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HomeMy WebLinkAboutBuilding Permit # 4/12/2016 TOWN OF NORTH ANDOVER � r APPLICATION PLICATION FOR PLAN EXAMINATION i Permit NO: Date Received-- 0 eceive " �. s Date Issued: O T TVT:Applicant must col late all items on this LOCATION Print PROPERTY OWNER t'"., �;� i Q i " MAP NO.: .,, ., Print ZONING DISTRICT: PARCEL: TYPE �A USE OF BUILDING :HISTORIC DISTRICT YES TRIPE OF IMPROVEMENT" PROPOSED USE �- Residential Non-Residential. C New Building Y�One family ` (Addition ❑Two or more family 11 Industrial C Alteration No. of units: C Repair,replacement C Assessory Bldg C Commercial CI Demolition Cl Movin relocation. Cl Other ❑ Others: C Foundation only .DESCRIPTION OF WO. � TO BEPREFORMED � l i �ucuwr. , p �4 k a b .� _. "1,„41 ) .. fl�flenlnflflcataoaa flease I ype oa ]P�iint�flea�fly) OWNER: Name � `' i� �° m, �� Address: CONTRACTOR Name: D-1 Pho Address: Supervisor's Construction License: � �" ��"` F w � p Lorne Improvement License:__1 ±'! i ARCHITECT/ENCIII�IEER l fame: Phone: Address: Reg. FEE.SCIREDULE.BULDING PE IT., 12.00 PER$1000.00 OF THE T07AL ESTIMATL'"D COST B �fD ON$125.00 PER�.F Total Project Cost :$ " x12.00=FEE: Check I"r]o. �� e � _ Receipt No Page 1 of 4 ua TYPE OF, SEWEi' DISPOSAL Public Sewer Tanning/massage/body Art [� SwimminE:Pools Well `tobacco Sales r-� Food Packaging/Sales C.1 Private(septic tank, etc. ❑ Permanent Dumpstcr an Site �_� Electric Meter location to project NOTE„ Persons craflt cretzre Wzth un"eA"'Stered c0ntr°aCtcrff cera not have aecesv to the gluurantyfivnd Signature of A 7ent/Own r" g ..� Signature of contractor ,, Plans Submitted ❑ flans Waived ❑ Certified Plot Plan ❑ Statped Flans ❑ THE FOLLOWING SE CTIONSFOR OFFICE USE ONLY INTlERD EPA 't E NTAL SIGN OFF-U FORM DATE R-JECTED DATE APPROVED X�"'P� LANNI I EVELOP EDIT ❑ ❑ ❑hater Shed Special.Permit ❑ Site Plan. Special Permit COMMENTS F1 Other .. DATE REJECTED DATE APPROVED _ 4, 4/ XCO ISEVATIC�lEl ❑ .. COMMENTS DATE REJECTED DATE APPROVED-- EA�,Tk � ElEJCOMMENTS _� � d ;honing Board of Appeals: Variance, Zot:ing Decision/receipt submitted yes Platzning Board Decision: Comments Conservation Decision: Comments Mater& Sewer connection/Si nature& Date - Dtivewax Permit Temp Dnmpster on site yes____no— Fire Department signature/date t%®RTH Town of _ Andover�. :.. ® ® z _ t 9n +//-AA��� ® L� C O LAKE h ` ve r' ass, CO"K"E WIC. x,95 RATE. � ,g2 U BOARD OF HEALTH 11111111mm" EU PE I Food/Kitchen rx I Septic System a THIS CERTIFIES THAT �% BUILDING INSPECTOR ..... .... ... .. .. ........... .. ..................... .... .............................................. has permission to erect .......................... buildings on .. .... ... ............ ... . . ........... Foundation /70. S E*. Rough ........ ...... .... ..`.............to be upied as A .............. ....... . .... .� .! ...... ... . • Chimney provided that the person accepting this permit shall in every respect conform to the terms of th plication 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 EXPIRESPERMIT IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONSTRUCTION T S Rough Service ................. .... ...��.:::'.�............................ Final BUILDING INSPECTOR GAS INSPECTOR ccldpancj1 Permit Rgquired to Occupy BuRough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathingor Dry Wall To Be Done FIRE DEPARTMENT Until Inspected and Approvedthe Building Inspector. Burner Street No. Smoke Det. rctly L;ontr ctors Inc. P.O. BOX 594 Dracut, Ma 01826 invoice 21 5f2ti16 3 US U T ` s' Barker at Nv , ver .