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Home My WebLink AboutBuilding Permit # 11/14/2016 t40 R TH BUILDING PERMIT o��t,Ea 'bq4o TOWN OF NORTH ANDOVER 10 ,.- APPLICATION FOR PLAN EXAMINATION Date Received �N Permit Flo#. 1m 'Rarer Pea `� Date Issued:_ a/ — -- -.------------- IMPORTANT. ---------lIMPf.RT I° T. Applicant must complete all items on flus page LOCATION not PROPERTY OWN ' ER Print 1 OD fear Structureyes , no o MAP PARCEL: ZOFIING DISTRICT.� � His District yes aa� Machine Shop Village yes CO TYPE OF IMPROVEMENT PROPOSED USE Resid ntial Non- Residential —� ew Building . ne family ❑Addition Cl Two or more family Industrial ❑_Alteration No. of units: 11 Commercial _� Repair, replacement i:]Assessory Bldg ❑ Others; ❑ Demolition [] Other El S ❑ ptic Well _ ❑ Floodplain ❑Wetlands ❑ Watershed District ater/Sewer - 4 n� ' C)F2f�lED. DESCRIPTION OF 'LIVOR TO D� PERF " en�ificatiars - I'leaac,Type m _ _— ---- -- Id yl r Pram Clearly OWNER: I`�ame. ro utt Phone: µ Address.-- Contractor ddress:Contractor Flame- Phone: Email: Address: M. Supervisor's Construction License: Ex . Date. Home Improvement License Exp. Date: ARCHITECT/ENGINEER _ Phone: Address: Reg. No. FEE SCHEDULE:BULDINO PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASER ON$125.00 PER S.F. Taal Project Cosi: $. . ` ..a FEE: $ - -° Check No.: ---_._--Receipt No.'_„__ -, N'( TE: Peryons contracting with unregistered contractors do Haat have access to guaFantyfund°" M Signature of Agent/( wne ,,.,, � F--- _ Signature of contractor Plans Submitted ❑ Plans Waived ❑ Certified Plot Pian ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer ❑ Ta ning(Massage/Body Art ❑ Swi.m ilg Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private (septic tank,etc. ❑ Permanent Dumpster on Site ❑ ------------------- THE FOLLOWING SECTIONS FOR,OFFICE;U-SE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING DEVELOPMENT Reviewed On)' (-p Signature COMMENTS �v' 41 W W016_e, awws CONSERVATION Reviewed on < < 1 Signature COMMENTS . . HEALTH,-. .. Reviewed on- -- Signature COMMENTS Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connectiorllsignature & pate Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE,DEPARTMENT Temp ,pmps,gr,bn site ,,`Y es nb Located at'f24,Mart Street Fire Department signaturelclafie COMMENTS r- 6 -o L7 'T NORTf1 own of o No. MA Y nO - LAKE h ver, Mass, /� • /0•x_0__1 � COC MICM[1VlCK RATED P,IF �,(y 11 BOARD OF HEALTH PERMIT T LD Food/Kitchen Septic System THIS CERTIFIES THAT 3V!4q.r4.. coNI�V' ( #612 1. BUILDING INSPECTOR has permission to erect.......................... buildings on ....$. .......'�'..V.rroN.. .� A.A,6 Foundation Rough It d to be occupied as ...j!!; ...... .1 'A.... .., .� ...�...�........ ..