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HomeMy WebLinkAboutBuilding Permit #010-2017 - 17 FAULKNER ROAD 7/5/2016 (3) NORTH BUILDING PERMIT °`,�z`eD "tio i TOWN OF NORTH ANDOVER 4 APPLICATION FOR PLAN EXAMINATION _ • 1• Permit No# ` ' Date Received �iAp�a^TED ,fig gss'q CH 5 Date Issued: ©5 IMPORTANT: Applicant must complete all items on this page LOCATION V7 i1UL.I-(IVEL(Z R� PROPERTY OWNER M lC tf rL-(-�L- -Z Print A A loo Year Structure yes no MAP / PARCEL:ZONING DISTRICT: Historic District yes P01,Machine Shop Village yes TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building P-0-he family [edition 0 Two or more family ❑ Industrial ❑ Alteration No. of units: 0 Commercial ❑ Repair, replacement ❑Assessory Bldg ❑ Others: 0 Demolition ❑ Other 4 DESCRIPTION OF WORK TO BE PERFORMED: _LOA.)-1'.> Identification- Please Type or Print Clearly OWNER: Name: 0\(. (zL J C(z At�cS-rz�r-1 Phone: Address: t'� �JLI�Ch(�c� $�E:) Contractor Name:nu[(,tJ,4-r( 4- R4t,1r2 13oiLO Z Phone: 9-7P, -45-7 -05 Zv Email: 001 t.c(_A-Av 5 14 P, V g(Lt Zo1y . ryrL i Address:_ �_�2, cT-y C T. t`(- Arc Dav r\-6Z tVL 1I Supervisor's Construction License: GS OSSA 2 �, Exp. Date: '" Home Improvement License: -Exp.- Date: ARCH ITECT/ENGINEER J aCLL S Lt_UkaWAMk{ Phone: (003—e' L{ `LI`l50 N•4-I _ Address: t 5S Lour amort V rLlZZ(Z .WtN(7WAReg. No. '3 2 FEE SCHEDULE:BULDING PERMIT:$12.00 PER$1000.00 OF THE TOTAL ESTIMATED COST BASED O/N,$125.00 PER S.F. Total ProjJect Cost: $ 1 lQ)nbo FEE: $ 1 '�✓ Check No.. 4fo�—�—Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the guaranty and r' Pians Submitted ❑ Plans Waived ❑ Certified Plot Plan IV Stamped Plans tom' TYPE OF SEWERAGE DISPOSAL Public Sewer Tuning/Massage/Body Art ❑ Swinming Pools ❑ Well ❑ Tobacco Sales ❑ Food Packaging/S'ales ❑ Private(septic tank,etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF m U FORM PLANNING & DEVELOPMENT Reviewed On � Signature_ j COMMENTS CONSERVATION Reviewed on )JAp Signature COMMENTS 1\� YM TH Reviewed on Signature MENTS Zoning 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: Lo ted 384 Osgood Street ,F�IRE�DEPA_� _ r, �r RT�MENT Temp, pumpster onsite ,yes�r .r, 1n L �� r - - ., .�_ i. . L+ocated(at 124�MaintStreet - , ��' -'F.iretD-gpartmentFsignature/date 011 i C®MMENTts NORT" E � Town of �� : _ ndover 0 .:� No. 02,611 Z h ver, Mass T O COC LAKE NIC Nl W1CN y�. �d 0RATEO S IJ BOARD OF HEALTH Food/Kitchen PERMIT T D Septic System THIS CERTIFIES THAT ......t. ........ . ......... ... .. ................................................. BUILDING INSPECTOR has permission to erect .......................... buildings .......Com.snFoundation. Rough to be occupied as ..41YAO&...... / ................................................................. Chimney provided that the person accepting this permit shall in every respect conform to the terms of the application Final on file in this office, and to the.provisions of the Codes and By-Laws relating to the Inspection, Alteration and Construction of Buildings in the Town of North Andover. PLUMBING INSPECTOR VIOLATION of the Zoning or Building Regulations Voids this Permit. Rough Final PERMIT EXPIRES IN 6 MONTHS ELECTRICAL INSPECTOR UNLESS CONST ON SM Rough Service .. ... .. .. .. . ........4BU61iMiN�6 . ....IZECtR Fina N GAS INSPECTOR Occupancy Permit Required to Occupy Building Rough Display in a Conspicuous Place on the Premises — Do Not Remove Final No Lathing or Dry