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HomeMy WebLinkAboutBuilding Permit #826-2017 - 1 HIGH STREET 3/2/2017 NORTIFi BUILDING PERMIT ,t? TOWN OF NORTH ANDOVER- APPLICATION FOR PIAN EXAMINA ` ��D� �* Permit NO. DA Date Received_ , �.,...... > Date Issued: � vL ACML9 IMPORTANT:Applicant must complete all items on this page LOCATION Rrin4 PROPERTY OWNER INET �1 t N ' Print MAP NO: _PARCEL: ZONING DISTRICT: Historic District no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑Addition ❑Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑Assessory Bldg 'k Others: ❑ Demolition ❑ Other ❑ Septic Ej Well ❑ Floodplain ❑Wetlands ❑ Watershed District ❑Water/Sewer I N STAtit_ S L P 0A1 EX t,S-n W IL 90r� i i� GJF-nokA4-TE l I Kw Cec) Paz,-�Wiz, IUD Identification Please Type or Print Clearly) OWNER: Name: C& VV*8 i 11J, PA LIL I Phone: Address: V7 yVA LIC1112 5,T) t-14 02 I L 3 CONTRACTOR Name: 5oL-f� Phone: '�D- 5'1`1 [®� Address: Supervisor's Construction License: GS [,0 g O L( Exp. Date: . l Home Improvement License: Exp. Date: ARCHITECT/ENGINEER �4-,A-At``f- 44n0(- Phone: R _7 E-; Address: l ®P T 'J'� '= - �� („ N[i?�!U Reg. No. I-f © q FEE SCHEDULE: DlNG PERMIT:$12.00 PER$1000.00 OF THE TOTAL EST/MCOST BASED ON$125.00 PER S.F. Total Project Cost: $ �� 1 FEE: $ q �-. Check No.: 5(o 0 0 Receipt No.: NOTE: Persons contracting with ist red contractors do not have XAaccess o th guaranty d Signature of A�gentOwner Signature of contractor Plans Submitted ❑ Plans Waived Certified Plot Plan ❑ Stamped Plans ❑ TyPF'OF SEWERAGE DISPOSAL Public Sewer ❑ Tannin g/MassageBody Art ❑ Swimming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/Sales ❑ Private(septic tank, etc. ❑ permanent Durapster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM PLANNING & DEVELOPMENT Reviewed On Signature_ COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature 1 COMMENTS Z#oning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Manning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature& Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT -.Temp Dumpster on site yes no Located at 124.Main Street Fire Department signatureldate COMMENTS I I . limension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: _.. ELECTRICAL: Movement of Meter location, mast or service drop.yequires approval of Electrical Inspector lies No ®ANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine NOTES and DATA— (For department use) 11 for pickup Call Email Notified p p r_ ate Time Contact Name Doc.Building Permit Revised 2014 I , Building Department The following is a list of the required forms to be filled out for theappropriate ermit to be obtained. r qp Roofing, Siding, Interior Rehabilitation Permits f ❑ Building Permit Application 1 ❑ Workers Comp Affidavit ❑ Photo Copy Of H.I.C. And/Or C.S.L. Licenses ❑ Copy of Contract ❑ Floor Plan Or Proposed Interior Work ❑ Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit i Addition Or Decks ❑ Building Permit Application ❑ Certified Surveyed Plot Plan ❑ Workers Comp Affidavit ❑ Photo Copy of H.I.C. And C.S.L. Licenses ❑ Copy Of Contract I� ❑ Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Mass check Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products r NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit New Construction (Single and Two Family) ❑ Building Permit Application ❑ Certified Proposed Plot Plan ❑ Photo of H.I.C. And C.S.L. Licenses ❑ Workers Comp Affidavit ❑ Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ Copy of Contract act ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products 40TE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg. Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. one copy and proof of recording must be submitted with the building application Doc:Building Permit Revised 2014 Location No. �(o Date .1�1�7 • - TOWN OF NORTH ANDOVER fr..r Certificate of Occupancy $ Building/Frame Permit Fee Foundation Permit Fee $ Other Permit Fee $ TOTAL $ _ f Check#3 o 16, �duilding Inspector , sol e c dfitzgerald@solect.com Smart Solar.Smart Business. "p mobile 508.579.1083 main 508.598.3511 David Fitzgerald fax 774.759.3027 Project Manager 89 Hayden Rowe Street Hopkinton,MA 01748 solect.com NORTft Town of 6 ndover p No. - 7 ��K. h ver, Mass a old �A COC NIC Kl WK:K �• w 7iQRATE D S U BOARD OF HEALTH Food/Kitchen PERMIT T. LD Septic System THIS CERTIFIES THAT ..... W �� LLC. .. . BUILDING INSPECTOR .. has permission to erect ..........................buildings-on ... Foundation.......... .... � ..... ,.. ......... , Rough g to be occupied as ......'ch...... Nwr..... .SO-W... .... 5..........�.w�ll...1..... ....... chimney provided that the person accepting this permit sh II 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 ONTH ELECTRICAL INSPECTOR UNLESS CONSTRU 0 S S Rough ........................................ Service Final BUILDING INSPECTOR GAS INSPECTOR Occupancy Permit Required to Occupy BuiWom 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. EAH Structural Consulting 11 Ponybrook Lane Lexington,MA 02421 PHONE 1.978.406.8921 EAy, CoNsuLr.swa Elaine@EAHstructural.com November 22"d, 2016 To: Solect Energy 89 Hayden Rowe Street Hopkinton, MA 01748 Subject: Structural Certification for Installation of Solar Panels RCG, LLC 50 High Street North Andover, MA 01845 To whom it may concern: A design check for the subject 'I g � ct bui dings was done on the existing roofing and framing systems for the installation of solar panels over the roof. From the site inspections,the existing roof support structures were observed as follows: The roof consists of EPDM roofing over 6-in rigid insulation on nominal 3-in tongue and groove wood decking. The wood decking is supported by true dimensioned 7"x15"old growth wood rafters at 10'-0" o.c.. The rafters have a span of 22'-0"and are framed into 7"x15"old growth wood beams. The wood beams are supported by 7"x7"wood posts at 15'-0"o.c.. The roof has a 5-degree pitch. The existing roof framing systems are judged to be adequate to withstand the loadings imposed by the installation of the solar panels. No reinforcement is necessary. The existing roof framing system can withstand an additional 8 psf solar ballast load. I further certify that all applicable loads required by IBC 2009 with Massachusetts amendments were applied to the solar ballast system and analyzed. The applicable loads are indicated in the load combination table and the summation of maximum loads indicated on permit plan,which is part of this submittal package. Furthermore, I was informed that the installation crews have been thoroughly trained to install the solar panels based on the specific roof installation instructions developed by the manufacturer for the ballast system and for the inter connections. Finally, I accept the certifications indicated by the solar panel manufacturer for the ability of the panels to withstand high wind and snow loads. OF lyjgssgc� ELAINE A. CD Sincerely, NIIANG —4 CIVIL -o .