•�F9r..., 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 CONSTRUCTIONOVTS Rough ............... .I.. .................................. Service Final BUILDING INSPECTOR GAS INSPECTOR 4ceMancy 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 Street No. Smoke Det. t%of?rM TOWN OF NORTH ANDOVER A�}O`,t4lD d,ye apt OFFICE OF ° . BUILDING DEPARTMENT a 1600 Osgood Street,Building 20, Suite 2035 D�Ar[D nro North Andover,Massachusetts 01845 SSACFIUSE Donald Belanger 'Telephone(978)688-9545 Inspector of Buildings Fax (978)688-9542 HOMEOWNER LICENSE EXEMPTION BUIDINC PERMIT APPLICATION Please print DA"Z"E: (C l JOB LOCATION: c4 l °• l __. Number Street Address Map/Lot HOMEOWNER -- Naive Horne Phone Work Phone PRESENT MAILING ADDRESS k - o Ri � City Town State Lip Code The current exemption for"homeowners"was extended to include owner occupied dwellings of one or two family dwellings and to allow such homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as su erp visor. DEFINITION OF ITOMEOWNER. Person(s)who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one-or two-family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. (780 CMR. Section I IO.R5.1..2) The undersigned"'homeowner"assumes responsibility for compliance with State Building Code and other applicable codes,by-laws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of North Andover Building Department minimrun inspection procedures and requirements and that he/she will comply with said procedures and requirements. HOMEOWNERS SIGNATURE__eM. (w e APPROVAL OF BUILDING OFFICIAL Revised 8.2015 Form I-Ionreowneis Exemption BOARD OF APPEALS 688-9541 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 SUTTON MILL ROAD S2 1p� 3t V P,W4T '£LEV ATI O A NoRT" kubovok. MA T Kl LLf tom_Iiti" ilvs" � 1,0" TDIY 14, LOI(o 1 N.: 1 { � 1 i 1 1 I A PI ,� , ic'i.:`:' .. �. 'At 03 t � w lJ ik kl�II �- I L �V. 1� lyt �) w.iktii�r� a«!�,•sw NAS*k��' � r � �, k 3 p. Wk, i a i NIla 104 S+1011k 1`d1SiN d .r1 q,.. rii�i •� „ 1 It lk�,} ; it iq..f..4:S? FN n ti'P � i +1 d � {1¢¢ ►S�iU�s1 1 ` A ,A -..��f �i� A�u,M.�+at* �+�` I't j Ali— WN c s vIIA a pp V C► 9 JN i I j Pb r I ►4 OKI-t0ftAAfitbA, J�3 0 �,y�] ; 'rem+�+i R►rN.�s w+,r �y ` p e�17 �Ir��•�,�s i n ;A;t /"" Iul 17 S�-r-w,m DEM TRAMS 10 I-IJ TL FAI.1 DFOC, K)Wit ,25 yA,aNltafi,lS � � tS sI. Ftll7 1iOTE�- %wl WtAwQic j tR '12'c t7x ttil I-Mk 2�tot� 1 —r�sxx�.z'�n�4x(t%M t,E?oRT +,wx.n►.,�esu —b:r�rt;e+at 87�vt�S vAtilcll5, �" �Tn'4 —ri.-- u $X"�Nti R14KES �8 � ' Z�+oCtyvl it3'Sp1C�nR noiJRS L�� W izy0� t8"aK a�:c „astLpwEuc � a i 'rs:•ewceentu TLEE1 tARC.S MSDJ"l� LO Vcsar i w 13 r E { � t2 Q�s o ei- L--A 2s f ! E I I I I I + Mbl. S E E 1 t 111 i �4l2xio 54CTIo0 utiMxTibul LO 97 14 0 LA umi Q.,d- �7 0 FIRST r-WCSR Pk_kN ro loo-u Q 1 vt(Klewrto QO > rD 03 (D cs rD xo 44469 *A tA 4q, �?�Sx Iq mr to 2-(A%ISM" PaYeW Pti1V, S%YLKS3 NOW q*9 09 C PORtN 3r .4.0 1 OX-0, 2.0 WA-0 yx (12—q-G)CIO 2,-o Z c fig Ix""om 3 0 54. '2 18,„u (4cl) mm c IZW v,31) FLOO?, ?LAt%3 Lict R, C�( REScheck Software Version 4.6.3 J Compliance Certificate Project Energy Code: 2012 IIIECC Location: North Andover, Massachusetts Construction Type: Single-family Project Type: New Construction Conditioned Floor Area: 0 ft2 Glazing Area 11% Climate Zone: 5 (6322 HDD) Permit Date: Permit Number: Construction Site: Owner/Agent: Designer/Contractor: 97 Sutton Hill