Wall To Be Done FIRE DEPARTMENT Until Inspected_ and Approved by the Building Inspector. Burner Street No. Smoke Det. Quinlan and Rand Builders 34 Trinity Court North Andover, MA 01845 Contract Quinlan and Rand Builders will provide all permits, labor, and materials to construct a second floor addition at 17 Faulkner Road, North Andover, MA as per plans by Silverwatch Architects. All work shall conform to the standards of the Massachusetts Building Code. The prescriptive method shall be used for the Massachusetts Energy Code. The work shall be performed for $118,000. Payments shall be performance based as follows: 1. Backfilled foundation 6% 2. Demolition of roof 8% 3. Second floor deck 10% 4. Roof tight 10% 5. Roofing, windows, siding 12% 6. Rough mechanicals 20% 7. Board and plaster 6% 8. Finish mechanicals 10% 9. Finish trim 10% 1O.Paint and flooring 8% Description of Work: -Remove existing deck -Excavate for new sunroom foundation as per plan -Construct new foundation with 3000psi concrete.as per plan -Backfill and compact foundation -Pour 4" concrete floor in sunroom area -Remove roof shingles, sheathing, rafters and insulation -Frame new second floor as per framing specs. Existing ceiling joists and plaster to remain -Remove chimney and replace with new metal chimney -Wall sheathing to be 1/2" Zip Wall with tape. Roof sheathing to be 1/2" Zip Roof with tape. Subfloor to be 3/4" Advantek -Roof shingles to be 25 year IKO Cambridge AR color B.O. -All exterior trim to be PVC Kleer -All existing siding to be removed -All existing windows on first floor to be replaced with Paradigm Vinyl Windows. Final window schedule and specs to be determined during framing. All siding to be replaced with Certainteed Monogram double 4" vinyl siding -All plumbing to be Pex for potable water PVC for drains. All plumbing done to code. Plumbing shall consist of all work to construct a full bath and laundry room on second floor. -All electric outlets to code, wire HVAC, smoke and CO detectors as required. 10 recessed cans on second floor. 2 cable tv's, 2 CAT 5 outlet, fan in bath, 220v dryer outlet. Home runs to be tied into existing panel. -New Goodman air handler and coil on second floor with 3 ton compressor. Line set to be run in walls. All second floor rooms to have AC vents. -2nd floor walls to be insulated with R-19 fiberglass batts. -Roof rafters to be R-38. No insulation has been figured for first floor.lf first floor walls are found to be uninsulated they can have blown in insulation down at an additional cost. -Interior walls to be 1/2" blueboard with skim coat plaster. Smooth walls, textured ceilings and closets. -All trim to be paint grade. Baseboard to be 1 piece 5 1/4" Speed Base. Door and window casing to be 2 1/2" colonial casing. Doors to be solid Masonite doors. Stairs to be plywood with oak ends. -All trim to be primed and have 2 coats of latex Benjamin Moore paint. All walls to be painted with Benjamin Moore Aura paint. -Owner to select all floorings with an allowance of $5000.. This is for master bedroom, master closet, bath, laundry, study and hall. All plumbing fixtures to have an allowance of $3500. This includes: 1 toilet - $300 2 sinks - 300 2 faucets - 500 1 shower valve - 400 1 vanity - 1500 tile for shower - 500 Quinlan and Rand Builders and all sub-contractors carry liability insurance and workers compensation. Quinlan and Rand Builders has MA Construction Supervisor License #055288 and H.I.C. Reg. #111089 The Ilowing term nd conditions are accepted. 