HomeMy WebLinkAboutBuilding Permit #729 - 124 OLD VILLAGE LANE 5/20/2010 BUILDING PERMIT NORTF/
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TOWN OF NORTH ANDOVER Fr44`: o
APPLICATION FOR PLAN EXAMINATION
4
Permit NO: Date Received ' ( D
lf� � pDgATED I'PP
Date Issued:
~G �.1��SSACHl1S
IMPORTANT:Applicant must complete all items on this page
LOCATION /0y CS/0 C/a, //Ake
Print
PROPERTY OWNER �>>,,,�� nr ,�,E- G`
Print
MAP 210 PARCEL: ZONING DISTRICT: Historic District yes 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 Others:
Demolition Other
Septic Well Floodplain; Wetlands WatershedDistrict
Water/Sewer
DESC IPTION OF WORK TO BE PREFORMED:
Identification Please Type or Print Clearly)
OWNER: Name: Phone:
Address:
CONTRACTOR Name:_ A"c� Phone: 7,6/-As-;q-3yay
T
Address: ' Cce � wgm A r,eeii t-
Supervisor's Construction License: .,6Q Exp. Date: 2-
Home Improvement License: /G-Y,990 Exp. Date: ao��
ARCHITECT/ENGINEER Phone:
Address: Reg. No.
FEE SCHEDULE.BULDING PERMIT.$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED ON$125.00 PER S.F.
Total Project Cost: $ /cq,s-ccD FEE:
Check No.: C;) Receipt No.: j
NOTE: Persons contracting with unregistered contractors do not have access to the guara ty fund
Signature of Agent/Owner Signature of contractor.
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
I
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
DATE REJECTED DATE APPROVED
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION Reviewed on 1 /'0 Signature g
COMMENTS
C�L
HEALTH Reviewed on Siqnature
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
I
Planning Board Decision: Comments
I
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 signature/date
COMMENTS
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
NOTES and DATA– (For department use)
❑ Notified for pickup - Date
_...._........._......................._.................................-- --................................__.._................... ......................_----........................._................----..._....................----.........._.........-.—._.._............................ ....................
Doc.Building Permit Revised 2010
0
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
❑ 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
0 Certified Surveyed Plot Plan
❑ Workers Comp Affidavit
❑ Photo Copy of H.I.C. And C.S.L. Licenses
Copy Of Contract
❑ Floor/Crossection/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
o Mass 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
❑ 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
❑ 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
Northeast Contracting Solutions
314 Clark Street North Andover MA 01845
978-685-0568 /fax 794-3780
Misc. Work
May 3, 2010
Proposal submitted to: Jodi and Mike Fina Address: 124 Old Village Road North Andover MA 01845
Service Address: same Phone, Email: jodifina@comcast.net
Salesman: Norman V, Lee GC# 102750 HIC# 291658
We hereby submit a description of work and materials to be u-s-eT-w-ith estimated cost,-s-u-bjec-fFo-a-11 terms and conditions as follows:
Project#1855(COPY OF 1843, BUT SMALLER PLANTS AND SOME REMOVED)
Plan#1 Immediate front of house Per design,except for smaller boxwood and holly,
with season guarantee $3931.00
Project#1853 Lawn installation
Remove Piles of debris and grindings and grass-cleanup of back area
Create bed lines,and prep beds for mulch on entire border(3500 square feet)
Install loam to grade lawn, Prep lawn for seed,hand rake,roll and hydroseed $4661.44
Project#
Mulch of entire border-3500 sq feet
35 yards of dark bark(or red or black) $2345
Project# Lawn installation—FRONT CIRCLE DOWN TO STREET
Remove birch tree and magnolia, as well as all underplanted shrubs
Leave in pile for chipper for one-two days
Grind stumps, Client will transplant hosta elsewhere
Remove grindings,add 12 yards of Ioam,Rake,grade, lime and fert,Hydroseed $1995
Project#1846 Deck installation#4(per McMullen design)
Demo existing brick stairs. Excavatefor footings, Exterior Trim&Decks all stock with timber tech decking
not to exceed$2.70 In ft,white vinyl•railings 6'sections with 4x4 post,Two 6'stairs on both sides,azek trim
and riser white. Exterior Trim&Decking labor to.install. Move down spouts and water supply line for hose.
