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HomeMy WebLinkAboutBuilding Permit #67 - 18 MOLLY TOWNE ROAD 7/25/2007V I Permit N0: j Date Issued: / IP- BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Date Received TYPE OF IMPROVEMENT PROPOSED USE Ver �•� f! g i�'1') f;1 © IR30 :CONTRACTOR Namerts Residential Non- Residential New Building One family Addition Two or more family Industrial Alteration No. of units: Commercial Others: Repair, replacement Assessory Bldg Demolition Other Sepfic INeJI Floodplaing, -Wetlands Watershed Dist .1 Water/Sewer I wn UT YVUKR 1 U t5 tt,F'KtF'URMED: anra5ey naei v r?o� zt i So mq� e- P�aT y� OWNER: Name: Clearly) C 78 3SS6 g8r1f Address: i95t ^c4rat� wa tl Ver �•� f! g i�'1') f;1 © IR30 :CONTRACTOR Namerts Address:: IperAsers. Construction License: _ Exp, Da#e '" '` c08,.: .. Horne Improvement Ucense `Exp. Date.* ARCHITECT/ENGINEER 94-U,06 . kSOc'A7Qs Phone: fC 7g (0$311S 3 Address: ,2a &-r k If y f2oAA . iN - 4o,A • r ASS Reg. No. 3 3 4 J Lf FEE SCHEDULE: BOLDING PERMIT. $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. 5r� ��� Total Project Cost: $ FEE: $ Check No.: 4a O Receipt No.: NOTE: Persons contracting with unregistered contractors do not have access to the -euaranty fund Plans Submitted Plans Waived Certified Plot Plan Stamped Plans J TYPE OF SEWERAGE DISPOSAL Public Sewer I/ Tanning/Massage/Body Art Swimming Pools Well Tobacco Sales Food Packaging/Sales Private (septic tank, etc. Permanent Dumpster on Site THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED PLANNING & DEVELOPMENT COMMENTS ECTED CONSERVA COMMENTS DATE APPROVED 2 f e -ti to-: 7 DATE APPROVED DATE REJECTED DATE APPROVED HEALTH COMMENTS r'%ti ��✓ Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Conservation Decision: Water & Sewer Connection/S Located at 384 Osgood Street Comments FIi E DEPARTMENT -hemp DUrn on site yes ' Located at -124. Maui Street fire ; rtm. slignaureldate: ' COMMENTS no Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Y L/ 18 Total land area, sq. ft.: �-S� CP 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 — ❑ Notified for pickup - Date Doc.Building Permit Revised 2007 nt use 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/Crossection/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: INSPECTIONAL SERVICES DEPARTMENT:BPFORM07 Revised 2.2007 ^4o Location No. % Date '712 NpRTM TOWN OF NORTH ANDOVER f Occupancy $ / 00 Certificate of bens �. �SSACNUSEt� Building/Frame Permit Fee $ b.27. Foundation Permit Fee $ 166— Other Permit Fee $ TOTAL $ 7 Check # .Z 6'v 204,�b Building Inspector CERTIFICATE OF /SEOCCUPANCY TOWN OF NORTH ANDOVER Permit # 67 (7/25/2007), Date: Aumast 14.2008 THIS CERTIFIES THAT THE BUILDING LOCATED ON 18 Moll3 wne Road MAY BE OCCUPIED AS Single Family Dwelling IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: North Andover Realty Corp 