7111, Ti Q nlan Date Michelle Cranston Date Generated by REScheck-Web Software Compliance Certificate Project 17 Faulkner Road Energy Code: 2012 IECC Location: North Andover, Massachusetts Construction Type: Single-family Project Type: Addition Climate Zone: 5 (6322 HDD) Permit Date: Permit Number: Construction Site: Owner/Agent: Designer/Contractor: trade-off�ompliance: Passes using UA Compliance: 15.7%Better Than Code Maximum UA: 140 Your UA: 118 The%Better or Worse Than Code Index reflects how close to compliance the house is based on code trade-off rules. It DOES NOT provide an estimate of energy use or cost relative to a minimum-code P gy ode home. Envelope Assemblies Gross Area Cavity Cont. Assembly or U-Factor UA Perimeter Ceiling: Flat or Scissor Truss 865 0.0. 38.0 0.025 22 Wall: Wood Frame, 16in.D.C. 1,156 0.0 21.0 0.039 43 Window:Vinyl Frame, 2 Pane w/Low-E 66 0.340 22 Floor:All-Wood Joist/Truss Over Uncond.Space 1,072 0.0 30.0/ 0.029 31 Compliance Statement: The proposed building design described here is consistent with the building plans, specifiEations, and other calculations submitted with the permit application.The proposed building has been designed to meet the 2012 IECC requirements in REScheck Version 5.5.0 and to comply with the mandatory requirements listed in the REScheck Inspection Checklist. t)A& 0vl w L�*N e#(z1-Nr12 av►ticAJ_t 4. -715 t 16 Name-Title >R/� Signature Date A�u�� JjU1CQh.(L� Project Title: 17 Faulkner Road Report date: 07/05/16 Data filename: Page 1 of 8 CREScheck Software Version 5.5.0 �J( Inspection Checklist Energy Code: 2012 IECC Requirements: 0.0% were addressed directly in the REScheck software Text in the "Comments/Assumptions" column is provided by the user in the REScheck Requirements screen. For each requirement, the user certifies that a code requirement will be met and how that is documented, or that-an exception is being claimed. Where compliance is itemized in a separate table, a reference to that table is provided. Section Plans Verified Field Verified # Pre-Inspection/Plan Review Value Value Complies? Comments/Assumptions &Re .ID 103.1, ;Construction drawings and `❑Complies 103.2 1 documentation demonstrate ❑Does Not [PR1]1 ;energy code compliance for the I ;building envelope. UNot Observable ❑Not Applicable 103.1, ;Construction drawings and ❑Complies 103.2, 'documentation demonstrate IEIDoes Not 403.7 energy code compliance for ![]Not Observable [PR3]1 ;lighting and mechanical systems. .i !❑Not Applicable ;Systems serving multiple pp icable ;dwelling units must demonstrate {compliance with the IECC ; ;Commercial Provisions. 302.1, Heating and cooling equipment is;, Heating: Heating: ;❑Complies 403.6 sized per ACCA Manual S based Btu/hr Btu/hr UDoes Not [PR2]2 ion loads calculated per ACCA CoolinF i Manual J or other methods Btu/hr Btu/hr 1❑Not Observable 'approved by the code official. ;❑Not Applicable Additional Comments/Assumptions: 11 High Impact(Tier 1) 2 1 Medium Impact(Tier 2) 3 Low Impact(Tier 3) Project Title: 17 Faulkner Road Report date: 07/05/16 Data filename: Page 2 of 8 Section # Foundation Inspection Complies? Comments/Assumptions & Re .ID 303.2.1 A protective covering is installed to ;❑Complies [FO11]2 protect exposed exterior insulation E❑Does Not and extends a minimum of 6 in. below grade. ,❑Not Observable; ❑Not Applicable 403.8 Snow-and ice-melting system controls![]Complies [FO12]2 installed. ;❑Does Not ❑Not Observable; ❑Not Applicable Additional Comments/Assumptions: 1 I High Impact(Tier 1) 2 1 Medium Impact(Tier 2) 13 JLow Impact(Tier 3) Project Title: 17 Faulkner Road Report date: 07/05/16 Data filename: Page 3 of 8 Section plans Verified Field Verified # Framing/Rough-In Inspection Value Value Complies? Comments/Assumptions & Re .ID 402.1.1, 'Glazing U-factor(area-weighted U- U- ;❑Complies ;see the Envelope Assemblies 402.3.11 average). _ !