�N o.4902 9O Q Elaine A. Huang, P.E. Structural Engineer NAL ti�G 1 EAH Structural Consulting 11 Ponybrook Lane Lexington,MA 02421 PHONE 1.978.406.8921 EAH CoNsuLTwo Elaine@EAHstructural.com Project: RCG LLC Client: Solect Energy Location: 50 High Street,North Andover,MA 01845 Date: 11/22/2016 Engineer: Elaine A Huang,PE Load and Load Combination: Dead Load:(wood roof) 3" Nominal T&G =8 psf(ASCE-7 Table C3-1) EPDM = 1 psf(ASCE-7 Table C3-1) Insulation =3 psf(6 inch of polyiso) Solar Panels=8 psf(Given by Product Catalog) Total Dead Load =8+ 1+3+8=20psf Snow Load: Ground Snow Load, Pg: Town of North Andover, MA=50 psf(Mass Building Code,780 CMR,81h Ed.) Flat Roof snow load= Pr=0.7 Ce Ct I pg=0.7 x 1.0 x 1.0 x 1.0 x 50 psf=35 psf (ASCE-7, Eq.7-1) Ce=exposure factor= 1.0, (ASCE-7,Table 7-2),Terrain C, Partially Exposed Ct=thermal factor= 1.0(ASCE-7,Table 7-3) I =importance factor= 1.0(ASCE-7,Table 7-4),occupancy category II Wind Speed: Basic Wind Speed: Town of North Andover, MA= 100 mph (Mass Building Code,780 CMR,8th Ed.) Wind Pressure: CZ,=0.00256 K,K,t Cnet V2(IBC Equation 16-35) Kz=0.81 (50' building) (IBC refers to ASCE-7) K,t= 1.0(IBC refers to ASCE-7) Cnet=0.41 or-1.17(Components and Cladding,zone 2) (IBC Table1609.6.2) V= 100 mph (Mass building code 81h ed.) Therefore,q,=0.00256 x 0.81 x 1.0 x 0.41 or-1.17 x 1002=8.50 psf and-24.3 psf(uplift) (IBC Equation 16-35) Seismic Load Ss=0.33 (Mass Building Code 8th ed.Table 1604.11) S1=0.075 (Mass Building Code 8th ed.Table 1601.11) Spectral Response Acceleration coefficients: 2 EAH Structural Consulting 11 Ponybrook Lane Lexington,MA 02421 PHONE 1.978.406.8921 EAH CaNsut.,r a Elaine@EAHstructural.com Sens= Fa Ss= 1.6 x 0.33=0.528(IBC Equation 16-37) Snn1= F„S1= 2.4 x 0.075=0.180(IBC Equation 16-38) Design Spectral Response Acceleration Parameters: SDs=2/3 x Sans=2/3 x 0.528=0.352 (IBC Equation 16-39) SD1=2/3 x SM1=2/3 x 0.180=0.120(IBC Equation 16-40) According to IBC Table 1613.3.5(1)and (2),the seismic design category is"B"and the calculation can be finished by using ASCE-7 equivalent force procedure. The importance factor, I,for this building is 1.0. The response modification coefficient, R, is 3.25 according to ASCE-7. TL=6 sec(ASCE Fig 22-15) T=Ct hnX=0.028 x 500"8=0.64 sec(ASCE-7 Equation 12.8-7) The seismic response coefficient, C,j is CS=SDs I/R=0.352 x 1.0/3.25=0.108 The maximum value of CS=SD11/(TR)=0.120 x 1.0/(0.64 x 3.25)=0.0577 The minimum value of C,=0.01 Therefore,CS=0.0577 IEBC Section 707.5 states that the lateral resisting frame structural elements need not comply with Section 807.4 if the alteration does not increase the demand-capacity ratio by more than 10%. In this case,the panels'weight,8 psf, is extremely small compared to floor live load (60 psf/floor for assembly area, 100 psf for storage)and building dead load. Therefore, seismic design should not be considered. Load Combination(ASD):(IBC 2009 Ch16)wood deck D+S=55 psf (Eq 16-10) 0.6D+W=-12 psf(Eq 16-13) D+0.75 (0.6W)+0.75S=50 psf(Eq 16-14) Roof Structures The roof consists of EPDM roofing over 6-in rigid insulation on nominal 3-in tongue and groove wood decking. The wood decking is supported by true dimensioned 7"x15"old growth wood rafters at 10'-0" 3 EAH Structural Consulting 11 Ponybrook Lane Lexington,MA 02421 PHONE 1.978.406.8921 E AN I