HomeMy WebLinkAboutBuilding Permit #738-15 - 18 LYMAN ROAD 3/24/2015NORTH q
BUILDING PERMIT j?0e1tuao 1'a76ti�L
TOWN OF NORTH ANDOVER ° ;
2 APPLICATION FOR PLAN EXAMINATION ;;
Permit N0: 7 Date Received * ° +`
A�AATlD I'pP/(y
Date Issued: 9SSACHus��
IMPORTANT: Applicant must complete all items on this pate
LOCATION I Q t o Ao-ri 9J, N v r'tk hrAove r IVIS- 61 FL(S
' Print
PROPERTY OWNER W a'rC-Gk( CC (" ftl
Print
MAP NO: PARCEL:_„�Z— ZONING DISTRICT: Historic District yes
See of+A-cl,ed) Machine Shop Village yes
TYPE OF IMPROVEMENT
PROPOSED USE
Lrectr
Phone:
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
❑ Watershed District
^ater/Sewer
J—a IS: sVn .SPef1 4 ej L li L
n.
I
Identification Please Type or Print Clearly)
OWNER: Name: Mare.
ad 1...k-uytin
Lrectr
Phone:
Address: 1- LyAAuh
",
Nov -711 &dovu,
IIIA- 01V(r
CONTRACTOR Name:
Phone: 6Q3-7Sr-1fYA
Address: a
33 Coil -e_rre i)Q Pa gel is dam PST? #-� Ald 03ey1
Supervisor's Construction License: Exp. Date:
rs-®iO3113
Home Improvement License: OAC r G Exp. Date: /
ARCHITECT/ENGINEER�1�Phone: 97A'`14,S`�-(I36
Address: .'SJ A AIaQ.i%f&Ui) 9191&9Ahva.y A411- Reg. No. 6 3211
FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Coat: $ j s 3 4,i . d2 Q FEE: $
Check No.: Receipt No.: 0
NO, Persons 6ntracting with unregis-
tered contractors do not have access!to the guaranty fund
Sj�nature of Agent/Owner -�,C., A Signature of contractor -Z
`t BUILDING PERMIT
TOWN OF NORTH ANDOVER:...
APPLICATION FOR PLAN EXAMINATION
PROPERTY OWNER __
Priv 100 Year Structure yes. rio.
MAP _ PARCEL:_.__ _ _ ZONING DISTRICT:_._Historic District yes 11
Machine Shop Village ves .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 0 Well
❑ Floodplain ❑ Wetlands
❑ Watershed �,Distnct
D Water/Sewer
DESCRIPTION OF WORK TO BE PERFORMED:
Identification - Please Type or Print Clearly
OWNER: Name: Phone: '
AddrPsc-
ARCHITECT/ENGINEER Phone:
Address: Reg_ No
FEE SCHEDULE. BOLDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F.
Total Project Cost: $
FEE:
Chep -, o.: Receipt No.-,".
NOTE: Persons contracting with unregistered contractors do not: have: access to the guaranty fund
n
Signature of.Agent%Owner..........:. . : . . _ _ r Signature of�corit�actor.:: _
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
❑ Certified Surveyed Plot Plan
❑ Workers Comp Affidavit
❑ Photo Copy of H.I.C. And C.S.L. Licenses
❑ Copy Of Contract
❑ Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And
Hydraulic Calculations (If Applicable)
❑ Mass check Energy Compliance Report (If Applicable)
❑ Engineering Affidavits for Engineered products
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 2014
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
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION
COMMENTS
e
HEALTH
COMMENTS
b
Reviewed On Signature_
Reviewed on
Sianature
Reviewed on Signature
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Conservation Decision:
Comments
Comments
Water & Sewer Connection/Signature & Date Driveway Permit
DPW Town Engineer: Signature:
Located 384 Osgood Street
(FIRE bOAR{TMENT - � Femp Dumpster.on- site ,yes no
;LQcete kat 124 Main `Street
Fire cDepartmentz. ature/date
+C;OMMENTS._
Dimension
Number of Stories: Total square feet of floor area, based onExterior 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
NU I t5 and UA I A — (I -or department use
❑ Notified for pickup Call Email
Date Time Contact Name 3
3
Doc.Building Permit Revised 2014
F-
Location 8'
No. Date
TOWN OF NORTH ANDOVER
Certificate of Occupancy $
Building/Frame Permit Fee $
Foundation Permit Fee $ ,
Other Permit Fee $
TOTAL $
Check #
9 Building Inspector
Enter construction cost for fee cal -
North Andover Fee Cakulation
Construction Cost
m
$ -
$
184.64
Plumbing Fee
$
23.08
Gas Fee 100 comm.