= mi In s oug r t home P8rpJ-a-n-s'rL"-%- 7T �r ' a nge existing mudFOOrn to now plan - i t3t3 r Match existing trig and ffnishwooyk as Close as Possabis I match ffoors to existing and fesand existing Kitditerr allowance ! ($10,000.00)includes 811 c8bir and 00unter top Does not include erP/appliances E ' s Flush{ ceiling in dinning room,and revealed beam in kitchen 1'7'opening fr fRegrade yard and hydroSOWf } Remove all dabry t i Pcl aleesibar and material to complete the job j s necessary Permits 0.00 1 �: iCleposit i t j Faundation Complete $10,0W.00 { Root Complete -00 t Roughed ani i3t 'OW-00 S3t1,4f�0(,�4p}0y� St Complete yH = Flooring complete �yr I Addition Complete $15,000,()0 $17,000.00 t t 3L"0 Subtotal t 10%Tax 1 X12, 1 _ 0,00_ / �. REScheck Software Version Compliance Certificate CK Project Energy Code: 2012 ICC Location: Andover, Massachusetts Construction Type: Single-family Project Type: Addition Climate Zone: 5 0322 HDD) Permit Date: Permit Number: Construction Site: Owner/Agent: Designer/Contractor: North Andover, MA John Lassanah Lasanah Associates 572 Boston Road Suite-20 Billerica, MA 01821 978-667-5431 jlassanah@comcast.net Compliance; 3.6%Better Than code Maximum UA: 138 Your UA: 133 The%Better or Worse Than Code Index reflects how close to compliance the house is based on code trade-off rules. It DOES NOT provide an estimate of energy use or cost relative to a minimum-code home. ED_V_Q1QP.Q_"&�nbJjgLa0 Ceiling 1: Flat Ceiling or Scissor Truss 130 49.0 0.0 0.026 3 Ceiling 2: Cathedral Ceiling 345 49.0 0.0 0.022 8 Wall 1:Wood Frame, 16"Q.C. 272 21.0 0.0 0.057 9 Window 3:Vinyl Frame:Double Pane with Low-E 120 0.320 38 Wall 2:Wood Frarne, 16"o.c. 132 21.0 0.0 0.057 4 Window 1:Vinyl Frame:Double Pane with Low-E 44 0.320 14 Door 3:Glass 20 0.320 6 Wall 3:Wood Frame, 16"ox, 272 21.0 0.0 0.057 16 Wall 4:Wood Frame, 16"ox, 132 21.0 0,0 0.057 4 Window 4:Vinyl Frame:Double Pane with Low-E 60 0.320 19 Floor 1:All-Wood Joist/Truss:Over Unconditioned Space 477 38.0 0.0 0.026 12 Project Title: Report date: 11/12/15 Data filename: CADocurnents and Settings\Owner\My Documents\RESchecl(\Bob—Drouin-Andover Page 1 of 9 Addition-7-15-2015.rck Compliance Statement, The proposed building design described here is consistent with the building plans,specifications, and other calculations submitted with the permit application.The proposed building has been designed to meet the 2012 IECC requirements in i RESche_ck Version 4.5.0 and to comply with the mandatory require _ nts listed in the REScheck Inspection Checklist. ► , 1 I6/ / � Nam -TW16 Si r Date Project Title: Report date: 11/12/15 Data filename: C:\Documents and Settings\Owner\My Documents\REScheck\Bob_Drouin-Andover Page 2 of 9 Addition-7-15-2015.rck REScheck Software Version Inspection Checklist Energy Code: 2012 IECC Requirements: 0.0% were addressed directly in the REScheck software Text in the"Comments/Assumptions" column Is provided by the user in the REScheck Requirements screen. For,each requirement, the user certifies that a code requirement will be met and how that is documented, or that an exception is being claimed. Where compliance is itemized in a separate table,a reference to that table is provided. ---------- F Verl�ied Plans Verifle lolles? ,11Pre-Inspection/P-lan Review Value Valu Con P IeS71 narnents/Assumptions IteeJ.if 103.1, Construction drawings and ElComplies 103.2 documentation demonstrate E]Does Not IPR111 energy code compliance for the E]Not Observable building envelope. E]Not Applicable ............ 