oNESULTANQ Elaine@EAHstructural.com I o.c.. The rafters have a span of 22'-0"and are framed into 7"x15"old growth wood beams. The wood beams are supported by TV"wood posts at 15'-0"o.c.. The roof has a 5-degree pitch. Structural Analysis and Calculation According to AWC Wood Sontruction Data,3-in nominal tongue and groove decking with simple span layup can stand 68 psf uniform load (1,000,000 psi Young's Modulous,conservatively assumed). Therefore,the decking is adequate to support an uniform load of 55 psf. ! fie CONSTRUCTION DATA 2 Table 4. Three and Four Inch Nominal Thickness- Allowable Roof Load Limited by Deflection- Simple Span Layup Nodulus of UeflecBan Affawable22=Distributed Total Roof Load''.psf Elasticity,psi Ute' 1 3 inch nominal ft duress,S #t 1 4 inch nominal thickness,Span,fL 8 9 10 11 12 13 14 15 161 8 9 10 11 12 13 14 15 16 17 18 19 20 700000 0180 63 44 32 24 19 15 12 10 8 174 122 89 67 51 40 32 26 22 16 15 13 11 L240 47 33 24 18 14 11 9 7 6 130 91 67 50 39 30 24 20 16 14 11 10 8 800000 Ulm 72 51 37 28 21 17 13 11 9 198 139 102 76 59 46 37 30 25 21 17 15 13 1/240 54 38 28 21 16 13 10 8 7 149_105 76 57 44 35 2823 19 16 13 11 10 800000 U180 81 57 42 31 24 19 15 12 10 223 157 114 86 66 52 42 34 28 23 20 17 14 U240 61 43 31 23 18 14 11 9 8 167 118 66 64 50 39 31 25 21 17 15 13 11 1000000 U180 90 64 46 35 27 21 17 14 11 248 174 127 95 74 56 46 38 31 26 22 19 16 U240 68 48 35 26 20 16 13 10 8 186 131 95 72 55 43 35 28 23 19 16 14 12 1100000 0160 99 70 51 38 29 23 19 15 12 273 192 140 105 81 64 51 41 34 28 24 20 17 U240 75 52 38 29 22 17 14 11 9 205 144 105 79 61 48 38 31 26 21 18 15 13 1200000 U160 109 76 56 42 32 25 20 16 14 238 209 152 115 88 69 56 45 37 31 26 22 19 U240 81 57 42 31 24 19 15 12 10 223 157 114 86 66 52 42 34 28 23 20 17 14 1300000 U1S0 118 83 60 45 35 27 22 18 15 323 227 165 124 96 75 60 49 40 34 28 24 21 L240 88 62 45 34 26 21 16 13 11 242 170 124 93 72 56 45 37 30 25 21 18 15 1400000 0180 127 89 65 49 38 30 24 19 16 347 244 178 134 103 81 65 53 43 36 30 26 22 U240 95 67 49 37 28 22 18 14 12 261 183 133 100 77 61 49 40 33 27 23 19 17 ISM= U180 136 95 69 52 40 32 25 21 17 372 261 191 143 110 87 69 56 47 39 33 28 24 L240 102 71 52 39 30 24 19 15 13 279 196 143 107 83 65 52 42 35 29 25 21 18 1600000 U180 145 102 74 56 43 34 27 22 18 397 279 203 153 118 93 74 60 50 41 35 30 25 L240 109 76 56 42 32 2S 20 16 14 298 209 152 115 88 69 56 45 37 31 26 22 19 1700000 0180 154 108 79 59 46 36 29 23 19 422 296 216 162 125 98 79 64 53 44 37 31 27 L/140 115 81 S9 44 34 27 22 17 14 316 222 162 122 94 74 59 48 40 33 28 24 20 1800000 U180 163 114 83 63 48 38 30 25 20 447 314 229 172 132 104 83 68 56 47 39 33 29 LI240 1122 86 63 47 36 28 23 19 15 335 235 172 129 99 78 63 51 42 35 29 25 21 Wood Rafters 7x15 Member Size=7"x15" Spacing= 10.0' O.C. Span Length=22.0 approximately P g pp Y w=55 psf x 120 in/(12 in/ft)=550 lbs/ft 4 EAH Structural Consulting 11 Ponybrook Lane Lexington,MA 02421 PHONE 1.978.406.8921 CAN; Co 3ULTING Elaine@EAHstructural.com Check moment capacity of Rafters: M=0.125wL2=0.125 x 550 lbs/ft x(22.0 ft)2=33275 lbs-ft S= bd2/6=262.5 in' M/S=33275 lbs-ft x 12(in/ft)/262.5 in3= 1521 psi Fb= 1500 psi (conservatively assumed for old growth)x 1.15 (Co)x 1.15 (CR)= 1984 psi,ok Check shear capacity of Rafters: V=SwL/8=5 x 550 lbs/ft x 22 ft/8=7562 lbs Vmax=3V/2A= [3 (7562 lbs)]/[2 (105 in 2)] =108 psi F„= 150 psi (conservatively assumed for old growth),OK Check deflection of