Dumpster and Building Permits Window in basement will need to be removed or a window well in deck????, -
Should be removed. $19,956
Stump Grinding payment $562.50
Notes:
Permits required to be obtained , obtained by Contractor
Owners that secure their own construction related permits shall be excluded from Guarantee Fund
Ledge, rotting materials, code related issuesor other unforeseen situations encountered that affect pricing,job duration, or
other issues will be discussed with the client,and change order submitted and signed off on by client to continue work. Like
or similar material will be substituted in the event that contractor is not able to obtah specified material,pending designer's
and/or client's approval.Slight fluctuations in texture, colors can be expected-contractor will make diligent effort to match
Items as close as possible.
This contract will act as thefinal bill, and final payments will be made from this document.Any additional work in changa
orders will be collected in the same manner.
Massachusetts provides a tl-ree day cancellation right to homeowners. Non-payment can lead to liens on your property.
Questions?Call us,write us and check out our website @ www.ncsne.com for more information on our other services.
PAYMENTS AND DISBURSEMENTS: Customer is responsible for obtaining any financing he deems necessary to comply
with this Agreement. If Customer is obtaining financing forma third party, Customer agrees to apply for such financing
without delay and this Agreement is subject to Customer being approved for such financing. All payments are due and
payable as specified in the Proposal/Contract. Northeast Contracting Solutions reserves the right to assess a $25.00 fee if
Customer requests us to re-invoice them for any reason. Overdue payments will bear a 1,5%service charge. Failure by
Customer to pay any invoice within five 5 days after payment is due per contract shall constitute a material b
C ) Y p each of this
i Y P
i
Agreement. All legal, court or otherwise collection cost incurred by Contractor cre to be paid by Customer.
Client Initials - 1 -
LABOR AND MATERIALS:Contractor agrees to furnish the materials for the project and complete the work to be done in a
workmanlike manner. All materials furnished under thisAgreement shall be construction grade and meet industry standards.
Where brand names have been specified,Contractor may at his optionselect substitutes when such substitutions are due to
unavailability or previously specified. Ccntractor shall pay all subcontractors, laboers, and material suppliers, unless
specified differently in writirg.
SPECIAL CONSIDERATIONS: For those selections of materials requiring special consicerations including, but not limited to,
cash deposits to hsure their production, Contractor may at his option require Customer to pay such required deposits
directly to distributor or manufacturer rendering such services. It is understood that when matching existing conditions such
as color, size, planes and texture, Contractor will provide materials so as to match,as closely as possible, the existing
materials. However Contractor does not guarantee materials will match existing conditions.
DISCLAIMED WORK: No soil testing, surveying, plan design or engineering are included in this Agreement unless expressly
specified. Contractors shall not beheld responsible for any existing violations of applicable building regulations or
ordinances, whether cited by the appropriate authority or not. Contractor is not responsible for any abnormal or unusual
pre-existing conditions including, but not limited to,damage caused by termites or dry rot, filled ground or graind of
inadequate bearing capacity, rock and other material not removable by ordinaryhand tools,inadequate electrical wiring
systems for the load imposed by the work under this Agreement, and plumbing, gas waste and waterlines not shown on
documents or plans furnished by Customer. Correction of any such violations or ab-iormal conditions by Contractor shall be
considered additional work.
ADDITIONAL WORK: Contractor shall promptly notify Customer of any additional rEquirements necessary to facilitate the
project's completion. Any additional work required orordered by Customer(or ary regulatory agency having jurisdiction
over the project)shall be set forth in a signed change order, and the agreed price shall become due and payable as
agreed upon between Contractor and Customer, or within 30 days if not specified, payment is due in full. Contractor, his
employees, subcontractors and agents areunauthorized to perform any additionalwork or to enter into any agreement to
perform additional work uness agreed to in writing by Customer and Contractor through a properly executed change
order,which shall become an integral part of this Agreement.