Road Peter Loughlin North Andover, MA 508-228-0048 Compliance: 2.9%Better Than Code Maximum UA: 380 Your UA: 369 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. Eaylpi_w_eAa �Ii Q5 Ceiling 1: Flat Ceiling or Scissor Truss 384 38,0 0.0 0.030 12 Ceiling 2: Cathedral Ceiling 1,561 38.0 0.0 0.027 42 Wall 1:Wood Frame, 1611 o.c. 3,049 21.0 0.0 0.057 152 Window 1:Vlnyl/Fiberglass Frame:Double Pane with Low-E 284 0.280 80 Window 2:Vinyl/Fiberglass Frame:Double Pane 40 0.280 11 Door 1: Solid 20 0.200 4 Door 2: Solid 20 0.200 4 Door 3: Solid 20 0,450 9 Floor 1:All-Wood joist/Truss:Over Unconditioned Space 1,666 30.0 0.0 0.033 55 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 REScheck Version 4.6.3 and to comply with the mandatory requirements IIstA In the h RE!S _ ��rKpection Checklist. Tom Barnes,HERS Rater#4583495 11-4-16 Name-Title MvOure Date Project Title: Report date: 11/03/16 Data filename: C:\Users\caryn\Documents\REScheck\Sutton Hill - 97,rck Page 1 of 8 REScheck Software Version 4.6.3 Inspection Checklist C�(J 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. .. ............ ... C d camplies? .Comm.., Section–!�e---o-awl------- Plans veril'ie Field Verifie # I Pre-Inspection/Plan Review V Value & Re 103.1, Construction drawings and OComplies 103.2 documentation demonstrate Oboes Not [PRI]l energy code compliance for the []Not Observable building envelope. ONot Applicable ............. 103,1, Construction drawings and ElCompiles 103.2, "documentation demonstrate ',Oboes Not 403.7 energy code compliance for tlNot Observable (PR3]1 lighting and mechanical systems. :Systems serving multiple EINot Applicable dwelling units must demonstrate ,compliance with the IECC Commercial Provisions. ------- 302.1, Heating and cooling equipment Is , Heating: Heating: ncomplies 403.6 :sized per ACCA Manual S based Btu/hr Btu/hr— ElDoes Not [PR2J2 ;,on loads calculated per ACCA Cooling: Cooling: ;[]Not Observable V) 'Manual J or other methods Btu/hr Btu/hr EINot Applicable approved by the code official. Additional Comments/Assumptions: [fl,HIgh Impact Medium Impact(Tier 2? Mww 3 Low Impact(Tier 3} Project Title: Report date: 11/03116 Data filename: C:\Users\caryn\Documents\REScheck\Sutton Hill - 97.rck Page 2 of 8 Sectiara _..__.. .. .... _. ......... w,.,,. �e 1� �, Foundation Compiles; C'ontrrrerrts/A earn X04.. _... _.__...�....__. , Inspection 303, ,1 p g ed to ❑Com Iles [FO11]2 protect exposed exterior insulation ClDoes Not and extends a minimum of 6 In. below �E] ot Observable grade. ;ONot Applicable _.. w... _..... _.._ ..... _...,..�.._..._ 403.8 Snow-and Ice-melting system controls DOomplies [FO12]2 installed, ODoes Not ^k ONot Observable; ONot Applicable Additional Comments/Assumptions: 1 Hiwgh Impact(Tler 1m)„ 2 Medium Impact(Tier 2)Mw 3mm�Low Impact(Tier 3)m Project Title: Report date: 11/03/16 Data filename: C:\Users\caryn\Documents\REScheck\Sutton Hill - 97,rck Page 3 of 8 .___._ I raining / oug6l-In Inspection Flans Verifies section W eg ID_40 �,..� Complies? Comments/Assumptions R ValvaValue..,-. ._..._ __.._.._ .. 