❑Does Not ;table for values. 402.3.3, 402.3.6, ,❑Not Observable 402.5 ;❑Not Applicable [FR2]1 303.1.3 U-factors of fenestration products P❑Complies [FR4]1 !are determined in accordance Z❑Does Not ;with the NFRC test procedure or o taken from the default table. '❑Not Observable ❑Not Applicable 402.4.1.1 :Air barrier and thermal barrier [ i❑Complies ' [FR23]1 installed per manufacturer's i❑Does Not instructions. i❑Not Observable '❑Not Applicable 402.4.3 Fenestration that is not site built ❑Complies [FR20]1 ;is listed and labeled as meeting 111Does Not AAMA/WDMA/CSA 101/I.S.2/A440 C-9 R or has infiltration rates per NFRC ;❑Not Observable 400 that do not exceed code []Not Applicable limits. 402.4.4 IC-rated recessed lighting fixturesgg ;❑Complies ; [FR16]2 sealed at housing/interior finish i 9❑Does Not and labeled to indicate 52.0 cfm ❑Not Observable leakage at 75 Pa. J❑Not Applicable 403.2.1 ;Supply ducts in attics are R- R- ;❑Complies [FR12]1 insulated to aR-8.All other ductsR 1 R ;❑Does Not in unconditioned spaces or ;outside the building envelope are: ,❑Not Observable rinsulated to aR-6. ;[]Not Applicable 403.2.2 All joints and seams of air ducts, i❑Complies [FR13]1 ;air handlers, and filter boxes are ❑Does Not ;sealed. ❑Not Observable ❑Not Applicable 403.2.3 Building cavities are not used as ;❑Complies [FR15]3 ducts or plenums. K❑Does Not j❑Not Observable I i❑Not Applicable 403.3 HVAC piping conveying fluids R- R- ;❑Complies [FR17]2 iabove 105°F or chilled fluids j ;❑Does Not i below 55 °F are insulated to aR- 3 ;,[]Not Observable ; ❑Not Applicable 403.3.1piping. _ I❑Complies ; Protection of insulation on HVAC [FR24] ❑Does Not i❑Not Observable ❑Not Applicable 403.4.2 Hot water pipes are insulated to R- R- ;❑Complies [FR18]2 aR-3. :❑Does Not ;❑Not Observable :,[]Not Applicable 403.5 Automatic or gravity dampers are ❑Complies [FR19]2installed on all outdoor air ❑Does Not intakes and exhausts. I w I❑Not Observable j❑Not Applicable Additional Comments/Assumptions: 1 I High Impact(Tier 1) 2 Medium Impact(Tier 2) 3 Low Impact(Tier 3) Project Title: 17 Faulkner Road Report date: 07/05/16 Data filename: Page 4 of 8 111 High Impact(Tier 1) 2 1 Medium Impact(Tier 2) 3 1 Low Impact(Tier 3) Project Title: 17 Faulkner Road Report date: 07/05/16 Data filename: Page 5 of 8 Section Plans Verified Field Verified # Insulation Inspection Value Value Complies? Comments/Assumptions & Re .ID 303.1 All installed insulation is labeled ± ❑Complies ; [IN13]2 :or the installed R-values 4 []Does Not provided. I 3❑Not Observable ; ❑Not Applicable 402.1.1, ;Floor insulation R-value. R- R- ;❑Complies ;See the Envelope Assemblies 402.2.6 ❑ Wood ;E] Wood ;❑Does Not :table for values. [IN1]1 ❑ Steel ❑ Steel ;❑Not Observable ❑Not Applicable 303.2, Floor insulation installed per ❑Complies 402.2.7 manufacturer's instructions, and ❑Does Not [IN2]1 ;in substantial contact with the v3 ;underside of the subfloor. ❑Not Observable ❑Not Applicable 402.1.1, :Wall insulation R-value. If this is a; R- ; R- :❑Complies ;See the Envelope Assemblies 402.2.5, mass wall with at least 1/2 of the ❑ Wood ;❑ Wood ;❑Does Not :table for values. 