103.1, Construction drawings and Elcomplies 103.2, documentation demonstrate ElDoes Not 403.7 energy code compliance for [:]Not Observable [PR3J1 lighting and mechanical systems. Systems serving multiple E]Not Applicable dwelling units must demonstrate compliance with the IECC Commercial Provisions. ................... 302 1, Heating and cooling equipment is Heating: Heating: ElComplies 403.6 sized per ACCA Manual S based Btu/hr— Btu/hr— 0Does Not [PR212 on loads calculated per ACCA Cooling: Cooling: E]Not Observable Manual J or other methods approved by the code official. Btu/hr Btu/hr— ONot Applicable Additional Comments/Assumptions: (1 High Impact(Tier 1) 2 Medium Impact(Tier 2) 3 t.ow Impact(Tier 3) Project Title: Report date: 11/12/15 Data filename: CADocuments and Settings\0wner\My Docurnents\RESchecl(\Bob–Drouin-Andover Page 3 of 9 Addition-7-15-2015.rck 2_012 1ECC Foundation Inspection Complies? C omn-tents/Assumptions 303.2.1 A protective covering is installed to ❑Complies [F011]2 protect exposed exterior insulation ❑Does Not and extends a minimum of 6 in. below grade. ❑Not Observable ❑Not Applicable 403.8 Snow-and ice-melting system controls ❑Complies [FO12]2 installed. ❑Does Not ❑Not Observable ❑Not Applicable Additional Comments/Assumptions: I I 1 High Impact(Tier 1) 2 Medium Impact(Tier 2) 3 Low Impact(Tier 3) Project Title: Report date: 11/12/15 Data filename: C:\Documents and Settings\Owner\My Documents\REScheck\Bob_Drouin-Andover Page 4 of 9 Addition-7-15-2015.rck Section Plans Verified Field Verified If Framing / Rough-in Inspection Value Value Complies? Cornment5/Assurnptious & R e q.I D 402.1.11 Glazing U-factor(area-weighted U_ U_ [-]Complies See the Envelope Assemblies 402.3.1, average). E]Does Not table for values. 402.3.3, 402.3.6, E]Not Observable 1 402.5 El Not Applicable [FR2]1 303.1.3 U-factors of fenestration products LIComplies [FR4]1 are determined in accordance ❑Does Not with the NFRC test procedure or taken from the default table. El Not Observable El Not Applicable 1402.4.1.1 Air barrier and thermal barrier DComplies [FR23]1 installed per manufacturer's E]Does Not instructions. E]Not Observable L1 Not Applicable 14 0 2.4.3 Fenestration that is not site built LIComplies ii[FR20]1 is listed and labeled as meeting E]Does Not AAMA/WDMA/CSA 101/i.S.2/A440 or has infiltration rates per NFRC L]Not Observable 400 that do not exceed code 0 Not Applicable limits. 402.4.4 IC-rated recessed lighting fixtures ElComplies [FR16]2 sealed at housing/interior finish 0 Does Not and labeled to indicate:52.0 cfm L1 Not Observable leakage at 75 Pa. El Not Applicable 403.2.1 Supply ducts in attics are R- R- ElComplies [FR12]1 insulated to�:R-8.All other ducts R- R- E]Does Not in unconditioned spaces or I :1, El Not Observable outside the building envelope are insulated to>R-6. L1 Not Applicable 403.2.2 All joints and seams of air ducts, ElComplies [FR13]1 air handlers,and filter boxes are E]Does Not '21) sealed. FINot Observable L]Not Applicable 403.2.3 Building cavities are not used as E]Complies [FR15]3 ducts or plenums. E]Does Not E]Not Observable El Not Applicable 403.3 HVAC piping conveying fluids R- R- DComplies [FR17]2 above 105 QF or chilled fluids DDoes Not below 55 9F are insulated to 2tR- 3. E]Not Observable E]Not Applicable 403.3.1 