILY INJURY $ Ell SCHEDULED AUTOS (Per person) ® HIRED AUTOS ®INJURY NON -OWNED AUTOS I (PeILY rp accident)$ I PROPERTY DAMAGE $ -- Ell"'— I (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT Is ❑� ANY AUTO I ❑. OTHER THAN EA ACC $ $ AUTO ONLY: qGG EXCESS LIABILITY EACH OCCURRENCE Is ofOCCUR Ia CLAIMS MADE AGGREGATE $ ` !$ DEDUCTIBLE is 01 RETENTION $ �$ WORKERS COMPENSATION AND WC STATU- OTH- EMPLOYERS' LIABILITY FR $ 500,000 C 2060231532 08/17/2000 08/17/2001 E.L. EACH ACCIDENT 500,000 E.L.DISEASE-EAEMPLOYEE$ '$ 500,000 I E.L. DISEASE -POLICY LIMIT OTHER i i i DESCRIPTION OF OPERATIONSILOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS CAPITAL IMPR PROJECT 667-1,2,3, DHCH FISH#196009 NO ANDOVER HOUSING AUTHORITY AND MA DEPT OF COMMUNITY AFFAIRS ARE ADDL INSD FOR JOB I AUUI I IVKNLIKJUKCU;IKJUKtKLt I 1 tK: \,MI�VGLL,/111V1\ SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION NORTH ANDOVER HOUSING AUTHORITY DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 010 DAYS WRITTEN 1 MORKESKI MEADOWS NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR NORTH ANDOVER MA 01845 REPRESENTATIVES. 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