PROPERTY RIGHTS AND RESTRICTIONS: Customer represents that he owns the property described as "property address", or
has authority to order and son for work. Customer shall locate and point out the boundary lines of the properly to
Contractor. Customer shall be solely responsible for accuracy of markers and boundary lines indicated to Contractor and
as detailed on plans and specifications approved b Customer. If a land survey is re uired for an
p p Pp Y Y q y reason to confirm
markers or boundary lines,Customer agrees to pay for such survey. Prior to the start of construction, Customer shall give
Contractor a copy of any restrictions easements or rights of way relating to theproperty.
ACCESS AND FACILITIES: Customer agrees to provide free access to work areas for workers and vehicles,and to provide
areas to store materials anddebris. Unless otherwise specified, all water, sewer, gas and electric utilities from the servicing
agency to the point of entry at Customer's property line(or to the metering device if such devices are required)are the
responsibility of the Customer. Customer agrees,at Customer's expense, to provide electricity at the project site as may be
required by Contractor to effect the work described herein in compliance with federal, state and/or provincial law.
Contractor shall not be held liable for minor damage tocurbs, driveways,walks, patios, unlesscaused by the gross negligent
movement of workers, vehicles, equipment, materials or debris.
START, DELAY AND COMPLETION OF WORK: Contractor agrees to commence work and to continueto work in a timely
fashion so as to insure the project's consistent development and ultimate completion. Contractor is bound by the terms and
conditions regarding start of work imposed by any licensing or regulatory agency having jurisdiction over the project.
Contractor shall not beheld responsible for project delays caused "acts of God," civil unrest, acts of Customer or
Customer's agent, inclement weather,strikes, labor disputes, material shortages, Icensing or regulatory agency inspections,
or any other actions or causes beyond the Contractor's control.
CANCELLATION CLAUSE: Option of Customer to terminate contract in the event of Contractor's failure to complete work. If
the Contractor shall refuse to or fail to perform the work with such diligence and force as specified in this contract, or shall
fail to complete said work in a timely manner, or if Contractor does not perform thework in a professional manner
according to industry standards, Customer reserves the right to give written notice to theContractor of its intention to
terminate this contract unless said violations of the specifications are corrected within fifteen(15)working days after serving
of said notice. If after fifteen(15)working days the violations have not been corrected or satisfactory arrangements for the
completion thereof made, this contract may, at the option of the Customer, be terminated, In the event of termination,
payment in full for all services performed to date by theterminated Contractor shall be made immediately at the time of
termination. Option of Contractor to terminate contract in the event of Customers failure to make timely payrrents as
specified or to abide byall terms and conditionsas outlined by this Agreement hereto, also, but not limited to any actions by
the customer to circumvent, interrupt or otherwise, any relationship with a subcontractor and the Company, Contractor's
option to terminate wil be immediate and communicated in writing.
DAMAGE AND INSURANCE: Contractor agrees to carry worker's compensation and business liability insurance io insure the
Customer against damages or defects caused by Contractor, his employees, or any agents acting in his behalf. A valid
insurance certificate will befurnished upon request.
MISCELLANEOUS: Contractor may subcontract all or any portion of the work and may assign this Agreement to another
Contractor, provided such assignment shall not affect the rights and privileges of Customer under this Agreement. In case
one or more of the provisions of this Agreement or any application thereof shall be invalid, unenforceable or illegal,the
validity, enforceability and legality of the remaining provisions and any other application thereof shall not in any way be
impaired thereby. If any legal action shall be instituted to interpret.or enforce thisAgreement,the prevailing party shall be
entitled to recover all litigation costs,hcluding reasonable attorneys' fees. It is agreed that this Agreement shall be
governed by, construed, and enforced in accordance with the laws of the State of Massachusetts.
Client Initials -2 -
CONTRACT ADJUSTMENTS: In the event of an unanticipated increase in the cost of fuel or materials used by Northeast
Contracting Solutions Inc„ reserves the right to pass through to the Customer such increases or, if the Customer does not
agree to pay any such increases,to terminate the contract.