$;
1:00-00
Electrical Fee
$
23.08
Total fees collected
$
330.81
18 Lyman Road
Kitchen Remodel
738-15 on 3/26/2015
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a REpIACEMENT SPECIALISTS
PO Box 606, Hampstead, NH 03841
603-759-44076i pre mode ing@comcast. net
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We propose to complete the following kitchen/dining area renovation at the home of Marc and Lauren
Credi, 18 Lyman Road, N. Andover, MA, 01845:
This quote includes necessary permits, liability and workers compensation insurance when
applicable, all related debris removal and daily and final job site cleanup.
SET UP AND DEMOLITION:
*Under the Federal EPA- RRP rule test for lead.
*Supply (1) 15 yard dumpster for all waste removal.
*Install dust control as needed to protect remainder of the home.
*Demo wall separation from kitchen to dining room. Approximately 11' height.
*Demo pantry closet at same location.
*Demo approx. 10" of wall at.side door entrance.
*Demo existing built- in corner china cabinet.
FRAMING:
*Install LVL beam and framing as needed (see specification sheet attached).
*Excavate and install (1) 24" x 24" x 12" concrete pad in basement at bearing point of LVL above.
*Install (1) steel cement filled lally column.
*Header between kitchen and dining area estimated to be approx. 11". To be determined when demo
of wall is complete. May be between 11" and 12", depending on existing ceiling strapping.
LVL AND ENGINEERING:
Allowance in original quote was $1,000 for LVL and engineering fees. Actual fees are $833. A credit
of $167 will be reflected in total job cost below.
ELECTRICAL:
*Allowance of $250 for pendant light over island. Material and labor is included in total job cost to
relocate one electrical switch by side entrance, provide GFCI power to island, pendant power supply,
installation of fixture, outlet conversion from 220V to 110V for new gas stove, (2) GFCI outlets
supplied and installed in new counter/cabinet unit as required by code. Arc -fault as required by the
Town of North Andover. Existing kitchen fan to be removed. A new recessed lighting plan will be
determined. Additional cans quoted at a rate of $150 per can. Additional cans will be priced as
necessary via change order when final layout is determined by homeowner and electrical contractor.
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WALL FINISHING:
*All plaster and new drywall application and blends to be applied with a combination drywall, tape and
USG compound.
FLOORING:
*Remove existing hardwood floor from front foyer to re -purpose.
*Prep area with'/" ACX underlayment, ready for tile. $5 per foot (material only) allowance is
supplied, including mortar and grout. Labor is carried elsewhere.
*I.nstall customer selected tile. Specialty patterns, designs and shapes may be additional. Allowance
of $5 per foot, including grout and mortar.
*Lace and weave re -purposed hardwood into kitchen as needed at wall void location. If hardwood
does not line up, a new plan will be presented and priced via change order (i.e. wood transition
piece). See below.
*Sand and finish dining and kitchen hardwood flooring approx. 350 sq. feet @ $3.50 per foot.
Includes 1 coat sand/seal, 2 coats poly.
TRIM WORK:
*Re -purpose trim removed from 1 opening (existing pantry) at side entrance new wall.
*New opening from kitchen to living room to be drywall with no trim. Trim option is an $870 additional
to contract price. This is an estimate as the profile could not be determined at this time. No crown
detail has been determined in the dining room. Trim option price can be utilized here if necessary.
Minimal modification of wine rack will be necessary to accommodate new refrigerator height.
CABINETS AND COUNTERS:
*An allowance of $3,500 was quoted for materials and labor in original quote. Homeowner is
purchasing all materials from The Home Depot. Price in final contract includes installation fee of
cabinets and crown only @ $1,100. Granite and installation priced through Home Depot.
