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HomeMy WebLinkAboutBuilding Permit #162-11 - 114 OLD VILLAGE LANE 8/24/2010 BUILDING-PERMIT of NORTH�t- E.tgLID TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO:-10, Date Received ^ CHU • Date Issued '�� ASE��� IMPORTANT:Applicant must complete all items on this page L �x;.5 _ _ = - - .....,�., .«.,z......,:�.r.... ;;' '_r.. ..•..�_,>,•�^" ,�:,n":... Vii'::^E�� _ �••>•ticti r2.:xu-r:_ - - _ .�:e�. .}:. - - �4..+:iia .rte`:^e:<ti_•a _ _ _ ..� ,. :»� .pec ,.... _ r.,:_,:�'=:.. -�':"xl.¢'+`:y -�'�s Y., _ !>:^.:y; - - ,..t. --:L..,u i r - _�a:1. ^,t:T,� - �I~L"n::^. •.n1 t"'_]. - .T_l:'i-e.- ,�- - - _•3;:t1...::» .^�a.+:.l'-'--- "".t4,';;C'.b:r.,.�._ P`r�,"<..✓`r-ez_. ..,r ter'` .f5' o-.✓ur- rrt- - ,..-s.,a� ..`Sgti.,:� ;:'h':^!_"�-.e. ,=2r« - `.'.F..r-E, �. .-� :.:n'_._5.,.,,.>,P..._ :.-,_-,. �- .r 1 e;'`'- - .. 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'Zy _:. .. ,F'dJ . ...... TYPE OF IMPROVEMENT PROPOSED USE Re ' Non- Residential New Building One famil Addition T or more.family Industrial No. of units: Commercial Repair, replacement Assessory Bldg Others: Demo i ion Other z a �-�ja7[- ��rF'��rW�a.�"'� r�'�Cx�r•F1r„ � �� � y �'��'.[v.' •i i�`�+ip`'•'!��•� 'ytr��L�� a."7F''d''`'a i:"}��:?'iS"..".`_vt. �.M.;:,,.,ter,,. ri � v���'�^'�5���Fi��a' �m � ����:1"..r=7".�7���L1L�tiG,�����,yy� d�u. J1..�. �Y:�►3� e+S �$+i�y,�•:G'L T.����r+:r`.r.vTl• �',;Ydt - p "•' +--.z5��'_-,"� J��^:. ,,;� N1`�jll` -:!G157 ¢F;k ..�L�, '�.,,:�,�,,,{vim,,.?.T�'Jti�i''ViC .`�'^rh �� ����.�.+�I�'IU���i���'l'�.��a �i�� �? ''►►s``.,c`�,,`. l`�; r`�..a� G -��p,�)�'�_n�,,� a.•- .J-��,r _.�',!�-„�_.���.u, '�:rwr. �,s^ �K u ..���- ' -..Y�r�-,r.�4.s. �)ce•_..LT::3.::=+ ���T�;:2i�i_stc_°�'n.'u-i:' ,��•- ,-.�+'_�'_tGf :4�i� ?�:=i'1�1'�'F::.•�.J't-y�?r:.1C.;�:�5•`"�`xi� a,^> f��;�y,�i-y�".•Si'YF�.r-�-`.'3�T �,�-.c: .r�;�Cjx.. ,=�-"'��;y�.. - .f!l. ._. ••....t✓•.`.�1h.'�'.#.Y._'I.�•L �.•uF:_.:.'�'L,,,4rw;�',n:aa.''.5:�kiS•TP{44���=�� ,t2`� "��5.'.T�-iit.'�;try•'li DESCRIPTION OF WO K TO'BE PREFORMED: . �, -tom;�l�dc,JS• ,- � � � f: how- S� .N Identification Please Type or Print Clearly) OWNER: Name: /,�G �j� Phone: Address: • �. i�'3-- .r: fi"�.7.:,,- ,r.,-�'?,^.., `Y �:- p a"7'f;k.;_ ARMS_-:C"'•`'•..•E�:;nL-:._s='!r""".^.o�:�.. • °+.�w.�-�-� ��_��3;nv'��"'P -.��..• �!-�-�- �`*a r: �,-a� .�,..r'k�'�,-r.r ��. :�r``.'•:E.�''5�:�' ria-d '�zG- a:"Cr.�Y; ��� _u-4�.�.a`n �'� e� � � .��s�-ri,:, "� 7�k� ��'��d �•.`';`•1-:-.t)y-N.1 -lxry i.M1�`,4; �"-;-r �'.!. .��sti-t �'-rE„ e. -;_•fit ter,+-' ) �c•� '�`s �-r,,.. r -:.P ..sY'F,f��'_.'..-.``�s���y-'1?-�1."_�j PRO ,.. � ..?ca'•• yr^-8� y�-.�.`r�..[.. { ,.,ry�,?'•Y.v ,� ��_yj 'h SS'c�'��,{'y`�..rk�",�Jrs��y� ����1`r•J" 1 �H_�,_.-sr..a-1$�` �r �'' �+� .2'.s�R c" car r.;x • '`�- � � ,Ss;�F�r � ..#�';i"�,4. _ fps,-.��ax' .c..�i.,��.,:�.,.c�?E-'i_ -.�: ���,�_i�. f,°Y•._"{2���." �..�`�' '._4,,'114 �f r�.� "'"In IJXy'r�i'" I~.•�-•�"y.. 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"'?4i.::""`:-ke`-•7i".,;'2;d::€.: -` `v_'q.�=3o-i,�� - � dries.>,!_�. y./ �?r�._. �:•9 _ .N.: a--Me: 1 rt+.;7�- '_•.?.t°.::9:-"' .�;..�..y.r-u ��;•'L�:.:=i.�a+;N:.:. r�r_ �';�,. t� .�+s`."` _.:asz`C-,"._:,;'.r � Yu.�.r:yi ar. � - J's ln._•yr :c•�- ,.. x a'3'i£x_-rte,r ac,-r:�--+�y.N �:'xMe� s'+`s.^�;;£;L <0' J S^:a,'s.