402.2.6 wall insulation on the wall [IN3]1 'exterior,the exterior insulation ] Mass E] mass ❑Not Observable requirement applies(FR10). ;E] Steel i❑ Steel ;[]Not Applicable J s , , 303.2 ;Wall insulation is installed per :❑Complies : [IN4]1 manufacturer's instructions. ❑Does Not ❑Not Observable : �❑Not Applicable Additional Comments/Assumptions: 1 High Impact(Tier 1) 2 Medium Impact(Tier 2) 3 Low Impact(Tier 3) Project Title: 17 Faulkner Road Report date: 07/05/16 Data filename: Page 6 of 8 Section Plans Verified Field Verified # Final Inspection Provisions Value Value Complies? Comments/Assumptions & Re .ID 402.1.1, ;Ceiling insulation R-value. R- ; R- ;❑Complies ;See the Envelope Assemblies 402.2.1, Wo0d ;❑ Wood CDoes Not `table for values. 402.2.2, Steel ❑ Steel 402.2.6 ❑Not Observable [FI1]1 ;❑Not Applicable J 303.1.1.1, ;Ceiling insulation installed per f❑Complies ; 303.2 ;manufacturer's instructions. ❑Does Not [F12]1 Blown insulation marked every 300 ft2. ,❑Not Observable ',[]Not Applicable 402.2.3 'Vented attics with air permeable J❑Complies ; (F122]2 insulation include baffle adjacent ! +❑Does Not to soffit and eave vents that extends over insulation. []Not Observable ; f ❑Not Applicable 402.2.4 ;Attic access hatch and door ; R- R- ;❑Complies ; [F13]1 ;insulation 2-11-value of the ;❑Does Not adjacent assembly. ;[]Not Observable ; ❑Not Applicable 402.4.1.2 'Blower door test @ 50 Pa. <=5 ACH 50= ACH 50 = ;❑Complies ; [FI17]1 :ach in Climate Zones 1-2, and ;❑Does Not <=3 ach in Climate Zones 3-8. ;❑Not Observable ' ;❑Not Applicable 403.2.2 ;Duct tightness test result of<=4 ; cfm/100 ; cfm/100 ;❑Complies [F14]1 ;cfm/100 ft2 across the system or ft2 ft2 ;❑Does Not <=3 cfm/100 ft2 without air42) ; handler @ 25 Pa. For rough-in UNot Observable tests,verification may need to ; ; ;❑Not Applicable ; + ;occur during Framing Inspection. 403.2.2.1 ;Air handler leakage designated ❑Complies ; [FI24]1by manufacturer at<=2%of !!❑Does Not design air flow. i ;❑Not Observable ❑Not Applicable 403.1.1 Programmable thermostats ❑Complies ; [FI9]2 installed on forced air furnaces. # ❑Does Not i ❑Not Observable I❑Not Applicable 403.1.2 i Heat pump thermostat installed '❑Complies ; [FI10]2 on heat pumps. j❑Does Not ` ❑Not Observable ❑Not Applicable 403.4.1 Circulating service hot water I❑Complies ; [FI11]2 systems have automatic or ' ❑Does Not Y accessible manual controls. Y i❑Not Observable ; !,❑Not Applicable ; 403.5.1 'All mechanical ventilation system 4❑Complies ; [FI25]2 fans not part of tested and listed ❑Does Not HVAC equipment meet efficacy and air flow limits. i❑Not Observable ❑Not Applicable 404.1 175%of lamps in permanent ❑Complies [FI6]1 'fixtures or 75%of permanent ❑Does Not ;fixtures have high efficacy lamps. !! + Does not apply to low-voltage I❑Not Observable lighting. ❑Not Applicable 11 High Impact(Tier 1) 12 1 Medium Impact(Tier 2) 3 Low Impact(Tier 3) Project Title: 17 Faulkner Road Report date: 07/05/16 Data filename: Page 7 of 8 Section Plans Verified Field Verified # Final Inspection Provisions Value Value Complies? Comments/Assumptions &Re .ID 404.1.1 'Fuel gas lighting systems have ❑Complies [F123]3 'no continuous pilot light. ❑Does Not s❑Not Observable I E❑Not Applicable 401.3 Compliance certificate posted. ❑Complies (FI7]2 ([]Does Not ❑Not Observable t UNot Applicable 303.3 Manufacturer manuals for 111complies [FI18]3 mechanical and water heating []Does Not systems have been provided. y ;❑Not Observable ❑Not Applicable Additional Comments/Assumptions: 1 High Impact(Tier 1) 2 Medium Impact(Tier 2) —F371-ow Impact(Tier 3) Project Title: 17 Faulkner Road Report date: 07/05/16 Data filename: Page 8 of 8 2012 IECC Energy Efficiency Certificate 'Insulation . Above-Grade Wall 21.00 Below-Grade Wall 0.00 Floor 30.00 Ceiling / Roof 38.00 Ductwork (unconditioned spaces): Glass & Door Rating . Window 0.34 Door Cooling'Heating & Heating System: Cooling System: Water Heater: Name: Date: Comments r \ ,. ��. � � '�_.__ , � � J;� � r V r �/ 1 � � Yc •� �� �•\_ The Commonwealth of Massachusetts Z . Department of IndustrialAccidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERNHTTING AUTHORITY. Applicant Information Please Print Legibly Name(Business/Organization/Individual): 0,J 1,14 LA44 -(— rCANP t�u L L0(L2� Address: 3 L( GT City/State/Zip: Q, 01-100L.,<_2 WA 0116q Phone#: 9_72,-14S7-1)Q_8 Are you an employer?Check the appropriate box: Type of project(required): 1.❑I a employer with employees(full and/or part-time).* 7. E]New construction 2. I am a sole proprietor or partnership and have no employees working for me in S. F]Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition 3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 uilding addition 4.F]I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12. ❑Plumbing repairs or additions 5. I am a general contractor and I have hired the sub-contractors listed on the attached sheet. ❑ � 13. Roof repairs These sub-contractors have employees and have workers'comp.insruanceJ ❑ 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have nmo.eployees.[No workers'comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. i Homeowners who subniif 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 state whether or not.those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. lam an employer that is providing workers'compensation insurance for my employees.•.below is the policy and job site information. Insurance Company Name: Policy#or Self--ins.Lie.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Y do hereby ce under the z a pen es ofpezjuzy that the information provided above is true and correct. Si natu�` Date: Phone#: T .G Official use onl . 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=contractox(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 carry 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 permit 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 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 bum leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-NUSSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia 0 F AC40 CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 7/1/2016 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Emil Costello NAME: y Costello Insurance Agency, Inc. FAX p/CNNo E:t: (978)374-6352 (A/C,No)_ (978)521-5127 2 S. Kimball St. E-MAIL ecostello@costelloinsurance.com ADDRESS: PO BOX 5248 INSURERS)AFFORDING COVERAGE NAIC# Bradford MA 01835 INSURERAMerchants Mutual 23329 INSURED INSURER B:AIM Insurance_ Co. _ 337_58_ _ Quinlan & Rand Contractors INSURER C: 34 Trinity Court INSURERD: INSURER E,._ No Andover MA 01845-4248 INSURER F: COVERAGES CERTIFICATE NUMBER:CL167100602 