PAINT PACKAGE:
*Paint all disturbed areas and dining walls, dining to match kitchen. color (paint supplied by owner)
and new trim only.
**Hardwood flat threshold transition piece from kitchen to dining area would allow for a no
tile/hardwood re -purpose option. Deduct $1,378 from total job cost to remove this option. Per
homeowner, first determine if existing kitchen hardwood and dining hardwood will align properly after
dividing wall is removed. If alignment cannot be achieved, a transition piece will be considered and
presented as an option. The current project price will be adjusted via change order to reflect the
change in flooring specs.
**Please read and sign attached Renovate Right Lead Paint Hazard Information as required by law.
TOTAL PROJECT COST: $15,387.20
Homeowner - -2
- / -
-- " - -- Date: �i �`ilfi-�
M
am ISS+LAl11TD map
'TU�Ct Err srE�rx
PO Box 606, Hampstead, NH 03841
fbipremodeling@comcast.net c:603-759-4407
mpibremodeling@comcast.net c: 603-321-7814
PAYMENT SCHEDULE
Total Job Cost: $15,387.20
Initial Deposit: $9,000
End of Week One: $4,000
Project Completion: $2,000
Punch List Complete: $387.20
EXPECTED TIMELINE
Week 1 (1 week includes 5 business days):
Install dust control.
Excavation of basement slab and pour concrete.
Demo of separating wall into dining area.
Evaluation of chimney condition, availability of hardwood flooring for repurpose, crown
availability for dining area, and plan accordingly.
Framing, install LVL, install Lally Column.
Town Inspections.
Rough electrical. Determine recessed can layout.
Insulation and start of drywall.
Cabinet Preparation and inspection.
Week 2:
Drywall complete.
Set cabinets, schedule granite template.
Install crown and trim.
Paint.
Remove appliances as needed for proper flooring finish
Wood flooring (sand, coat).
Plumbing by other for gas stove.
Week 3:
Punch list as needed.
Appliance installation by other (if flooring not ready in week 2)
Homeowner initials: / ZLt'y ry- 20'r
1
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& R PJ,AGEMENT SPECIALISTS
PO Box 606, Hampstead, NH 03841
603-759-4407
fbipremodelinqc@comcast.net
CLIENTS PLEASE READ ALL ITEMS CAREFULLY AND SIGN BELOW:
DUMPSTER STORAGE:
A dumpster may be stored on site for the duration of your project. A homeowner's specified location will be
accommodated whenever possible. Dumpster waste removal and storage has been priced for demolition of items listed in
your contract only. If additional waste removal is required due to homeowner requested change orders or unforeseen
contract changes, additional dumpster fees may apply; such as storage and waste removal fees. These fees will be
executed through a written change order, as necessary and to be approved by all homeowners.
PORTABLE TOILET:
A portable toilet may be stored on site for the duration of your project for the use of any employees and or subcontractors
of Big Island Pond Remodeling & Replacement Specialists. A homeowner's specified location will be accommodated
whenever possible. A portable toilet for this project has been priced the time frame estimated to complete the original
contract specifications. Additional storage fees may be applied if longer storage is required due to unforeseen damages
or contract changes, or homeowner requested change orders that extend the estimated time period of job completion.
These additional fees will be executed through a written change order as necessary, to be approved by all homeowners.
UFORSEEN DAMAGES AND CHANGE ORDERS:
Contract changes brought upon by hidden damages, unforeseen conditions, additional work required by the local building
inspector, and or homeowner requested changes shall always be executed through written change orders. It is the
responsibility of BIP Remodeling to price these changes and present the written change order to the homeowners in a
timely fashion. It is the responsibility of all homeowners to request all changes in writing (through email preferably),
carefully read and understand each change order, and sign each order. This contract price does not reflect unforeseen
conditions. Those costs will be over and above the total job cost outlined in your detailed contract.