�;}x;...:4'�: "i:' Y1•_ 'r.-;r:2F:.7�;.:i?�_ cFa'd )"�--„- _aa _•7-?+�: r'�:�n,'74;1�:r.. d�ti. Y� rr..�-�3':-<�x. �7� aiz•�.,�rar•••q rte: .w,•iia ¢,.._534.",d-.ift'I'� r'-�la.:�'::C�'�'• �i'•,0113 �;nrie�7��1]LL}�I�O�y 7'�'r �ii4e``:r:,.. :.,- � y''F`rr..,:�.. .a,:rr•.:r.:_r..•::.r : -e%�:- � �.�+Tlt��,:',�:.��• :..t - �:5'{"�-��':�-Y�r.:�=��G �r rte;+-� 'r4.,rg, y..,..: :�-'stl=•'�, �.:.+nlz-ar_>:"•:,,r - _,. u. -.-�..:_ _.::._.:z'13•:'iLx'�;>� �Pr i-"'4�i�i'�� �: _ � _ ,y�'�'�x$ ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE:BULD/NG PERMIT:$12.00 PER$9000.00 OF THE TOTAL ESTIMATED COST BASED $123.00 PER S.F. t Total Project Cost: $ -F-J00. d 0FEE : �� r Check No.: 7v Receipt No.:_ 'e 3 NOTE: Persons contracting with unregistered contractors do not have access to th guaranty fund i s"'lW. �'Fwq�eJWrl/^OWYt� i_ Fn-r Si ry y. er' S:ignatiare ofort�rcatDr: t Plans Submitted Plans Waived Certified Plot:Plan Stamped Plans TYPE OF SEWERAGE DISPOSAL Public Sewer Tanning/Massage/Body Art Swimming Pools Well Tobacco Sales Food Packaging/Sales Private(septic tank,etc. Permanent Dumpster on Site THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APPROVED- PLANNING & DEVELOPMENT I COMMENTS CONSERVATION Reviewed on Signature COMMENTS HEALTH Reviewed on Signature COMMENTS Zonln�Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision: Comments Water & Sewer Connection/Signature&Date Driveway Permit DPW Town Engineer: Signature: Located 384 Osgood Street .. _..rara.:.:•c.,:s.r�.. .rr.;},r:—•:�_:.c;.•.}.:_--:r:,• r;>.-_:rc::o:.r..,..:r<:.,:,�: -:a_c-- x,,.r - - "-=':% - ''��'p _ .}. ..-1- ,:r+tJ. -r•.d._ «Y..i .+lS::-_�I Mom, _ ual � _}.. 01 '}i:k'a�:3:`�'.jji:�.±rSf.'r_L:_ -w�=: :::FF - -'�.i�: vc�. ,.. ..y.r ...�• - - _ _ r.. .... -L ..1. -^.^t•. ..�} -:[^'rte'• - _ .Lni.:•' - .1,24 _ �,:�itain fr el•?rr_�: ';4. .ts• — - ^�^z:� .;a;. �;.:`k:: ,•::r, __.!•:zi:_� _�=�,_ r-• Grsi+. •_'3�_� nit.. - - ri•r. e �,r.�....--r.,4 - - xu., - r. - �,E.�a�i�enJt�, `i`�r��yT,r��,e1- its - _ _ ::L.::..;:,�„r::.::_�,�'t. :-r S �{}y� W 1�3ate.�: �':/_ �:Y,Y.:? - •�lti _�.- .)S'w'" -=?5Jt[!'r.. s":'-.: .—_._.;.f:ilrx- :r.�f 1..- - _ __ _ - _ _ .y:.i'_':._. .-r..Y.aa-n v_._... :.. - ��- - - - _ h 'u_ - f,r _P S. - r i "ter?:psi::•'.%' :�.1 1 1 i Dimension ' 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 requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A—F and G min.$100-$1000 fine I NOTES and DATA— (For department use) i I ❑ Notified for pickup - Date Doc.Building Permit Revised 2010 I i Building Department The following is'a list of the required forms to be filled out for the appropriate permit to be obtained. Roofing, Siding, interior Rehabilitation Permits I - ❑ Building Permit Application ❑ 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 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 a Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) ❑ IVI "ass check.Energy Compliance Report (If Applicable) ❑ Engineering Affidavits for Engineered products 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 ❑ Urel1.1111'ed Proposed Plot , lal r. ❑ 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 ❑ Mass check Energy Compliance Report ❑ Engineering Affidavits for Engineered products NOTE: 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 2008 I :Pam