Protection of insulation on HVAC ElComplies [FR24]2 piping. E]Does Not F1 Not Observable El Not Applicable 1403.4.2 Hot water pipes are insulated to R- R- ElComplies [FR18]2 �!R-3. L]Does Not F]Not Observable Applicable 403.5 Automatic or gravity dampers are E]Complies [FR 19]2 installed on all outdoor air E]Does Not intakes and exhausts. -]Not Observable []Not Applicable Additional Comments/Assumptions: 1 High Impact(Tier 1) 2 Medium Impact(Tier 2) 3 Low Impact(Tier 3) Project Title: Report date: 11/12/15 Data filename: C:\Documents and Settings\Owner\My Documents\REScheck\Bob-Drouin-Andover Page 5 of 9 Add ition-7-15-2015.rck I 1 High Impact(Tier 1) 2 Medium Impact(Tier 2) 3 Low Impact(Tier 3) Project Title: Report date: 11/12/15 Data filename: C:\Documents and Settings\Owner\My Documents\REScheck\Bob_Drouin-Andover Page 6 of 9 Addition-7-15-2015.rck s ertion Pl,_f� s Vorified Field Vey fieri �, if 'vl"WationInspection �"oinp lies'. Cor�r�7er� s1� sur�aari�rs 303.1 All installed insulation is labeled ❑Complies [IN13]2 or the installed R-values ]Does Not provided. []Not Observable ❑Not Applicable 402.1.1, Floor insulation R-value. R- R- ❑Complies See the Envelope Assemblies 402.2.6 ❑ Wood ❑ Wood ❑Does Not table for values. [IN1]1 ❑ Steel ❑ Steel ❑Not Observable ❑Not Applicable 303.2, Floor insulation installed per [-]Complies ;402.2.7 manufacturer's instructions, and -]Does Not [IN2]1 in substantial contact with the underside of the subfloor. ❑Not Observable ❑Not Applicable 402.1.1, Wall insulation R-value. If this is a R- R- ❑Complies See the Envelope Assemblies 402.2.5, mass wall with at least 1/2 of the F-1Wood F1Wood ❑Does Not table for values. 402.2.6 wall insulation on the wall ❑ Mass ❑ Mass ❑Not Observable [IN3]1 exterior,the exterior insulation requirement applies(FR10). ❑ Steel ❑ Steel ❑Not Applicable 303.2 Wall insulation is installed per ❑Complies [IN4]1 manufacturer's instructions. ❑Does Not [-]Not Observable - �— ❑Not Applicable Additional Comments/Assumptions: I 1 High Impact(Tier 1) 2 Medium Impact(Tier 2) 3 Low Impact(Tier 3) Project Title: Report date: 11/12/15 Data filename: C:\Documents and Settings\Owner\My Documents\REScheck\Eob_Drouin-Andover Page 7 of 9 Add ition-7-15-2015.rck - Section Plans Verified Field Verified # Final Inspection Provisions Value Value Cornplies? Comments/Assumptions & Req.ID 402.1.1, Ceiling insulation R-value. R- R- ❑Complies See the Envelope Assemblies 402.2.1, ❑ Wood ❑ Wood ❑Does Not table for values. 402.2.2, ❑ Steel ❑ Steel ❑Not Observable 402.2.6 [Fill' ❑Not Applicable 303.1.1.1, Ceiling insulation installed per ❑Complies 303.2 manufacturer's instructions. ❑Does Not [F12]1 Blown insulation marked every 300 ft2. []Not Observable ❑Not Applicable 402.2.3 Vented attics with air permeable ❑Complies [FI22]2 insulation include baffle adjacent ❑Does Not to soffit and eave vents that extends over insulation. ❑Not OPPervable 1402.2.4 Attic access hatch and door R R-_ ❑Co plielscable [1`13]1 insulation >_R-value of the ❑Does Not adjacent assembly. ❑Not Observable ❑Not Applicable 402.4.1.2 Blower door test @ 50 Pa. <=5 ACH 50 ACH 50 = ❑Complies [FI17]1 ach in Climate Zones 1-2,and ❑Does Not <=3 ach in Climate Zones 3-8. ❑Not Observable ❑Not Applicable 402.4.2 Wood-burning fireplaces have ❑Complies [F18]2 tight fitting flue dampers and ❑Does Not outdoor air for combustion. ❑Not Observable ❑Not Applicable 403.2.2 Duct tightness test result of<=4 cfm/100 _cfm/100 ❑Complies [FI4]1 cfm/100 ft2 across the system or ft2 ft2 ❑Does Not <=3 cfm/100 ft2 without air handler @ 25 Pa.For rough-in ❑Not Observable tests,verification may need to ❑Not Applicable occur during Framing Inspection. 