402.1.1, Door U-factor. U- U ❑Complies see the Envelope Assemblies 402,3,4 ❑Does Not table far values. [FR1]1 ❑Not Observable ,t ;❑Not Applicable 402.3.1 Glazing ) ❑ moble for factor(area-welghted U_._.... ._.. - U- °❑Complies mmµ eEnvelope Assemblies e es average Does Notvalues. 402,3.3, (]Not Observable 402.3,6, ❑Nat Applicable 402.5 t [FR2]1 t 303.1.3 U-factors of fenestration products ❑Complles [FR4]1 are determined in accordance ❑Does Not with the NFRC test procedure or ❑Not Observable ' taken from the default table. ❑Not Applicable 402.4.1 1 ,Air barrier and thermal barrier ❑Complies [FR23]1 installed per manufacturer's ❑Does Not Instructions. ❑Not Observable ❑Not Applicable [R20�3 VmN Fenestration labeled o meeting built OD.__-____._..._. omplles p g oes Not AAMA/WDMA/CSA 101/I.S.2/A440 ;❑Not Observable or has infiltration rates per NFRC :400 that do not exceed code ❑Nat Applicable limits. 402.4.4 IC.-rated recessed lighting fixtures" ;❑Complies [FR16]2 sealed at housing/interior finish ❑Does Not and labeled to Indicate s2.0 cfm ❑Not Observable leakage at 75 Pa. ❑NotAppllcable 403.2.1 Supply ducts In attics are R- R ❑Complies [FR12]1 insulated to z-11-8.All other ductsR- R_ ❑Does Not in unconditioned spaces or ❑Not Observable ;outside the building envelope are f Insulated to zR-6. ❑Not Applicable , ------------ ....._... ..,__w_._........ _____ . ._ 403.2.2 IAII Joints and seams of air duets, '❑Compiles [FR13]1 'air handlers, and filter boxes are ❑Does Not sealed. ❑Not Observable ❑Not Applicable 403,2.3 Building cavities are not used as ❑Complies [FR15]3 ducts or plenums. ❑Does Not ❑Nat Observable ❑Nat Applicable _ _..__.. ...,._... _. _..,.. __..._.. ..... ___.__..._. 403,3 HVAC piping conveying fluids R- R- ❑Complies [FR17]2 :above 105 QF or chilled fluids j❑Does Not below 55 QF are insulated to 2-11- ❑Not Observable 3' j❑Nat Applicable ❑Comlie 403.3,1 Protection of insulation on HVAC p s [FR24]1 'piping. i]Does Not ❑Not Observable ❑Not Applicable 403.4.2 ;Hot water pipes are Insulated to R- Ry.._._...._,._._,___._._ ❑Complies [FR18]2 >11-3. ❑Does Not ;❑Not Observable ❑Not Applicable C._1_ Hlgh Impact(Tier 1)w 2M Medium Impact(Tier 2) . Low Impact(Tier 3)w Project Title: Report date: 11/03/16 Data filename: C:\Users\caryn\Documents\REScheck\Sutton Hill - 97,rck Page 4 of 8 fonJFr ming Rough-in Inspection . Pians luefietimm�mFieiVail e�teci Complies? Comments/Assumptions seot & Re Ill _.. .. ..,. .....,.,w..w,.,..._.w.. __._. _..w._..........._.. m. w. ,., 403.5 Automatic or gravity dampers are OComplies [FR1912 installed on all outdoor air ❑Does Not Intakes and exhausts. Nat Observable ❑Nat Applicable Additional Comments/Assumptions: i ...__ 1 Nigh„Impact(Tier 17..._. �2 Medium impact(TIer,2)LL ] 3jt.ow Impactu(Tier 3) Project Title: Report date, 11/03/16 Data filename: C:\Users\caryn\Documents\REScheck\Sutton Hill - 97.rck Page 5 of 8 lection Flans Verified Field Verified Insulation Inspection Com Value Value complies? Comments/Assumptions Rei _._ � p .. _._�__.._..,_.�.�_. ...�.... .