Rafters: Atotai=5wL4/384E1= (5 x 0.550 K/ft x 224 ft4 x 123 in3/ft3)/(384 x 1400 Ksi x 1969 in')= 1.05" L/240=22.00'x(12 in/ft)/240=1.10 in,OK Wood Beams 7x15 Member Size=7"x15" Spacing=22.0'0.C. Span Length= 15.0' approximately P=55 psf x 22 ft x 10 ft= 12100 lbs Check moment capacity of Rafters: M = Pa= 12100 lbs x(2.5 ft)=30250 lbs-ft S= bd2/6=262.5 in' M/S=30250 lbs-ft x 12 (in/ft)/262.5 in = 1383 psi 5 EAH Structural Consulting 11 Ponybrook Lane Lexington,MA 02421 PHONE 1.978.406.892.1 Cart C0N5uLriNQ Elaine@EAHstructural.com Fb= 1500 psi (conservatively assumed for old growth)x 1.15 (CD)x 1.15 (CR) =1984 psi,ok Check shear capacity of Rafters: V= P= 12100 lbs Vmax=3V/2A= [3 (12100 lbs)]/[2 (105 in2)] = 172 psi F„=180 psi (conservatively assumed for old growth),OK Check deflection of Rafters: Atota,= Pa/24E1 (31-2—4a2)=0.514 in L/240= 15.00'x(12 in/ft)/240=0.750 in, OK 6 NORTH OF tied '^qbG 0� 'own of North Andover Machine Shop village Neighborhood Conservation District Commission 4ys „�o•��h* 1600 Osgood Street North Andover,MA 01845 SACHUS A plication For EXCLUSION From Certificate to Alter t i Certain alterations are excluded from review by the Maclaine Shop Village Neighborhood Conservation District.Commission in accordance with the BYlaw. .APPlicantsfor exempt projects I must fill out the form below and submit to the Commission Chair erson(contact info below). J P f � Date: 1 Z/Z Contact Name&Address: C 1K LL( /7 lyaroo f. i J'0tWY yr II f - WA t7 Z/43 f Project Address: 50 A�---h cf Project Description(attach additional pages,if needed): r DG1 tlf to u C}64 10W —:Py a R 1 P ght f I IJ i t 1 Exclusion From Review Requested or: ❑ 1.Interior Alterations existing conditions including materials, design and dimensions. ❑ 2.Storm windows and doors,screen windows and doors. ❑ 9.Replacement of existing substitute doors,substitute siding or substitute 3.Removal,replacement or installation of windows with new materials that are gutters and downspouts. substantially similar to the existing condition. j 4.Removal,replacement or installation of window and door shutters. ❑ 10.Replacement of original fabric windows or doors with substitute 5.Accessory buildings of less than 100 windows or doors that maintain the square feet of floor area. architectural integrity with respect to j form,fit and function of the original ❑ 6.Removal of substitute siding. windows or doors. l 7.Alterations not visible from a public 11 Re consuvction,substantially similar in way. exterior design,of a building,damaged or destroyed by fire,storm or other disaster, ❑ 8.Ordinary maintenance and repair of provided such reconstruction is begun architectural features that match the within one year thereafter. MSV NCDC Page 1 Current Chair:Liz Fennessy,77 Elm Street,lizettafennessy@yahoo.com, i t t s ttk nTMq 3r°' Town of North Andover w s Machine Shop Village Neighborhood Conservation District Commission 1600 Osgood Street North Andovcr,MA 011345 3$ACNUyt Application For EXCLUSION From Certificate to Alter For Items 9,10 or 11,provide the following documentation: Photos/drawings of existing doors,windows or siding,as applicable Description/Catalog Cuts of proposed materials to be used for doors, windows or siding _Plan and elevation of reconstruction for Item lI Determination: 1 This project is determined to be X exempt O not exempt from review by the Machine Shop Village Neighborhood Conservation District Connnission. Projects