LIMITED WARRANTY: Northeast Contracting Solutionsguarantees workmanship,subject to the following ccnditions.
• Contractor warrants all labor and material for a period of thirty(30)days from the date of completion of work,
unless otherwise stated or an Extended Warranty is purchased. This limited standard warranty extends only to
Customer and is not transferable.
Contractor will provide replacements as stated alcove on a one-time basis only at the request of the Customer, at
no charge to the Customer except for supportive materials deemed necessary and labor, Please note, however,
that Contractor is not liable under this limited standard warranty for actual of consequential damages resulting from
"acts of God," excessive weather conditions(extreme cold/drought,washouts,etc.), soil conditions,abuse,
vandalism,poor drainage, salt damage.
• Any warranties given by manufacturers pertaining to materials used by Ccntractor in.with the project will be passed
through and inure to the benefit of the Customer.
* There is no implied warranty of merchantability or any mplied warranty of fitness for any particular purpose.
There are no warranties either express or implied beyond the description within this section.
The contractor and the homeowner herby mutually agree in advance that in the ev t the contactor has
a dispute concerning this contract, the contractor may submit such di to to a Nate 4bitration service
which has been approved by the Office of Consumer Affairs and Bu ' s Reg ation a the consumer shall
be required to submit s h art)itration as proved in MGL c 142Ac
Owner ✓G Contractor
Accepted:The signatures below indicate thaoalTined
ices, specifications and conditions are satisfactory
and hereby accepted. Payment will be madBove. ,
DO NOT AGN THIS CRE ARE ANY BLANK SPACES!
2v
Owner Signature; Date:
Contractor Signature: Date: w��
7-C..
f
Date to be started* 5 kV_"-te_J Date to be Completed" /0 J 5vS V rzJ lece1r
6
Payment Schedule Total amount to be Paid*** $33, 888.44
$16,644,77-Paid
$5781.67- Paid
$11, 025.27-Due upon completion of work as outlined above
The following material/Equipment must $ o be paid for
Be special ordered before the contracted
ku fi / V.
Schedule. $ to be paid for
Company Policy rcredit card number,vcode and expiratio ate on file to process project.
CC# 'M;7equir V-Code Exp, Date A00
*Based on receipt of bankable check, and availability of materials, **Assuming no weather, material availability
or unforeseen issues. *** Excluding change orders, unforeseen issues
All home improvement contractors and subcontractors shall be registered and that any inquiries about a
contractor or subcontractor relating to a registration should be directed to:
Office of Consumer Affairs and Business Regulation
Ten Park Plaza, Suite 5170 Boston, MA 02116
Phone: (617)973 8700
Client Initials - 3 -
N°RT" ver
Town of
ndo
No.� * _ -
-� Z
o
_ - dower, Mass., ---
�. O
A_.p COC HIC HE WICK V
�1,q ADRATED P '�� BOARD OF HEALTH
S
Food/Kitchen
PERM I D Septic System
BUILDING INSPECTOR
THIS CERTIFIES THAT M ......... ................ ............... . ..................................... Foundation
has permission t ct.........................
buildings on ' ...... .I ....U.k.1. .. ............. Rough
to be occupied as... �. 0Chimney
...........
provided that the person accepting this permit shall in every respect conform to the terms of the application on 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 CONS ST S Rough
....... Service
BUILDING INSPECTOR
w 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
Until Inspected and Approved by the Building Inspector. Burner
FlRE DEPARTMENT
Street No.
SEE REVERSE SIDE Smoke Det.
The C'ommonweaith of Massachusetts
Department o f rndustrial Accidents
Office of investigations
600 Washington Street
Boston, AL4 02II1
www•massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractorsxlectricians/P'lumbers
An licant Infortnatioa
Please Print Legibly
Name (Business/organization/Individual):
Address: .