�..._m__._.._..__...__.. 3031 All Installed insulation Is labeled ❑Complies [IN13]2 'orthe installed R-values ❑Does Not provided. ❑Not Observable ❑Not Appllcable . .. _._. ---------- 402.1.1, _.___-__402.1.1 Floor insulation R-value. R- R ®Com Iles 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 ❑Not Observable underside of the subfloor. ❑Not Applicable 402.1.1 Wall Insulation R-value.lif this is a Wood Q Woad ®Complies See t peA Hes See the Envelope Assemblies 402.2,5 mass wall with at least /Z of the ❑Does Not table for values. 402.2.6 wall insulation on the wallMass =❑ Mass '[:]Not Observable f [IN3]1 exterior, the exterior insulation ❑ Steel ❑ Steel ❑Not Applicable opq requirement applies(FRIG)• 303. p 2 ;Wall insulation is Installed ❑Complies 1 -manufacturer's instructions. .❑Do..-... ...._.. ___.,,_ ._.._..__..__..._.__.__....-..._W 303. I i es Not pia j ❑Not Observable ; ❑Not Applicable Additional Comments/Assumptions: 1�Hfgh Impact(Tierml) 2 Meudium Impact(Tier 2) 3 Low Impact IT .3 ) w µ Project Title: Report date: 11/03/16 Data filename: C:\Users\caryn\Documents\REScheck\Sutton Hill - 97.rck Page 6 of 8 mm.. ..m Final ir►sprctinM� rvisinrys.-_ pia 1! 1UeYfied - lei laef.�. _- ._. ... Complies? Comments/Assumptions secinrt IRec .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, j F] steel E] Steel ;❑Not Observable 1 402.2.6 [Fill' ( ❑Not Applicable 303.1.1.1, Ceiling insulation installed per ❑Complies 303.2 manufacturer's instructions. ❑Does Not [F12]1 jBlown insulation marked every :[:]Not Observable f 1300 ft2. ❑Nat 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 Observable ❑Not Appllcable 402.2.4 Attic access hatch and door R- R ❑Complies [F13]1 insulation zR-value of the ;❑Does Not adjacent assembly. ❑Not observable i ❑Nat Applicable Appli_c._a. ble . ------- 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 ....._A._.pl.p_li cable 403,2.2 Duct result of<= cfm/100 cfm/100 ❑Compliesftz �z ❑Does Not[FI4l_ across the j<=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 [FI24]1 by manufacturer at<=2%of ❑Does Not design air flow, ❑Not Observable ❑Not Applicable 403.1.1.�T._ thermostats Programmable Pra g ❑Complies [FI9]2 installed on forced air furnaces. ❑Does Not IV) ❑Not Observable i ❑Not Applica ble 403.1.2 Heat pump thermostat Installed ❑Complies [FI10]2 on heat pumps. ❑Does Not ; ❑Not Observable ❑Nat Applicable _. _ . _...,..... .....w _......... 403.4.1 Circulating service hot water ElComplies CFI11]2 systems have automatic or ❑Does Not accessible manual controls, ❑Not Observable ❑Not .. Applicable .__�._ __._._ 403.5.1 All mechanical ventilation system ❑Compiles [FI25]2 ;fans not part of tested and listed -❑Does Not HVAC equipment meet efficacy and air flow limits. ❑Not Observable ❑Not Applicable 404.1 75 r, ___..... . ..�.-�dw...,,.�.__..__._.�..-.._. _......., ..-r._„ ...� .,�...._..__.___._.._..... ........ .w._._._._ ...___.._._..�-,..._ %of lamps p inpermanent ❑Co mplies ; [17I6]1 fixtures or 75%of permanent ❑does Not CoA, {fixtures have high efficacy lamps.' :]Not Observable Does not apply to low-voltage lighting. ❑Not Applicable 2High Impact(Tier{) .. 