403.2.2.1 Air handler leakage designated ❑Complies [F124]1 by manufacturer at<=2%of ❑Does Not design air flow. ❑Not Observable ❑Not Applicable 1403.1.1 Programmable thermostats ❑Complies [F19]2 installed on forced air furnaces. ❑Does Not ❑Not Observable ❑Not Applicable 403.1.2 Heat pump thermostat installed ❑Complies [FI10]2 on heat pumps. ❑Does Not ❑Not Observable ❑Not Applicable 403.4.1 Circulating service hot water ❑Complies { [FI11]z systems have automatic or ❑Does Not accessible manual controls. ❑Not Observable ❑Not Applicable 403.5.IL All mechanical ventilation system ❑Complies [FI25]2 fans not part of tested and listed ❑Does Not HVAC equipment meet efficacy and air flow limits. ❑Not Observable ❑Not Applicable 1 High Impact(Tier 1) 2 Medium Impact(Tier 2) 3 Low Impact(Tier 3) Project Title: Report date: 11/12/15 Data filename: C:\Documents and Settings\Owner\My Documents\REScheck\Bob_Drouin-Andover Page 8 of 9 Addition-7-15-2015.rck `ection i # Final inspection Provisions dans Verified Field, 19erii€aed Value ValQhcompiies'? Comments/Assun'iptions � - 403.9.1 Readily accessible switch on ❑Complies [F112]3 heaters for swimming pools or ❑Does Not permanent in-ground spas. ❑Not Observable ❑Not Applicable 403.9.2 Timer switches on heaters and ❑Complies [FI19]3 pumps serving pools and []Does Not permanent spas. ❑Not Observable ❑Not Applicable Heated lies [F1120]3 - spas have al vapors and retardantp ❑Do sNot cover. ❑Not Observable ❑Not Applicable 404.1 75%of lamps in permanent ❑Complies [F16]1 fixtures or 75%of permanent ❑Does Not fixtures have high efficacy lamps. ❑Not Observable Does not apply to low-voltage lighting. ❑Not Applicable - - - - - 404.1.1 Fuel gas lighting systems have ❑Complies [F123]3 no continuous pilot light. ❑Does Not ❑Not Observable ❑Not Applicable i 401.3 Compliance certificate posted. ❑Complies [F17]2 ❑Does Not ❑Not Observable ❑Not Applicable 303.3 Manufacturer manuals for ❑Complies [F118]3 mechanical and water heating ❑Does Not — systems have been provided. — - _. ❑Not Observable ❑Not Applicable Additional Comments/Assumptions: i 1 High Impact(Tier 1) 2 Medium Impact(Tier 2) 3 Low Impact(Tier 3) Project Title: Report date: 11/12/15 Data filename: C:\Documents and Settings\Owner\My Doc uments\REScheck\Bob_Drouin-Andover Page 9 of 9 Addition-7-15-2015.rck ENDRD: ®FND 1. PIPE 150' DEED BK 9412 PG 218 7' PLAN #3506 LOT 2 N 44, 000 SF 0) FND I. PIPE cV PytH OF Q'i tyn LEO �G 0 6 WHITE No.29641 ZONE: R2 REQUIRED: t L^N0 sJ FRONTAGE 1150' 44.9' FRONT SETBACK 30' 21 , SIDE SETBACK 30 REAR SETQ ACK 30' -t3 EXISTING: 125.5' 20.2' .7, 52.7' FRONTAGE 150' EXIST SINGLE FAMILY HOME - FRONT SE :BACK 98.5 M SIDE SETBACK 25.5' 36.2'x6.1' PORCH to REAR SETBACK 147.2' 20' ^ iss 50.2' PROPOSED 2.1� FRONTAGE !150' FRONT SE BACK 98.5' SIDE SETB CK 25.5' REAR SET TACK 142.9' N zo 0-) 06 N 150' 150 FND I. PI�E V BARKFR STREET JOB NAME.