CHANGE ORDERS CAN SIGNIFICANTLY AFFECT JOB PROGRESS AND ORIGINAL ESTIMATED TIME OF JOB
COMPLETION:
Change orders are to be paid in full prior to execution of the order, not at the end of the contract. Change orders shall not
affect the Progress Payment schedule outlined in your contract. All change orders are to be priced through BIP
Remodeling and not directly through subcontractors of BIP Remodeling, unless approved by all parties. Any work
contracted by the homeowner, directly through a subcontractor of BIP Remodeling shall not be warranted by BIP
Remodeling. Any work contracted as such shall be paid by the homeowner directly to the subcontractor. Any work
contracted directly by the homeowner, through a subcontractor of BIP Remodeling, shall have no effect on the Payment
Schedule outlined in your contract. Please be aware that these changes, although not contracted through BIP Remodeling
may affect the estimated job progress and contract completion time.
FIXTURE WARRANTIES:
BIP Remodeling removes itself from any liability of materials purchased by the homeowner outside of this contract and
contract specifications. In the event of a defective product or material purchased directly by the homeowner, the contract
warranty shall not cover labor of removal and or re -installation of such defective product or material. This labor and any
additional material needed shall be executed through a change order.
PERSONAL PROPERTY:
BIP Remodeling and its subcontractors will take all necessary means to protect the homeowner's personal property;
however, it can sometimes be difficult to protect all surfaces from the debris that can occur during the construction
process. Please remove or cover all personal property that may be sensitive to this debris/dust from the construction area
prior to the beginning of your renovation. Items can include all electronics, furniture that may be difficult to clean,
appliances, antiques, pictures and hanging fixtures on all construction walls, etc. Please make sure these items are stored
in an area where construction is not taking place. If storage space is limited, we encourage our homeowners to obtain a
storage pod when necessary. Furniture removal service can be provided by BIP Remodeling if the customer does not
have the means to move or cover such objects.
PAYMENT SCHEDULES:
Your payment schedule is outlined in your contract. Payments are due upon completion of each item. In some instances a
payment may be requested upon 90% completion. Progress payments within the Payment Schedule may not be in order
of job progress. They are arranged for efficiency in material purchases, subcontractor required deposits and payments,
etc. It is imperative for timely job completion that the Payment Schedule be followed. Change orders shall not affect
progress payments outlined in your Payment Schedule.
WEEKLY MEETINGS:
Weekly meetings are requested by BIP Remodeling with all homeowners present whenever possible. These meetings are
to discuss job progress, outline changes, discuss concerns that may arise throughout job progress, discuss change
orders, etc. The renovation process can be challenging for both the homeowners and contractor at times. It is very
important to maintain open and honest communication throughout these meetings to allow for timely project completion
and the full customer satisfaction we strive for. Email communication is important, however, it is encouraged that emails
not replace communication necessary in weekly meetings. Meetings can be declined if not necessary and if all parties
agree.
MANAGEMENT OF ITEMS NOT LISTED IN CONTRACT:
BIP Remodeling shall not be responsible for the management of any items not listed in contract. For example, items the
homeowner has decided to manage themselves such as.paint, flooring etc. If a homeowner would like to use their own
subcontractor, BIP Remodeling will collaborate with such subcontractor regarding schedules etc. Homeowners should be
aware that managing and utilizing their own subcontractors can affect job progress.
PUNCH LIST:
A punch list shall be compiled by the homeowner after the last payment outlined in your payment schedule has been
made and prior to the final payment.
NOT INCLUDED:
If an item is not included in the detailed contract, the homeowner should assume that the item is not included.
EXIT INTERVIEW:
A final meeting is requested by BIP Remodeling with the homeowner(s) to discuss all aspects of your project from start to
finish. This meeting is very important as it enables us to discuss your experience with our company, as well as help us
determine where we need to make improvements for future projects. Your input is very valuable.
I have read the terms stated above:
Homeowners Signature:
Homeowners Signatu
R Date: 2,t{ yy q, ,f%r" 2p I �;7
i Date:
D,
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g,E�MoDELI�N�
HOME IMPROVEMENT CONTRACT
This contract satisfies all basic requirements of the state's Home Improvement Contractor Law (MGI,c.142a).