2Medium Impact(Tier 2)w 3 µLow Impact(Tier 3] _._. .� Project Title. Report date; 11/03/16 Data filename; C.\Users\caryn\Documents\REScheck\Sutton Hili - 97.rck Page 7 of 8 ct Sinai Inspection F�rr�visia. . .,... F+Ime�V lVer umfimd lumfimci.. Complies? Cca�nmmnts/Assupp. ions ..... . .. ns� Itm .ICf 404.1.1 Fuel gas lighting systems have ❑Complies (FI23]3 no continuous pilot light, ❑Does Not []Not Observable ❑Not Applicable 401.3 Compliance certificate posted. ,,..„M _....M . ,❑Complies [FI7]2 !❑Does Not .� ❑Not Observable ❑Not Applicable 303.3 Manufacturer manuals for ❑Complies [FI18]3 "mechanical and water heating ODoes Not j systems have been provided. ;❑Not Observable 1 ❑Not Applicable Additional Comments/Assumptions: I �1�High Impact(Tier 1) �2Medlum Impact(Tier 2) 3Law Impact(Tier 3) Project Title; Report date: 11/03/16 Data filename. C,\Users\caryn\Documents\REScheck\Sutton Hill - 97,rck Page 8 of 8 C 20 12 IECC � i Effciency Certificate(j Pete - you'll adhere 011IM212, M thiis to eled'lic panel Above-Grade Wall 21.001110110111111MMILI Below-Grade Wall 0.00 at end of job. Floor 30.00 Assuiiiing we go thru Ceiling / Roof 38.00 Ductwork (unconditioned spaces): MassSa,ve incetiti"WIS program iveyou 9 Window 0.28 this at f ed o *o nb Door 0.20 1 fromniy i,eports Heating System: 0 Cooling System: using full energy, Water Heater: modeling. It" will Name: Date: reflect blowei,- doorl, Comments etc,,,Aes1,S. Permit Listink Re art Date Range:Issued between OlI0lf24I6 And 1110712016 by Permit Type47124I6 Printed 4n:Mon Nov 4 r,241 b SQL Statement:(Street like"SUTTON HILL ROAD"OR Work Location like"*SUTTON HILL ROADS")and([Type of Permit]="Building") Permit Type Address(Work Location) District Zoning Owner Work Category Est.Cost Proposed Use Details Map/Block/Lot Permit No Online Permit No Permit Status Date Issued Contractor(Phone#) Work Description Fees Paid Check# Building 211 SUTTON FALL ROAD ANGELA LUKENS Residential Alteration $6,300.00 060.0/0079/ 1047-2016 Expired Apr-11-2016 Richard Fluet(978)685-7010 Install 2 c channels added to beam in garage $76.00 1615 (97 SUTTON BILL ROAD) TKZ Inc. FOUNDATION $12,500.00 1/ 108-2017 OPEN Aug-03-2016 TKZ Inc.(978)687-2635 FOUNDATION ONLY $150.00 2122 101 SUTTON HILL ROAD WATSON REALTY TRUST ELIZABETH FOUNDATION $12,500.00 B WATSON,TR 060.A/0008/ 109-2017 OPEN Aug-03-2016 TKZ Inc.(978)687-2635 FOUNDATION ONLY $150.00 2122 110 SUTTON HILL ROAD TKZ Inc. Demolition $15,000.00 097.0/0064/ 1214-2016 OPEN flay-20-2016 Thomas Zahariko(978)687-2635 Demo of Existing Structure $180.00 1984 101 SUTTON FALL ROAD WATSON REALTY TRUST ELIZABETH Shell Only $245,450.00 B WATSON,TR 060.A10008/ 358-2017 OPEN Oct-13-2016 TKZ Inc.(978)687-2635 Shell Only 52,943.00 2200 (97 SUTTON HILL ROAD) TKZ LLC Single Family Dwelling $175,400.00 !