City/State/Zip:ti Phone#: 1-
u
Ar
e an employer?Check the appropriate boat
1• a employer with 4. ❑ I a o Type of project(required):
general contractor and I
2.0 employees(full and/or part-time) * have hired the sub-contractors 6. 0 New construction
I am a sole proprietor or partner- listed ted on the attached sheet 1 7• ❑Remodeling
ship and have no employees These sub-co
ntractors have
working for me in any capacity, workers' comp.insurance. 8' Demolition
,
[No workers' comp. insurance5. ❑ We are a corporation and its 9. 0 Building addition
3•E] required.) officers have exercised their 10.0 Electrical repairs or additions
I an a homeowner doing all work
right of exemption per MGL 11.0 PlumbiMgrepairs or additions
myself. [No workers'comp. c. 152,§1(4),and we have no
insurance required.] t employees_ [No workers' - 12.0 Roof repairs
Pomp.insurance required-] 13.0 Other
`.-.ny 2PP1icr t that ch�c';s tbov#t
must=?st+aur cuff inti sectio"beioa snc�>W.
Homeowners who submit this affidavit indica ="=r wor=e s'con Y_s� �: yV
�`^'are do g all work and then hire outsirL contractors Auq submit a new affidavit indicating such.
'Contractors that checs, this box must attached an additional sheet showing the
uame of the sub-contractors and their workers'comp.Poirc}'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-ASSUC�n�N� tMn
�y�•Plr .y �� ��n, n.rt
Policy#or Self ins.Lie.#: C,--) �Ot
Expiration Dater-
Job Site Address: /'�� O�
Attach a copy of the workers'compensation policy declaration age (showingCity/State/Zip: �•;y_�_
Failure to secure coverage as required under Section 25A of MGL cp. 152canlead to ththe e impositionolicy nmoer and expiration date).
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WO criminaI� ER penalties
nd a of
of up to$250.00 a day against the violator. Be advised that a copy of
Investigations of the DIA for insurance coverage verificatiorL
statement maybe forwarded to the Office of
I do hereby cera fy u the pains and penalties of perjury that�e information provided above is true and correct
SiQnature?�
Phone#: .e _
Official use only. Do not write in this area, to be completed by city or town offLciaL
Cita or Town: Permit/License#
Issuing,Authority(circle one'
1. Board of Health Z.
Building Department 3. City/Town Clerk 4.Electrical Inspector 5.plumbing
6. Other b Inspector
Contact Person:
Phone#:
Information an- d 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 ox-other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartrri eats and who resides therein,or the occupant of the
dwelling house of another who employs persons to do mainte3nance,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 co:impliance 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-contractors) nnme(s), address(es)and phone number(s)along with their cerdficate(s)of
insurance. Limited Liability Companies(LLC) or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers' comp ensation 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 Ww-n that the aMIJI-c8uon for pe-awt or 1 .S ��
e r ,cense' beim rrY:`s*fid not a cDepar=_=t.of
Industrial Accidents. Should von have any questions regard rt,P ;f,,,, �'*' `t UIL•'. ;�� t
g b tai or u;,u are re.T.:rred to o�,am a Loi ler-,
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-mcu-rance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant
Please be sure to fill in the permit/license number which will be used as a reference number. In addition;an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(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 permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit
The Office of Investigations would Ince to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call
The Deparanent's address,telephone and1ex.number....
The Commonweal& of Massachusetts.
Department of Industrial Accidents
Office of Invesfibatlons
600 Washington Street
Boston,MA 02111
Tel. ri 617-72.7-4900 ext 406 or 1-977-KkSSAFE
Revised 5-26-05
Fax r 617-72.7-7749
Uf'ViTw-mass._a ov/dia
NIAY-14--2010 (FRI ) 11 : 35 14ALCOLM � PARSONS INSURANCE (FAK) 1?813441425 P 002%00?