Guerrette FaxID:Santo Insurance Page 1 of 2 Date:8/24/2010 01:37 PM Pagel of 2 /24 10 --r-�v CERTIFICATE OF LIABILITY INSURANCE OP ID PG DATE ( ) 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 NAME: PHONE Planright Insurance-Salem (A/C,No,Ext): (A/C,No): 224 Main Street Suite C ADDRESS: Salem NH 03079 CUSTOMERID#: EDMUN-2 Phone:603-912-5646 Fax:603-912-5647 INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A: Rive=port Insurance Company Edmunds General INSURER B: Contractor LLC PO Box 2214 INSURER C: Salem NH 03079 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 CONTRACTOR 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. LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER (MM/DD/YYYY) (MM/DDL'M YftAr) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence) $ CLAIMS-MADE F OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY PEa LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE $ HIRED AUTOS (Per accident) NON-OWNED AUTOS $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ jj WORKERS COMPENSATION- WC282800042502 04/03/10 04/03/11 }{ l - AND EMPLOYERS'LIABILITY Y/N TORY LIMITS ER ANY OFFICER/MEMBEREXC UDED?ECUTIVE /A E.L.EACH ACCIDENT $ 100000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100000 It yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) WC: 3A NH / David Edmunds has elected to be excluded from coverage. Job: 114 Old Village Rd. , North Andover, MA CERTIFICATE HOLDER CANCELLATION 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 Attn: Bldg Inspector AUTHORIZED REPRESENTATIVE 1600 Osgood St Bldg #20 Suite 2-36 James A Santo orth Andover MA 01845 ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD I From:Pam Guerrette FaxID:Santo Insurance Page 2 of 2 Date:8/24/2010 01:37 PM Page:2 of 2 FDATE08/24/10) .ICOR CERTIFICATE OF LIABILITY INSURANCE OPID PG 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(les)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). PRODUCER NAME: PHONE Santo Insurance - Salem (A1C,No,Ext): (A/C,No): 224 Main Street, suite 2A ADDRESS: Salem NH 03079 CUSTOMERID#: EDMUN-1 Phone:603-890-6439 Fax:603-890-0315 INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A: p St Paul Surplus Lines Ins Co Edmunds General INSURER B: Contractor LLC PO BOX 2214 INSURER C: Salem NH 03079 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. LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 -DAMAGE TO RENT_u A X COMMERCIAL GENERAL LIABILITY CP572203 11/11/09 11/11/10 PREMISES(Ea occurrence) $50,000 CLAIMS-MADE FX]OCCUR MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE s2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 }{ POLICY PRO )ECT 171 LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE $ HIRED AUTOS (Per accident) NON-OWNED AUTOS $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ RKERS COMPENSATION AND EMPLOYERS'LIABILITY Y/N TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVEEl /A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space Is required) Residential Roofing & Carpentry Job: 114 Old Village Rd. , No Andover, MA 01845 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of North Andover Attn: Bldg inspector AUTHORIZED REPRESENTATIVE 1600 Osgood St Bldg #20, Suite 2-36 James A Santo North Andover MA 01845 ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD NORTH TONM of And over No. ego// S,::; �o Q == LAKE -O CloVeY', 1VIaSS., COCMICMEWICK RATED �7 BOARD OF HEALTH PERMIT T D Food/Kitchen Septic System I r BUILDING INSPECTOR THIS CERTIFIES THAT........ . .` ...........�fC!►...... .14. ........ ..r................................................................. Foundation p1 has permission to erect..............:......................... buildings on ............................ .4,......... ...... ..................... Rough L . to be occupied as.. .. .I.. .....w?.. .!�c�aku.s.— -.. l'4 .... cl. ...WP.�......c�.�... 1..... ... Chimney . .. .. . . . . . provided that the pe on accepting this permit shall in every respect conform to the terms of the application n file in Final 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 CONSTRUCTIO T Rough ....................... .............. ............................................ Service BUILDING INSPECTOR Final Occupancy Permit Required to Occupy Building GAS INSPECTOR 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. SEE REVERSE SIDE smoke Det. Office of Consumer Affairs&B smess Regulation HOME IMPROVEMENT CONTRACTOR i Registration:�,-;1,66661 Type: Expiration: -16/2:1.%2012 Corporation ED UNDS GENERAL'-QGNTRACT,ING, LLC. i O DAVID EDMUNDS ` 1 SHAKER LN ,,+. ,_�.:. > •�' g z�� o_ I.. HAMPSTEAD, NH 0384,1;; Undersecretary '` :�Iassatcht,ucts --De .lr.irrmcnrrif'Public5afcf� Biru'd rit•'`t3uildin, Regri,lations and:Staiidat-ds',f Construction SLiPefvisor License License: Cs 104290 GREGORY BUCHANAN 23 EAST NASHUA RD WINDHAM, NH 03087 Expiration: 11/29/2013 ----— -- Tr:: 104290 The Commonwealth of Massachusetts Department of Industrial Accidents P,ow IA uj;, Office of Investigations 600 Washington Street Boston,MA 02111 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print'Lelzibly Name (Business/Organization/Individual): 4utJd!& C,QA�C9(ICnt�", Gt.6 Address: i s ,der L AJ City/State/Zip: a&y5/k0 03g9/ Phone#: (Q03 365- 773oL Are you an employer?Check the appropriate box: Type of project(required): 1.[B 1 am a employer with 41 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. t 7• ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers'comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.]t employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: //J/�V 1(1104 ,�ANe.e LQ/>►,�Gti�/ Policy#or Self-ins. Lic.#: (fie^ al)5 307g 01%0 Expiration Date: /3 42e Job Site Address: JGf (90 UPC166 / / City/State/Zip:Al AO�b}(N_ Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement tnay be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certif der th pa is and penalties of perjury that the information provided ab ve itstr a and correct. Sel, i nature: Date: Phone#: �� �� 5� 77 31� Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. 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 enterprise,and including the legal representatives of a deceased employer,or the receiver or 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 be 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 required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this 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 cavy workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be 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 pen-nit or license is being requested,not the Department of Industrial Accidents. 