/ 358-2017 OPEN Oct-11-2016 Thomas Zahariko(978)687-2635 SFR Frame Structure-Shell Only $2.104.80 2191 GeoTMS0 2016 Des Lauriers Municipal Solutions,Inc. Page 1 of 2 The Commonwealth of Massachusetts Department oflndustriar.Aeddents „ • .: .; X Congress Str"eet,SOe 100 ' tl•� 02114-2017� Boston,MA www mass.gov/dia iM y�Y - gVke& Compensationllnsurane6A.ff"rdavit-Bnilde)r, nt , ractors(L+,'lectxXciauslt'�umbe�s. TO BE TIGEv`WIT1T THE FrmW 1:"]JNG AUTHO;�I'['Y, _Please Print Le A, ''licantinformation � Name(Business/Oigait zatic)wlndividital): Ad(lx''tiSS:_ City/state/Zig: . Phone#: ._--- — ... _ Type orpr `set( er uxxed}; tyre you au erp, r?(.heel flee apprapxla#e box'• 7. � ��C(instrllCtian 1.[J I am a employer with _ _ ._employees(hill and/or part-tirne). 2.[jI ain a sole proprietor or partnership and have no employees v9orkixrg for me in &. LI C:emodolitig any capacity.[No workers'comp.insurance required:] 9, ❑Demolition 3.2 I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10�Building addition 4. as oraahomeownerandwillbehiringcon#rac#ors to conduct 11.��lea icalzepqtzsof gtc(ditiols ensure that all contractors either have workers'compensation insurance or are solo ..12 '1'�i tlribirtg rspai�rs of additions proprietors with no erriplciyees, 5.F—]I am a general cantractox and I have hired the sub-eontrac#ozs listed.an the attached sheet. 13% Koofrcl aW These sub contractorsKnave ernployces and have workers'comp.insurance.# 1 1 Other6,t__t We are a corporatio,4 and its,officers have exercised their right of exeraptian per 1410E a. 1 152,§1(4),and eve have no employees.[Na workers,comp.insurance required *Any applicant that checks bb>E#1 rrirzst also fill asa`fill out section below showing their workers'aampensatianpolicy enformation. .i Homeowners who submit-this k u t attached ar additional she tshowing the all work pdname of the hire tside h cantracto s and state wheth.,must submit a er ar #bas ow affidavit ent ti have In tC,ontractars that clteakthrp.policy employees. If the sub-contractorshave employees,they must provide their workors'cum ale number. lana an ern-player that is providing worlce�s'co�nper�rsation ar�sra�•ancefaj°My eM1�rbyees• �'ezaw zs trie•poZicy ar�rZj�aX�szte information. fnstirance Company Name-:_� expiration Datm -- policy#or Self-ins.Lic. :�-_ _____._______.— - _ City/State/L"ip; �1 -°= +�'"" � " �• rob Site Address:_._ , a 6( 4 Attach a copy of the�'axlt:exs' compensation p 0.00 olicy declaxatian gags(shoYving the policy nnrnbsx and s�cpirati.ou date}. .Failure to sev uxe coverage as required underivi� 0rlaities��n§hc�rm of a QST Ol'rWORI�OI�D�TZ and a fine of uli to X250,00 a and/or one-yeast'imprisonment,as well as p day against the violator.A copy`of this statement may'be forwarded to the Offico of es Ong of tlra DrA for insurarrco covexage verification. X da riea'eby certify under flee pains and peaaalties of pefjury that t1ie ilifarmationprovided above is true and correct Date: t il U, Official use Only. Do not-rna'ite in dais area,to lie completed by city or town official. Perrnit/Licenso City or Town: Issuing Authority(circle one): :1.Board offlealth 2.BuildingDepartment 3.City/Town Clerk d•,Electrical Xnspeetar 5.Plrrrubinglnspectox 6,Other -- Phone Contact