shat are not exempt nutst complete the Application for Certificate to Alter,available from the Building Department and be reviewed by the Commission. Determination made bv: y' Signature Lizetta M. Fennessy Neighborhood Conservation District Commission 12/20/16 Date -- MSV NCDC Page 2 Current Chair:Liz Fennessy 77 Elm Street,0� ttefenneKsvfEi♦c�hno,cam, Initial Construction Control Document To be submitted with the building permit application by a Registered Design Professional for work per the 8 edition of the Massachusetts State Building Code,780 CMR, Section 107 Project Title: 1 HIGH STREET,BUILDING 36(RCG WEST MILL NA LLC) Date: 1/12117 Property Address: 1 HIGH STREET, BUILDING 36(RCG WEST MILL NA LLC) Project: Check one or both as applicable: 0 New construction Existing Constructio Project description: install soar panes on existing rool to generaleKVV ) power, o ruc ural amendments necessary per s ruc ura I ELAINE HUANG MA Registration Number:49029 Expiration date: 6/30/18 am a registered design prvfgssiunal, and I have prepared or directly supervised the preparation of all design pl ins, computations and specifications concerning: J Architectural [X) Structural [ ] Mechanical j Fire Protection [ ] Electrical j ] Other for the above named project and that to the best of my knowledge,information,and belief such plans,co putations 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 ray designee)shall perfo rm the necessary professional services and be present on the construction site on a regular and periodic basis to: I. Review,for conformance to this code and the design concept,shop drawings,samples and other ubmittals 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 performed in a manner consistent with he approved construction documents and this code. Nothing in this document relieves the contractor of its responsibility regarding the provisions of 780 CM R 107. When required by the building official,I shall submit field/progress reports(see item 3.)together with p rtinent comments,in a form acceptable to the building official. `rU MASS40 Upon completion of the work,I shall submit to the buil ' g official a'Final Construction Control Enter in the space to the right a"wet"or Signal i E\A G 9 electronic signature and seal: date: 2 .0 9EGISS�P���� �FFSs 10%P�` Phone.number.978-406-8921 Email: ELAINE@EAHSTRUCT Building Official Use Only ~ [Buildi:gOff:i..a1Name: Permit No.: Date: Version 06 11 2013 Appenduc 2 Construction Documents are required for structures that must comply with 780 CMR 107. The checklist below is a compilation of the documents that may be required for this. The applicant shall fill out the checklist and provide the contact information of the registered professionals responsible for the documents. This appendix is to be submitted with the building permit application. Checklist for Construction Documents' Mark"x"where a iicable No. I Submitted Incomplete Not Required 1 Architectural 2 Foundation 3 Structural 4 Fire Suppression 5 Fire Alarm(mav require repeaters) 6 HVAC 7 Electrical 8 Plumbing include Iocal connections 9 Gas(Natural,Propane,Medical or other 10 Surveyed Site Plan(Utilities,Wetland,etc. 11 Specifications 12 Structural Peer Review 13 Structural Tests&Inspections Program 14 Fire Protection Narrative Report 15 Existing Building Survey/luvestigation 16 Ener Conservation Report 17 Architectural Access Review 521 CMR)_ 18 Workers Compensation Insurance 