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 1 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(if necessary)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 pen-nits 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 Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax#617-727-7749 www.mass.gov/dia FIft LkMISM and ft3sffM-Mtn W NA 93ettta&mkessetas dyli mbar of NH Better tis t3ur e GAF-ELK Cert WoEI6226 IL �o "61 IG t l o General Contracting 10 Stevens Street#141 •Andover,MPS 01810•(975)475-0895 LSt/1D'rA _- .PROW -- Dfrr1; G — G wa-ibc t Uel- -- JUS WCATIO Ah- / � .�� —6 crfY STA7E.AMD ZAP CODE �f'�>��+V � t k -7� 013 U ILO �- WWOWri OVI -- Scra WJ t it IVIIn (( } lk t - 'fit lfKJL—kl-ln �l c iiti t t a — EatrxttasrrLs Gedemi Matra ung W+9I= 20a-4--, - •Obtain all necessary permits to complete work. •Furnish and install all necessary materials to complete work. •Perform work as efficiently as possible without sacrificing quality- Provide ualityProvide a daily clean up and disposal of a!l debris generated With our own dump trucks.NO LARGE DOLE OFF CONTAINERS will be used. •Guarantees all workmanship performed. ADDITIONAL(NOTES;Edmunds General Contracting prohibits smoking on customer's property. E rna of auiSnrarr 1 r�y l rntz i�atrf tJuv Fay La?er 'Thank you for the opportunity to bid on your roof replacement strorks Me VropoArn hereby to furnish trtaten I and labor-complete in acro ante with above specifications,for the slam of: ` 1/ ® C C"<h dollars ( l ). AR matemat is guaranteed to be as spvOwd,AN work to be campteted M a,wancrEsa w manner Authorized Signature-, amOldr9 10 sW)dafd pnii0k"f Any VkrXmn or devia on from abore speacagom imowi Ig aura costa vAU be eAeWed orgy upon written orders,and vm woonte m oft cftarye ores and above abs,estimate.AN aTeerxnts corovem upon stAtm acddents or delays beyond vo Now This proposal may be withdraw cwretrot.Orrtsec to cagy Ike,tornado and other nemimmy n*aanm.Ow wonders ave tufty covered us if not af9Ge tecf wiitlin �— days. by W=sC.omperosatyon 6rouranco_ CDale of YrD$I1D aT[ -Theabove prices,specifications acralts are salisfactary and are ftera�by accept. !®D are auftttxized toAtxif torczed Si attire+orts as ssseci5ed.Payrnerttgrill be rratleas ocrUint d abare.acceptance: ` Authorized Signature, Boise Cascade Double 1-3/4" x 11-7/8" VERSA-LAM® 2.0 3100 SP Floor Beam1F1301 BC CALC®3.0 Design Report-US 1 span I No cantilevers 10/12 slope Tuesday,July 19,2011 Build 440 r File Name: fleury 110426.BCC Job Name: ictol`F el ry Description: FB01 Address: 114 Old Village Specifier: Victor Gleury City, Sta Zi er, MA Designer: Gregory R Doyle Customer: PRELIMINARY ONLY Company: Code reports: ESR-1040 Misc: Customer provided specs 3 10-06-00 BO B1 LL 1,838 lbs LL 1,838 lbs DL 1,975 lbs DL 1,838 Itis SL 4,463 lbs SL 4,463 lbs Total of Horizontal Design Spans=10-06-00 Live Dead Snow Wind Roof Live Trib.