- DRAWN BY: RWC ICHECKED BY: LBW ANDREW & ELIZABETH MCDEMT SCALE: 1„=4-0' LOCATIO : 266 BA KER ST DATE: 3/28/2016 NORTH ANDOVER, MASS i JOB NUMBER SHEET DESCRIPTION: PROPOSED ADDITION 16-08 1 0F 1 Boise Cascade Uuadrupiel-3/4" xll-7/8" VF=HSA-LAM92.031005P mor iseam\FB01 ME- E Dry 12 spans I No cantilevers 10/12 slope March 31, 2016 08:52:22 BC CALCO Design Report ow q Build 4516 File Name: BC CALC Project Job Name: MCDEVITT Description: Designs\FB01 Address: 266 BARKER ST. Specifier: City, State, Zip: NO.ANDOVER, MA Designer: Customer: Company: Cade reports: ESR 104Q Misc: 2 3 13.00-00 19-00-00 130 131 132 Total Horizontal Product Length=32-00.00 Reaction Summary(Down/Uplift) (Ilas) Bearing Live Dead Snow Wind Roof Live — BO, 5-1/4': 2,117/716 1,397/0 1,759/0 B1, 5-1/4' 7,045/0 7,027/0 7,045/0 B2, 5-1/4" 2,905/151 2,746/0 2;829/0 Live Dead Snow Wind Roof Live Trib. Load Summary Tag Description Load T Ref. Start End 100% 90% 115% 160% 125% - 1 Standard Load Unf. Area(lb/ftA2) L 00-00-00 32-00-00 30 10 07-00-00 2 wall Unf. Lin. (lb/ft) L 00-00-00 32-00-00 0 80 n/a 3 ATTIC Unf. Area(lb/ftA2) L 00-00-00 32-00-00 20 10 07-00-00 4 ROOF Unf. Area(lb/ftA2) L 00-00-00 32-00-00 15 50 07-00-00 Controls Summary Value %Allowable Duration Case Location Pos. Moment 25,827 ft-lbs 52.8% 115% 12 23-11-01 Neg. Moment -29,625 ft-lbs 60.5% 115% 13 13-00-00 Neg. Moment -29,625 ft-lbs 60.5% 115% 13 13-00-00 End Shear 5,800 lbs 31.9% 115% 12 14-02-08 Cont. Shear 8,674 lbs 47.8% 115% 13 14-02-08 Total Load Deft. U314(0.711 76.4% n/a 12 23-01-14 Live Load Dell. L/496 (0.451 72.6% n/a 27 23-01-14 Total Neg. Deft. 0999 (-0.108") n/a n/a 12 08-10-08 Max Dell. 0.711 71.1% n/a 12 23-01-14 Span/ Depth 18.8 n/a n/a 0 00-00-00 %Allow %Allow Bearing SupportsMaterial BO Post 5-1/4"x 7" 4,305 lbs n/a 15.6% Unspecified B1 Post 5-1/4"x 7" 17,594 lbs n/a 63.8% Unspecified B2 Post 5-1/4" x 7" 7,047 lbs n/a 25.6% Unspecified Notes Design meets Code minimum (0240)Total load deflection criteria. Design meets Code minimum (U360) Live load deflection criteria. Design meets arbitrary(1") Maximum total load deflection criteria. Calculations assume Member is Fully Braced. Design based on Dry Service Condition. Deflections less than 1/8"were ignored in the results. Fastener Manufacturer:Simpson Strong-Tie, Inc. – I — Boise Cascade W Quacirupiel-3/4" XII-7/,B" VF-HSA-LAM(R)2.031005P FloorBeaMTBOI Dry 2 spans No cantilevers 10/12 slope March 31, 2016 08:52:22 BC CALCO Design Report Build 4516 File Name: BC CALL Project Job Name: MCDEVITT Description: Designs\FB01 Address: 266 BARKER ST. Specifier: City, State, Zip: NO.ANDOVER, MA Designer: Customer: Company: Code reports: ESR 1040 Misc: Connection Diagram d Disclosure Completeness and accuracy of input must be verified by anyone who would rely on output as evidence of suitability for particular application.Output here based on building code-accepted design properties and analysis methods. Installation of Boise Cascade engineered wood products must be in accordance with current Installation Guide and applicable building codes.To obtain Installation Guide a minimum= 1-1/2"c= 8-7/8" or ask questions,please call b minimum= 6" d= 24" (800)232-0788 before installation. e minimum BC CALM,BC FRAMER®,AJSTM, ,BC RIM BOARIDTM,RAMINBCI6G ' Beams 7 inches wide will be assumed to be either top-loaded only, or equally loaded from ALLJOISTOBOISE GLULAMTSIMPLEM, each side. F SYSTEMO,VERSA-LAMO,VERSA-RIM Install Screws with screw heads in the loaded ply. PLUSO,VERSA-RIMO, Member has no side loads. VERSA-STRANDO,VERSA-STUN are Connectors are: SDW22634 trademarks of Boise Cascade Wood Products L.L.C. The Commonwealth ofMassqehusefis Department ofIndustrialAccidents 1 Congress Street,Suite 100 Boston,AM 02114-2017 WWW.Mass.jzov1d1a Workers'Compensation Insurance Affidavit:Builders/Contractors/E icetricians/Plumbers. Applicant Information TO BE TILED WITH THE' PERMITTING AUTHORITY. Please Print Ledb Name (Btisiness/Organization/Individtial): 0, Address: City/State/Zip: Phone#: Are you an employer?Check the appiiop'rlate box; Type of project(Vequired), 1.01ani.acriployerwith employees(fall and/orpart-time).