INFORMATION PAGE
Associated Employers insurance Company
Burlington, Massachusetts NCC( NO 40059
(800)876-2765
POLICY NO. W>✓C 50002 2009
ITEM PRI09 NO. WCC 50002;9012008
1. The Insured KB Flooring
Mailing Address; 46 Schanda Drive Now Market. NH 03850
INo, street Tom or City Caurly Stato Lp Codi
® Individual ❑ Partnership ❑ Co-porallon ❑ Other ETFFED IN, 0,- 82
Other workplaces not shown above: v C
2- The pollcy period Is from10/01/2001) to 10101"2010 1201 E.rn.standard Qms at the insured's miOng address
3. A. Workers Compensation Insurance: Port One of the policy applies to the Wo;icers Compensation Lew of the stales listed here;
MA
B. Empfoyers Liability insurance: Part Two of tate policy apples to work In each stats listed In itern 3.A.
The limits of our liablltytrtderftlTwo are: Bodily Injury byAccidert$ 500,00C eachaccident
Bodlly Injury by Disease $_ 500,00C policylimit
Bodily Injury by(Disease $ _ 500, 0 00 each employee
C. Other States Insurance: COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06 A
D. This policy Includes these endorsements and schedules SEE SCHEDULE
4.•. The premium for this pogo;will be determined by our Manuals of Rules,Classifications,plates and Rating plans.
All information required bolum is subject to verification and&urge by audit.
Classifications Pramium Basis Elates
Gods EarlwaW Par$I Do &,Irrs.gad
Tatni Anlire of Arcual
Ramunorallon Flemuntmcailon premum
INTRA 25I:i21
SEE EXT SIGN OF INFOR ATION PAGE
fdinimum premium$ 500.00 Total Estimated Annual Premium $ 1632.00
As Indicated:Interlm aidiuslments of premium shall be made: Deposit Premium S 1.721-00
® Annually ❑ Semi Annually ❑ Quarterly ❑ Monthly
MA As:;ussmarit Chg.
$i.239.75)L 7.2000% 569.00
Tills policy,Including all endorsements,Is hereby countersigned by — 09/04/2009
Aulhorized signature CAIa
GOV GOV KIND PLACING CLAIM NAME (SAFETY
STATE CLASS AUDIT OFFICE OFFICE CHECK GROUP Malcolm& arsons Insurance
KLA 5437 7 15C15 agency Inc
WC 00 00 01 A11-06 6 Freeman Street-P O Bax 527
Inctudes copyrignied f elariar,I Ina N.dooa)Council an C�rnpenaaticn lmuranso: SinoghlDn,MA 02072
wad with Qs pmmlaaton,
1
STRESS ANALYSIS
CUSTOMER: KB FLOORING
DATE:-W05/18/10 DESIGN: DECK10132 REF: 10132085 . ZP1
SALESMAN # SC91
-------------------------------------------------------
MEMBER STRESS FACTOR COMPOSITE
TYPE SIZE FACTOR LOAD LOAD
-------------------------------------------------------
JOISTS 2X10 DEFLECTION 59 PSF
16" BENDING '65 PSF
SHEAR 88 PSF
COMPRESSION 182 PSF 59 PSF
BEAMS 3-2X8LM DEFLECTION 72 PSF
BENDING 65 PSF
SHEAR 71 PSF
COMPRESSION 295 PSF 65 PSF
POSTS 4X4 STABILITY 342 PSF
BEARING 367 PSF 342 PSF
-----------------------------------
TOTAL LOAD 59 PSF
DEAD LOAD 10 PSF
LIVE LOAD 49 PSF
-------------------------------------------------------
STRINGERS 2X12 DEFLECTION 292 PSF
BENDING 239 PSF
SHEAR 170 PSF
COMPRESSION 657 PSF
-----------------------------------
TOTAL LOAD 170 PSF
DEAD LOAD 10 PSF
LIVE LOAD 160 PSF
-------------------------------------------------------
STRINGERS 2X12 DEFLECTION 307 PSF
BENDING 252 PSF
SHEAR 179, PSF
COMPRESSION 692 PSF
-----------------------------------
TOTAL LOAD 179 PSF
DEAD LOAD 10 PSF
LIVE LOAD 169 PSF
-------------------------------------------------------
Location oil 141 Na _ Date C -z
NORTq TOWN OF NORTH ANDOVER
Of "'O '•,�O
OL
F .. 9
• ; ; Certificate of Occupancy $
Building/Frame Permit Fee $
s�CHus
Foundation Permit Fee $
Other Permit Fee $
TOTAL $
Check # o -4-�
23 'i '/ 1
Building Inspector