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 ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MM/DDIYYYY) IMM/DDNYYYII LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADE X❑ OCCUR DAMAGE TO RENTED 500,000 PREMISE�Ea occurrence) _$ - BOP1064274 3/12/2016 3/12/2017 MED EXP(Anyone person) $ 15,000 PERSONAL&ADV INJURY $ _ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY F PRO ❑ LOC PROD_U_CTS-COMP/OP AGG $ 2,000,000 X JECT _ OTHER: Property damage-single limit $ AUTOMOBILE LIABILITY _CO aBINEDtSINGLE LIMIT $ cq ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ PROPERTY DAMAGE-- -— --_ HIRED AUTOS AUTOS APer accident ______$ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE _ _ $ DED RETENTION$ $ WORKERS COMPENSATION PER _— OTH- AND EMPLOYERS'LIABILITY Y/N _STATUTE ER__ _ ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100,000 OFFICER/ EXCLUDED? N/A -- - — -- - -- B (Mandatory in NH) VWC-100-6015279-2016A 3/8/2016 3/8/2017 E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under — — — - DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS!VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE MICHELLE CRANSTON THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 17 FAULKNER ROAD ACCORDANCE WITH THE POLICY PROVISIONS. NORTH ANDOVER, MA 01845 AUTHORIZED REPRESENTATIVE z ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025(201401) Massachusetts Department of Public Safety /eo-rrr�rra�arce �l/a�C�/1caauc/c�rett ��. Board of Building Regulations and Standards � ,Office of Consnr►zer Affairs&Business Regulation License: CS-055288fOPJIE IMPROVEMENT CONTRACTOR Type: Construction Supervisor lm egistration: 111089 . t �' Expiration: 11/251201.6 Partnership TIMOTHY R QUINLAN 1 SAINT ONGE TERR QUINLAN&RAND BUILDERS HAVERHILL MA 01830 TIMOTHY QUINLAN i 34 TRINITY CT a CN ANDOVER,MA 01845 Undersecretary ^^^ Expi ration: Commissioner 03/05/2018 DATE: JUNE 20, 2013 F �; REVISIONS: FRANK & GILES II LAND CONSULTING . � 73 FERN STREET » FAULKNER ROAD SCALE: I INCH=20 FEET LAWRENCF , MA 01841st o OP SITE:X � 4C 01 20 40 978-975-2059 SURVO c; FrankGiles �6rncast.net �i JUNE 20 2013 LOCUS 4 NTS PLOT PLAN OF LAND ZONING DISTRICT R4 SUBJECT PROPERTY LOCATION MICHELLE CRANSTON 17 FAULKNER ROAD 17 FAULK 4ER ROAD NORTH ANDOVER, MA, 01845 NORTH ANDOVER, MA. 01845 BOOK 4882,PAGE 223 PREPARED FOR MAP 33 LOT 14 MICHELLE A. CRANSTON SEE PLAN#409 MAP 33 LOT 21 MAP 33 LOT 20 N 6 °43'30'' W 50.44' I e' SIZED 101 oo 110 `! X MAP 33 LOT 14 8,000 S.F. W z -A 0 00 PROPOSED Vii-k 44 i'OT 20 �� 1:.:_i i' / MAY 33 LQ 15 Ll__LLL j EXIST. 1 STORY j S INGLE FAMILY DWELL HSE,/#1 TOTAL CURVE DATA: Delta=43°38' Radius=368.0' Q % .� A. Length=280.25' ' \ 'I FRONTAGE=72.13' ----- . - I - _ D=11°-13'-50" R=368.0' L=72.13' -:_...--- ------ — FAULKN -D AD O THE LOCATION OF TITE BUILDING AS SHOWN HEREON EITHER WAS IN COMPLIANCE WITH . THE LOCAL ZONING BY LAW IN EFFECT WHEN CONSTRUCTED(WITH RESPECT TO SETBACK REQUIREMENTS ONLY)OR IS EXEMPT FROM VIOLATION ENFORCEMENT ACTION UNDER MASS G.IL.TITLE VII BUILDING CHAPTER 40A SECTION 7. THE OFFSETS SHOWN ARE FOR THE USE OF THE BUILDING INSPECTOR ONLY ANDS CH USE IS FOR THE DETERMINATION OF ZONING CONFORMITY OR NON-CONFORMITY WHEN CONSTRUCTED. I declare I at this plan and survey was done in accordance with the Procedural and Technical Standards for the practice of Land Su�, eying in the.Commonwealth of Wssachusetts. �-A14 'RANK S. GIMM lid.#41713 E:\LEXAR/MICHELLE CRANSTON\PLOT PLAN.DRG