* 7. UNew construction 2.[J I am a sole proprietor or partnership and have no employees working for me in 8. Fj Remodeling any capacity,[No workers'comp.insurance required.]• 9. U Demolition 3.F1 I am a homeowner doing all work myself.[No workers'compAnsurance required.]t , , "e, 4.n I am a homeowner and will be hiring contractors to conduct all work on my property. 1will 10 [q,-M-illding addition ensure that all contractors either have workers'compensation insurance or are sole 11.F1 Electrical repairs or additions proprietors with no ernployees. 12.[]Plumbing repairs or additions 5.F1 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. Roof repairs 'fhosb sub-contractors have employees and have workers'comp.insurance.$ 6.Q We are a corporation and its officers have exercised their right of'exemption per MGL c. 14.Q Other 152,§1(4),and we have na,employees.[No workers'comp,insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. Homeowners who submif�iis 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 state whether or not those entities have 'or employees. If the sub-c6nirac6s have employees,t ey must provide their workers'comp,policy number. I ain an employer treat is p i6vid6ig i v orkers compensation insurance for my employees.' Belo 1V is the policy and job site information. Insurance Company Name: Policy#or Self-ins,Lie. Expiration Date: Job Site Address: City/State/zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under thepains andpenaldes ofpeijuiy that the information provided above is true and correct. 0—_ Signature• Date: Phone#: Official use only. Do not write in this area,to he 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#: MCCAC01 OP ID: BW ,d►C®�® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 03/30/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER, IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). CONTACT PRODUCER _NAME: _ __ .._. Francis Provencher Insurance PHONE FAX Agency, Inc. IA No Ext): 978-459-8681 we NII: 978-454-9343 530 Rogers Street p DRIESS: Lowell,MA 01852 INSURER(S)AFFORDING COVERAGE NAIC# _ INSURER A:Preferred Mutual Insurance Co. 15024 INSURED McCarthy Contractors Corp. INSURER B:SAFETY INSURANCE PO Box 594 INSURER C: Dracut,MA 01826 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 TYPE ADDL SUBR POLICYNUMBER MM DDNYY MM DD YEXP LIMITS LTR S A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 CLAIMS-MADE OCCUR BOP0100721656 12/09/2016 12/09/2016 PREMISES Ea occurrence 5 50,000 MED EXP(Anyone person) S 10,000 PERSONAL&ADV INJURY S 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 2,000,000 PROJECT 0 LOC- PRODUCTS-COMP/OPAGG S 2,000,000 POLICY❑ 5 OTHER AUTOMOBILE LIABILITY Ea accidentSINGLE LIMIT S 1,000,000 B ANY AUTO 6227181 01/22/2016 01/22/2017 BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED BODILY INJURY(Per accident) S AUTOS AUTOS NON-OWNED PROPERTY DAMAGE S HIRED AUTOS AUTOS Per accident 5 UMBRELLA LIAB OCCUR EACH OCCURRENCE S EXCESSLIAB CLAIMS-MADE AGGREGATE 5 DED RETENTION$ S WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANY PROP RIETOR/PARTNER/EXECUTIVE F—_] N/A E.L.EACH ACCIDENT 5 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE 5 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached if more space is required) "CERTIFICATE FOR WORKERS'COMP COVERAGE WILL BE ISSUED DIRECTLY FROM THE COMPANY WITHIN 2 BUSINESS DAYS`* CERTIFICATE HOLDER CANCELLATION NANDOVE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of North Andover 120 Main Street AUTHORIZED REPRESENTATIVE N.Andover,MA 01845 ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD 0-3 3/17/2018 4 : 42 :57 AM PAGE 2/002 Fax i5erver ' CERTIFICATE OF LIABILITY INSURANCE I DATE(MM/DD/YYYY1 IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS ETUWaN20TIFICATE TIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE No THE CEUCIQA=HOLQFR. IMPORTANT.ifthe Certificate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION 15 WAIVED,subject to he terms and conditions of the policy,certain policies may require and endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsenten s . PRODUCER CONTACT NAME: FRANCIS E PROVENCHER INS PHONE FAX 530 ROGERS ST (AIC,No,Ext): (A/C,Noy E-MAIL LOWELL,MA 01852 ADDRESS: 26179G INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A: TRAVELERS INUEMN rY COMPANY OP AMERICA MCCARTHY CONTRAC'T'ORS CORP INSURER B: INSURER C: INSURER D: PO SOX 594 INSURER E: DRACUT,MA 01826 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO VERTIFY THAT THE POLICIES Of INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED HAM M ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANENG ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER nOCUMENT 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, NSR ADD SUB POLICY EPF DATE POLICY EXP DATE LTR ME OF INSURANCE L R POLICY NUMBER (K"ODIYYYY) (MmODIYYYY) LIMITS GENERAL LIABILITY ACI I OCCURRENCE $ COMMERCIAL GENERAL LIABILITY CLAIMS MADE M OCCUR. PREMISES TO RENTED $ REMISES(Ea occurrence) MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY [:D PROJECT O LOC PRODUCTS-COMPIOP AGG $ AUTOMOBILE LIABILITY COMBINED SINGLE $ ANY AUTO LIMIT(Ea acoldent) ALL OWNED AUTOS BODILY INJURY $ SCHEDUI.E AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per occident) PROPERTY DAMAGE $ (Per aceident) UMBRELLA LIAB OCCUR CACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DEDUCTIBLE _ $ '•• „ RE-FENTION $ $ A WORKER'S COMPENSATION AND XWe STATU TORY OTHER EMPLOYER'S LIABILITY YIN UMG03954A-15 05/1912015 05/19/2016 LIMITS ANYF-ROPERITOR/PARTNER/EXECUTIVE M N/A E.L EACH ACCIDENT $ OFIGE FR/MEMBER EXCLUCE07 100,000 (MandaI6ry Ih NH) E.L.DISEASE-EA EMPLOYEE $ 10Q000 If you,0000rIbe Undel OEBCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERAT10NWLOCATIONS/VEHICLES/RESTRICTIONS/SPECIAL ITEMS THIS REPLACES ANY PRIOR C13RTrRCATE ISSUED TO THE CERTIFICATE II AFFEC'T'ING WORKERS COMP COVERAGE. CERTIFICATE HOLDER CANCELLATION` TOWN OF METHUEN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED 41 PLEASANT ST STE 313 IN ACCORDANCE WITH THE POLICY PROVISIONS, AUTHORIZED REPREBETIT TYE fJ MEI'HUEN,MA 01844rvS4 ACORD 26(2010/05) The ACORD name and logo are registered marks of ACORD 1888-2010 ACORDCORPORATION.All rights reserved. g�Office of Consumer Affairs&Business Regulation a# OME IMPROVEMENT CONTRACTOR ( - registration: 149258 Type: k � PVExpiration: 1/19/2018 Individual ROBERT J MCCARTHY ROBERT MCCARTHY 81 LONGMEADOW DR. LOWELL,MA 01852 Undersecretary 960Z/M% 1auoisslwtuoo s 0 !f J� f Y 9ZEI0 Vjq.LILT 66S CLOS'O'd ?R SW&50-S3 :asueol-1 SP epu131g Pue suoReM1308&ulpyne jo pleoe allgnd I®3uaLupedaO= sj4asny3esse1A1