HOMEOWNER INFORMATION
Homeowner Name: Marc and Lauren Credi
Address: 18 Lyman Road, N. Andover MA, 01845 a�
Phone: (DAYTIMEIEVENINGICELL) 617-335-0273
Email: mcredi@comcast.net
CONTRACTOR INFORMATION
Company Name: Big Island Pond Remodeling & Replacement Specialists
Address: PO Box 606, Hampstead, NH 03841
Phone: 603-759-4407
Email: fbipremodeling(aD-comcast.net mbipremodest.net
Construction Supervisors License#: 063173 HIC Registration#: 180419
WORK TO BE PERFORMED
CONTRACTOR AGEES TO PERFORM THE FOLLOWING: (Please initial that you have read the attached detailed quote)
Please see attached detailed quote
DATE WORK SCHEDULED TO BEGIN
(Barring unforeseen circumstances such as weather or permitting issues)
/Pre construction meeting scheduled March 27th 2015/
EXPECTED DATE OF COMPLETION
(Barring unforeseen circumstances such as weather and change orders)
/2 weeks from start date planned for April Vt/
-r
ACCELERATION OF PAYMENT
HOMEOWNERS FINANCIAL INSECURITY- A CONTRACTOR MAY NOT DEMAND PAYMENTS IN ADVANCE OF THE DATES SPECIFIED ON THE
PAYMENT SCHEDULE IN CASES WHERE THE HOMEOWNER DEEMS HIM/HERSELF TO BE FINANCIALLY INSECURE.
CONTRACTORS FINANCIAL INSECURITY- IN INSTANCES WHERE A CONTRACTOR DEEMS HIMSELF TO BE FINANCIALLY INSECURE, THE
CONTRACTOR MAY REQUIRE THAT THE BALANCE OF FUNDS NOT YET DUE BE PLACED IN A JOINT ESCROW ACCOUNT AS A
PREREQUISITE TO CONTINUING THE CONTRACTED WORK. WITHDRAWL FROM SAID ACCOUNT WOULD REQUIRE SIGNATURE OF BOTH
PARTIES.
NOTICE OF CANCELLATION
You may cancel this transaction without penalty or obligation within three business days from the above date.
If you cancel, any property traded in, any payments made by you under the contract or sale, and any negotiable
instruments executed by you will be returned within ten business days following receipt by the seller of your
cancellation notice, and.any interest arising out of the transaction will be cancelled.
If you cancel,; you must make available to the seller at your residence, in substantially as good condition as when
received, any goods delivered to you under this contract or sale; or you may, if you wish, comply with the
instructions of the seller regarding the return shipment of the goods at the seller's expense and risk.
If you do make the goods available to the seller and the seller does not pick them up within twenty days of the date
of cancellation, you may retain or dispose of the goods without any further obligation. If you fail to make the goods
available to the seller, or if you agree to return the goods to the seller and fail to do so, then you remain liable for
the performance of all obligations under this contract.
To cancel this transaction, mail or deliver a signed and dated copy of this cancellation notice or any other written
notice, or send a telegram to (Big Island Pond Remodeling & Replacement Specialists) at (PO Box 606,
Hampstead, NH 03841) not later than midnight of three business days following the signing of the agreement.
I hereby cancel this transaction.
Buyers Signature: Date:
93)
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
3y Boston, Massachusetts 02116
Home Improvement Contractor Registration
BIG ISLAND POND REMODELING
FREDERICK PAPPALARDO
P.O. BOX 606
HAMPSTEAD, NH 03841
SCA 1 iJ 20M-05/11
/4 VV "d?'M4ef
Office of Consumer Affairs & Business Regulation
Tx
ME IMPROVEMENT CONTRACTOR
gistration: :1"$0419 Type:
piration: -11/x.2/2016, LLC
BIG ISLAND POND REM DE ING�i'r
& REPLACEMENT SRECIAL=ISTS LLC.
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FREDERICK PAPPALARDO_r !:
33 COLLETTE DR.
HAMPSTEAD, NH 03841 ` Undersecretary
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Registration: 180419
Type: LLC
Expiration: 11/12/2016 Tr# 260307
Update Address and return card. Mark reason for change.
0 Address [:] Renewal ❑ Employment F] Lost Card
License or registration valid for individul use only
before the expiration date. If found return to:
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, MA 02116
Not valid without signature
i M.gssacl usetts-{Depa4rnertt7of #public Safety '
-Board of 13uilding Re,gtilatrons .and Sta»da.rds
a Xbristiuction Supenaso`r.'