(in.) Load Summary Tag Description Load Type Ref. Start End 100% 90% 115% 133% 125% 1 2nd floor joists paralell to beamUnf.Area(psf) L 00-00-00 10-06-00 30 10 00-08-00 2 Shed Roof/Dormer Rafters Unf.Area(psf) L 02-06-00 10-06-00 10 50 06-00-00 3 Dead Load from Dormer End...Conc. Pt. (Ibs) L 02-06-00 02-06-00 0 260 n/a 5 Main Rafters Left of Dormer Unf.Area(psf) L 00-00-00 02-06-00 10 50 17-00-00 6 Main Rafters Right of Dormer Unf.Area(psf) L 02-06-00 10-06-00 10 50 11-00-00 7 Bearing Wall above Beam H... Unf. Lin. (plf) L 00-00-00 10-06-00 0 40 n/a 8 Ceiling Joists Unf.Area(psf) L 00-00-00 10-06-00 30 10 11-00-00 Controls Summary value %Allowable Duration Case Span Disclosure Pos. Moment 21,527 ft-lbs 88.0% 115% 2 1 -internal Completeness and accuracy of input must End Shear 6,640 lbs 73.1% 115% 2 1 -Left be verified by anyone who would rely on Total Load Defl. U288 (0.438") 83.4% 2 1 output as evidence of suitability for Live Load Defl. U375(0.336") 96.0% 2 1 particular application.Output here based Max Defl. 0.438" 43.8% 2 1 on building code-accepted design Span/Depth 10.6 Na 1 properties and analysis methods. p p Installation of BOISE engineered wood products must be in accordance with Notes current Installation Guide and applicable Design meets Code minimum U240 Total load deflection criteria. building codes.To obtain Installation Guide g ( ) or ask questions,please call Design meets Code minimum(U360) Live load deflection criteria. (800)232-0788 before installation. Design meets arbitrary(1") Maximum load deflection criteria. Minimum bearing length for BO is 3-1/8". BC CALC®,BC FRAMER®,AJSTM, Minimum bearing length for B1 is 3-1/8". ALLJOISTO,BC RIM BOARD'"',BCI®, Entered/Displayed Horizontal Span Length(s) =Clear Span+ 1/2 min. end bearing+ BOISE GLULAMT"' SIMPLE FRAMING 1/2 intermediate bearing SYSTEM®,VERSA-LAM®,VERSA-RIM 9 PLUS®,VERSA-RIM®, VERSA-STRAND®,VERSA-STUD®are trademarks of Boise Cascade,L.L.C. Page 1 of 2 ®Boise Cascade Double 1-3/4" x 11-7/8" VERSA-LAM® 2.0 3100 SP Floor Beam1F1301 BC CALC®3.0 Design Report-US 1 span No cantilevers 10/12 slope Tuesday,July 19,2011 Build 440 File Name: fleury110426.BCC Job Name: Victor Fleury Description: F601 Address: 114 Old Village Lane Specifier: Victor Gleury City, State,Zip: North Andover, MA Designer: Gregory R Doyle Customer: PRELIMINARY ONLY Company: Code reports: ESR-1040 Misc: Customer provided specs Connection Diagram Disclosure Completeness and accuracy of input must b d be verified by anyone who would rely on a output as evidence of suitability for ' r• • particular application.Output here based on building code-accepted design c properties and analysis methods. Installation of BOISE engineered wood products must be in accordance with current Installation Guide and applicable building codes.To obtain Installation Guide or ask questions,please call a minimum=2" c=7-7/8" (800)232-0788 before installation. b minimum=3" d= 12" BC CALC®,BC FRAMER®,AJST"" Connection design assumes point load is'top-loaded'. For connection design of'side-loaded' ALLJOISTO,BC RIM BOARDTm,BCI®, point loads, please consult a technical representative or professional of Record. BOISE GLULAM-,SIMPLE FRAMING Member has no side loads. SYSTEM®,VERSA-LAM®,VERSA-RIM Concentrated loads are not considered in side load analysis. PLUS®,VERSA-RIM®, Connectors are: 16d Sinker Nails VERSA-STRAND®,VERSA-STUD®are trademarks of Boise Cascade,L.L.C. r i Page 2 of 2 Location &Ni No. Ael %& Date �pR,h TOWN OF NORTH ANDOVER Certificate of Occupancy $ CHU +, I Building/Frame Permit Fee $ G% JA�NSt Foundation Permit Fee $ E Other Permit Fee $ TOTAL $ Check # 2354 Building Inspector