19 Hazardous Material Mitigation Documentation 20 Other(Specify) 21 Other(Specify) 22 Other(Specify) *Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein.Work so identified must not be commenced until this application has been amended and the proposed construction document amendment has been approved by the authority having jurisdiction.Work started prior to approval may be subjected to triple the original permit fee. Registered Professional Contact Information Name(p�_--^strant) — Telephone No. - Regis"ationNumbe°l . Street Address City/Town g Zip "— Discipline Expiration Date Name(Registrant) Telephone No. e-mail address Registration.Number Street ddress Ci Town State Zi Discip]lne Expiratro Dat Name(Registrant) Telephone No. e-mail address Registration Number Street Address Ci Town State Zi Discipline Expiration Date ..a: The C'on1if1101 vealth or f Massachusetts Department Of f'Itgdarstrial Accidents Of ice of Investigations 600 ff ashington Street Boston, MA 02111 yMyv.inass.gov1dia tt'orkers7 Compensation Insul-anee Affidavit: Builders/Contiactors/Electriciails/Plumbei-s Applicant Infrli-mntion Please 11rint Lecribiv Name (Business,'OrLanization;lndi�'idual): � � � � y,tfi,��,� (fit/-�•'� �r�' Ut�\ Address: U!51 - ,� � 1 `' Giry,State,'Zilj: Vit; �� 1�'(� �� ;^� _� G`i t .Phone Are you an employ er?Check the appropriate box: 1. I am a employer With 50+ 4. ❑ I am a general contractor and I TtW of•project(required): employees (full and/prpart-time).` have hired the sub-contractors 0• ❑ New copstruction 2.❑ I atr. a sole proprietor of partner- listed On the attached sheet. 7. ❑ Rerijodelizns ship and have no ernplovees These sub-contractors have , w0l-kino, for me in an)'capacity_ employees ployees anti have workers" � ❑ Demolition (1\o workers' comp. insurance eonip. insurance.= 9• ❑ Building addition }_❑ required,1 5. ❑ We are a corporation and its 10,❑ Electrical repairs or additions 1.ant a homeowner doinig all work officers have exercised their 11.❑ Plumbing repairs or additions myself. No workers' conjp, rte}nt of exemption per NMGL ` insurance required.] ., c .152. 00), and we have no l2 ❑ Roof repair's :>nplo)'ees. [moo workers' 13•Q OtherSOLAR ARRAY comp. insurance required.] \m ipph 1 ti that checks,buy=1 must also fill oft the- ction below slioNvl.ig their workers'compensation p,)licy infornnation. Homeowners who Submit tniti a:ridavit indicating rhes ,.e doing all work and glen hire outside connuctOts must submit a new affidavit ind:c iir,Y stteh. 'Contractor that dig k this baa must attached n additional sheet showin,the name of rhe snb-cont i elltplovees, If rhe sub contractors have:mplovecs,the V rlilcl ibvid@ their tt CI'QrS and State tt'nc[iter(?r lilt tllOtie 2i1iliiCS have P` orker:"curnn.Polk)'number. ifo (Ut el)11JI()yer deur is pro"irli7tg it'ot•kers'co7npensatioii iiist(ruitce for ett}.eiiiplt y�ees. Bclrin,is the policy a>ed ' e itrfuritrutian• P 3 (b sttc J Insurance Company Na ''�rti_o tr' ._ Name.: t . ( n� (; �.