License: CS-063173eV
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Frederick A Pappa}a`rdo ® ��
P.O BOX # 606
Hampstead NH 03841 rr
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579A North End Blvd.
Salisbury, MA 01952-1738
Phone 978.465.6436 (Fax 5160)
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579A North End Blvd.
Salisbury, MA 01952-1738
Phone 978.465.6436 (Fax 5160)
The Commonwealth of Massachusetts
Department of IndustrialAccidents
1 Congress Street, Suite 100
t
Boston, ALL 021142017
www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): &4 Is i oxuA ppb L Penna b -1 l ,NG
Address: Po Ra lob .3 3 t--cile-ae 6P . I-
City/State/Zip: N AM re &A AJ 0 a 3 6 g I Phone #:
.Are you an employer? Check the appropriate box:
1. 21fam a employer with I., i employees (full and/or part-time).*
2. ❑ I am a sole proprietor or partnership and have no employees working for me in
any capacity. [No workers' comp. insurance required.]
3. ❑ I am a homeowner doing all work myself. [No workers' comp. insurance required.] t
4. ❑ 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
proprietors with no employees.
5.❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet.
These sub -contractors have employees and have workers' comp. insurance.$
6. ❑ We are a corporation and its officers have exercised their right of 'exemption per MGL c.
152, §1(4), and we have no employees. [No workers' comp. insurance required.]
Type of project (required):
7. ❑ New construction
8. (?remodeling
9. ❑ Demolition
10 ❑ Building addition
11. ❑ Electrical repairs or additions
12.E] Plumbing repairs or additions
13. ❑ Roof repairs
14. ❑ Other
*Any applicant that checks box # 1 must also fill out the section below showing their workers' compensation policy information.
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 state whether or not those entities have
employees. If the sub -contractors have employees, they must provide their workers' comp. policy number.
I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: h TAA M 11TU IF,
Policy # or Self -ins. Lic. #;, Ely— 600 - yWo7 a 7 - P c I q A Expiration Date: Grp -,I-N -167,
Job Site Address: / 8 gym AN 0 City/State/Zip: AIAm .t. ��n atia.
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.
I do hereby ceWfy under the pains and penalties of perjury that the information provided above is true and correct.
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 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'
compensationi'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 burn 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-MASSAFE
Fax # 617-727-7749
Revised 02-23-15 www.mass.gov/dia
®Boise Cascade Double 1-3/4" x 11-1/4" VERSA -LAM@ 2.0 3100 SP Floor BeamlHeader two ply
BC CALC® Design Report Dry 11 span I No cantilevers 10/12 slope Saturday, March 07, 2015
Build 3272 File Name: BC
Job Name: Description: DesignslHeader two ply
Address: 18 Lyman Rd Specifier: Dan L Gelinas, PE ; Gelinas Structural Engineering LLC
City, State, Zip: North Andover, MA job 15024A Designer: 579A North End Blvd, Salisbury MA 01952
Customer: Big Island Pond Remodeling [Fred P] Company: ph 978.465.6436 [danlgelinas@comcast.net]
Code reports: ESR -1040 Misc:
Total Horizontal Product Length=12-06-00
Reaction Summary (Down / Uplift) ( lbs )
Bearing Live Dead Snow Wind Roof Live
BO, 3-1/2" 4,125/0 1,821/0
B1, 3-1/2" 4,125/0 1,821/0
Live Dead Snow Wind Roof Live Trib.
Load Summary
Tag
Description
Load Type
Ref. Start
End
100%
90% 115% 160% 125%
1
2nd
Unf. Area (Ib/ft^2)
L 00-00-00
12-06-00
40
10 12-06-00
2
wall
Unf. Area (Ib/ft^2)
L 00-00-00
12-06-00
0
10 07-06-00
3
attic
Unf. Area (lb/ft^2)
L 00-00-00
12-06-00
20
10 08-00-00
Controls Summary
Value
%Allowable Duration Case
Location
Pos. Moment
17,244 ft -lbs
89.8%
100%
1
06-03-00
End Shear
4,777 lbs
63.9%
100%
1
01-02-12
Total Load Defl.
L/267 (0.542")
90%
n/a
1
06-03-00
Live Load Defl.
L/384 (0.376")
93.7%
n/a
2
06-03-00
Max Defl.
0.542"
54.2%
n/a
1
06-03-00
Span / Depth
12.8
n/a
n/a
0
00-00-00
% Allow
% Allow
Bearing Supports
Dim. (L x W)
Value
Support
Member
Material
BO Post
3-1/2" x 3-1/2"
5,946 lbs
n/a
64.7%
Unspecified
B1 Post
3-1/2" x 3-1/2"
5,946 lbs
n/a
64.7%
Unspecified
Notes
Design meets Code minimum (L/240) Total load deflection criteria
Design meets Code minimum (U360) Live load deflection criteria.
Design meets arbitrary (1") Maximum total load deflection criteria.
Calculations assume Member is Fully Braced.
Design based on Dry Service Condition.
Deflections less than 1/8" were ignored in the results.
Page 1 of 2
OF
DANIEL L.
p GELINAS
U STRUCTURAL
No. 33994
X31 4
Job No. 15024A
Mar 7, 2015
®Boise Cascade Double 1-3/4" x 11-1/4" VERSA -LAM@ 2.0 3100 SP Floor BeamlHeader twoply
BC CALCI Design Report Dry 11 span I No cantilevers 10/12 slope Saturday, March 07, 2015
Build 3272 File Name: BC
Job Name: Description: Designs\Header two ply
Address: 18 Lyman Rd Specifier: Dan L Gelinas, PE ; Gelinas Structural Engineering LLC
City, State, Zip: North Andover, MAjob 15024A Designer: 579A North End Blvd, Salisbury MA 01952
Customer: Big Island Pond Remodeling [Fred P] Company: ph 978.465.6436 [danlgelinas@comcast.net]
Code reports: ESR -1040 Misc:
Connection Diagram Disclosure
b d Completeness and accuracy of input must
be verified by anyone who would rely on
a output as evidence of suitability for
c particular application. Output here based
on building code -accepted design
properties and analysis methods.
Installation of BOISE engineered wood
a ' ' 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 = 3-5/8" (800)232-0788 before installation.\n\nBC
b minimum = 3" d = 12" CALC@, BC FRAMER@ , AJS-,
ALLJOIST@ , BC RIM BOARD-, BCI@ ,
Calculated Side Load = 625.0 Ib/ft BOISE GLULAM- SIMPLE FRAMING
SYSTEM@, VERSA -LAM@, VERSA -RIM
Connectors are: 16d Sinker Nails PLUS@ , VERSA -RIM®,
VERSA -STRAND@, VERSA -STUD@ are
trademarks of Boise Cascade Wood
s� Products L.L.C.
y Y+f A 0 1 e
€ t� N ,SVA OF
v STS L,tir
3 94 DANIEL L. j1
;4 GELINAS
STRUCi URAL
fPp
No.33994 f -
Job No. 15024A
Mar 7, 2015
Page 2 of 2
®Solsecascade Quadruple 1-3/4" x 9-1/2" VERSA-LAM®2.0 3100 SP Floor BeamlHeader 4 ply
BC CALC® Design Report Dry 11 span I No cantilevers 10/12 slope Saturday, March 07, 2015
Build 3272 File Name: BC 15024A.bcc
Job Name: Description: Designs\Header 4 ply
Address: 18 Lyman Rd Specifier: Dan L Gelinas, PE ; Gelinas Structural Engineering LLC
City, State, Zip: North Andover, MA job 15024A Designer: 579A North End Blvd, Salisbury MA 01952
Customer: Big Island Pond Remodeling [Fred P] Company: ph 978.465.6436 [danlgelinas@comcast.net]
Code reports: ESR -1040 Misc:
Total Horizontal Product Length=12-06-00
Reaction Summary (Down / Uplift) ( lbs )
Bearing Live Dead Snow Wind Roof Live
B0, 3-1/2" 4,125/0 1,870/0
B1, 3-1/2" 4,125/0 1,870/0
Live Dead Snow Wind Roof Live Trib.