---� 1, (� Policy ; Or Self iris. I_:ic. t: S L' �� �j — L'�,( Cl L� :` S '> l✓ 1 9"G E-piratlon Date: iol� Site:�ddress: 614-1S7 1�C1D 14U. G CIt1�%St1te:Zl p,._.7 Attach a cop) ot'the �votkei�nsation Policydeclaration page(showing the policy t�umt5et and expiration Failure to secure covera�7e as required under Section 25A of MGL c. 152 can lead to the imposition of criminal pen altie of a tilte up to 51,500.00 andior one rear imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to 5250.00 a day against the violator. Be advised that a cop) of this statement may be forwarded to the Office of Investigations of the DI for insurance coverage verification. do hereby Bert under t uin.c andpenalties ofpetjrery thut the iiafori7tutiat provided above is trite ural correct SiUnaturc: , Phone#: 508-579-1083 — _ Offcial mise only. Ido not write in this area,to he completed by city=or town official. Cite or Toiirn: Perinit/License# I.sstritlg Authority(circle.one): I. -Board of Health 2. Building Departale.at 3. Cit<</Toii'n Clerk 4.Electrical "Inspector 5.Plumbing Inspector G. lather Contact Person: Phone#: SOLEINC-01 CFERGUSON ACORO� DATE(MMIDDNYYY)CERTIFICATE OF LIABILITY INSURANCE 0310112017 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 have ADDITIONAL INSURED provisions or 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 CNTACT E• Provider GroupPHONE FAX 160 Gould Street,Suite 122 AIC,No,Ext:(781)444-0347 (a/c,No:(781)444-8961 Needham,MA 02494 E-MAIL .needhamr@providerig.com INSURERS AFFORDING COVERAGE NAIC# INSURER A:Landmark American Insurance Co INSURED INSURER B:Ohio Security Insurance Company 24082 Solect,Inc.,Clean Energy Installs LLC,Solect Energy Dev INSURERC:RSUI Indemnity Company LLC 89 Hayden Rowe St.Suite E INSURER D:Hartford Hopkinton,MA 01748 INSURERE: 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 OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF PM/pCY EXP LIMITS LIRA X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE F_X] OCCUR LHA110983 01/09/2017 01/09/2018 DAEAGETO RENTED MISES(Fa occurrence) $ 50,000 MED EXP(Any oneperson) $ PERSONAL&ADV INJURY 1'000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000'000 X POLICY❑PECT F-1LOC PRODUCTS-COMP/OPAGG $ 2,000'000 X OTHER:Deductible: $5000 $ B AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 cede ANY AUTO BAS56258949 09/04/2016 09/04/2017 BODILY INJURY Perperson) $ OWNED SCHEDULED AUTOS ONLY X AUTOpS�N�p BODILY INJURY Per accident $ X AUTOS ONLY X ATOS ONLY PeOr acatlen DAMAGE $ C X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5'000'000 EXCESS LIAB CLAIMS-MADE NHA078225 01/09/2017 01/09/2018 AGGREGATE $ 5,000,000 DED I I RETENTION$ $ D WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y6S60UB-OG04294-8-16 05/16/2016 05/16/2017 STA UTE ER 1,000,000 ANY PROPRIETORIPARTNER/EXECUTIVE ❑ OFFICER EXCLUDE[EXCLUDED? N/A E.L.EACH ACCIDENT $ (Mandatory n HHS) E.L.DISEASE-EA EMPLOYE $ 1,000,000 If es,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) CERTIFICATE HOLDER O CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of North Andover THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. North Andover,MA 01845 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD _ Massachusetts )Department�€Pub.iic Set€ety � f� - . \ Office of Consumer Affairs&Business Regulation ' --=ROME IMPROVEMENT CONTRACTOR t Garai Of Building Regulations and Standards egistration: 182158 ==n,tructiun Supers icor xpiratlon 6/i1201�. al License: CS-108041 _ ►ndividual - �;i BRIAN MCPHAIL - RIAN MCP - , B HAIL` I 22 FRENCH STREET BRIAN MCPHAIL ti Billerica lV1A 01831 22 FRENCH STREET BILLERICA,MA 07821 Undersecretary ` Expiration F` ^Commissioner 0710912 018 'Oslo L:.s.t)epartvrw_r{t of iab4i --. .: 0=mationat Safety are,Health Adn-mistraWn f has suocessfi&c mp►eteel'a 3t)hour Occupational Safety and HealthTrair»ng•Coume 3n i C uohon Safety&Health J _. �