Load Summary
Tag Description Load Type Ref. Start End 100% 90% 115% 160% 125%
1 2nd Unf. Area (Ib/ft42) L 00-00-00 12-06-00 40 10 12-06-00
2 wall Unf. Area (Ib/ft"2) L 00-00-00 12-06-00 0 10 OF 07-06-00
3 attic Unf. Area (Ib/ft^2) L 00-00-00 12-06-00 20 10��-�M 08-00-00
L.
G0`
Controls Summary Value %Allowable Duration Case Location DANIEL ANIELGELIN,S
Pos. Moment 17,387 ft -lbs 62.3% 100% 1 06-03-00 o STRUCTURAL
End Shear 4,956 lbs 39.2% 100% 1 01-01-00 No. 339N
Total Load Defl. U319 (0.454") 75.4% n/a 1 06-03-00
Live Load Defl. L/463 (0.312") 77.8% n/a 2 06-03-00 ° R
Max Defl. 0.454" 45.4% n/a 1 06-03-00 t
Span / Depth 15.2 n/a n/a 0 00-00-00
$U %Allow %Allow
Bearing
g pports Dim. (L x W) Value Support Member Material
BO Post 3-1/2" x 3-1/2" 5,995 lbs n/a 65.3% Unspecified Y 3Aft ,L i,_ .°
B1 Post 3-1/2" x 3-1/2" 5,995 lbs n/a 65.3% Unspecified ` 'E > i w
u S RuCI PAI_ I
Cautions ;,,. 33
Member is not fully supported at post B0. A connector is required at this bearing. . V,
Member is not fully supported at post B1. A connector is required at this bearing.
Notes
Design meets Code minimum (L/240) Total load deflection criteria.
Design meets Code minimum (L/360) Live load deflection criteria. Job NO. 15024A
Design meets arbitrary (I") Maximum total load deflection criteria.
Calculations assume Member is Fully Braced. Mar %, 2015
Design based on Dry Service Condition.
Deflections less than 1/8" were ignored in the results.
Fastener Manufacturer: Simpson Strong -Tie, Inc.
User Notes
2 ply center bearign \only allowed
as in 3-1/2 x 3-1/2 bearing
Page 1 of 2
®Boise Cascade Quadruple 1-3/4" x 9-1/2" VERSA -LAM® 2.0 3100 SP Floor BeamlHeader 4 ply
BC CALC® Design Report Dry 11 span I No cantilevers 10/12 slope Saturday, March 07, 2015
Build 3272 File Name: BC 15024A.bcc
Job Name: Description: DesignslHeader 4 ply
Address: 18 Lyman Rd Specifier: Dan L Gelinas, PE ; Gelinas Structural Engineering LLC
City, State, Zip: North Andover, MA job 15024A Designer: 579A North End Blvd, Salisbury MA 01952
Customer: Big Island Pond Remodeling [Fred P] Company: ph 978.465.6436 [danlgelinas@comcast.net]
Code reports: ESR -1040 Misc:
Connection Diagram
+ b
a
C
a minimum = 1-1/2"c = 6-1/2"
b minimum = 6" d = 12"
e minimum = 1"
Calculated Side Load = 625.0 Ib/ft
Beams 7 inches wide will be assumed to be either top -loaded only, or equally loaded from
each side.
Install Screws with screw heads in the loaded ply.
Connectors are: SDW22634
Page 2 of 2
Disclosure
Completeness and accuracy of input must
be verified by anyone who would rely on
output as evidence of suitability for
particular application. Output here based
on building code -accepted design
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
(800)232-0788 before install ation.lnlnBC
CALC@, BC FRAMER@) , AJSTM,
ALLJOISTO , BC RIM BOARD-, BCIO ,
BOISE GLULAMTM, SIMPLE FRAMING
SYSTEM@ , VERSA -LAM@, VERSA -RIM
PLUS@ , VERSA -RIM@),
VERSA -STRAND@, VERSA -STUD@ are
trademarks of Boise Cascade Wood
Products L,L.C.
y�rt tJ�
"# DANIEL L.
GELINAS
r �m
� 11Ni
�ey..Y �,. O
G �i U STRUk i URAL
AST, R UC i J ,AL � t No. 33994
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Job No. 15024A
Mar 7, 2015
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