459 East Broadway Haverhill MA 01830 Building Inspector ***a 0 0 z C/) 0 Cf) l�A 40. Z3 O E O O CA CM CO3 co .co) CD g cm a) 0 CD L- CL I-- = CD C L) Q cc C CL CL 0- cm< CO2 On = en —j C. 0 V3 CD C.) C CL 0 -1 -:Z W f, <) 0�4 Z,4 0-4 Al �' o C-3 a a d CLC cc 0 4�, cz I'Ai >- ; Vk v W cc 0 Va. u 'm C:F C/) 0 Cf) l�A 40. Z3 O E O O CA CM CO3 co .co) CD g cm a) 0 CD L- CL I-- = CD C L) Q cc C CL CL 0- cm< CO2 On = en —j C. 0 V3 CD C.) C CL 0 -1 C o C-3 CLC cc 0 o cc 'm C:F ts 0 CL. 7n L cm 29 C2 Cos MA N ca N; N;: 0.3 CO ccm cc co =C3 CLC.3 CD CD Me 4D So cm ��o CL cm CD :gym= CD =3: Cc 0601.- CD CO) cr-, =4D • AD 16 Wr= OLD C=L -Z z CD c 3 -0 coa Sm C3 CL C/) 0 Cf) l�A 40. Z3 O E O O CA CM CO3 co .co) CD g cm a) 0 CD L- CL I-- = CD C L) Q cc C CL CL 0- cm< CO2 On = en —j C. 0 V3 CD C.) C CL 0 -1 q-18 9- 7,' - � Z -7 6 APPLICATION FOR CERTIFICATE OF OCCUPANCY/INSPECTION Building Permit # ADDRESSILOCATION OF PROPERTY:. S I '� Ae >? Map 5� Parcel o -RU Lot Number 1 A SUBDIVISION 1A �Jtm A ( So, DATE REQUESTED FILED/READY FOR INSPECTION d 8 CLOSING DATE ON PROPERTY:_ FIVE (51 DAYS NOTICE PRIOR TO CLOSING DATE IS REQUIRED ALL WORK AND SIGN -OFFS MUST BE COMPLETED WITHIN THIS TIME FRAME. A RE- INSPECTION FEE OF TWENTY DOLLARS $20.00) WILL BE CHARGED IF TNF ATRi IrTI im: DOES NOT MEET ALL APPLICABLE CODES Permit Issued to: Address 2, O ? SIGNED ROUTING CONSERVATION Vo � PLANNING qAlo� DPW -WATER METER 6,D 8/6[0� SEWERIWATER CONNECTION NOTE DPW MUST INDICATE THAT THE WATER METER HAS BEEN INSTALLED PRIOR TO SUBMITTAL OF THE OCCUPANCY/INSPECTION REQUEST DPW 44� Signature File: Application for OC form revised Jan 2007 *� e CHRISTIANSEN & SER�I, INC. PRPLgSSIONAL ENGINEERS AND LANG} SURVEyi)nS 160 SUA9thFR STREET, HAVLRHII.�, Md, 01L".i0-B�18 (973)373.4;310 FAX: (9T8)3T2.3960 Juiy .2 2, 2008 I41s.-Judy Tya►an, Town Planner Town of North Andover Planning Department 1600 Osgood. Street No Andave.r, IMA 01.845 Re: ;Y 18 'Nfolly Towne Road (Lot 7 "Awumn Chase" Dear Mls. Tynan; In accordance with Condition 412a of the ARD Special permit Approval issue.( by the Planning Board, I hereby rectify that the building and site layout on Bot 7 substantially co.raply with tl?c platts approved by the Planning Board. Very truly. yours, Christi sen & Ser, Inc. Plc. • hrisnansei� James Carroll, Nortb An tit, f , EASEMENT \ X LOT 6 \ \ LOT 7 EXISTING FOUNDATION ELEV. =208.9' lon 0 oo� LOT 8 ZONING DISTRICT R-2 Q MIN. AREA = 21,780 S.F. MIN. LOT WIDTH = 100' MIN. FRONTAGE = 100' MIN. FRONT SETBACK = 20' MIN. SIDE SETBACK* = 20' MIN. REAR SETBACK = 20' (* — THE STRUCTURE MAY BE PLACED UPON A SIDE LOT LINE WITHOUT A SIDE ^ SETBACK, PROVIDED THAT THE ADJACENT LOT TO WHICH THE ZERO SETBACK IS LOCATED HAS THE REQUIRED SIDE YARD SETBACK.) FOUNDATION LOCATION PLAN CLIENT: NORTH ANDOVER REALTY THIS CERTIFICATION IS MADE AND LIMITED TO THE ABOVE CLIENT. LOCATION: MOLLY TOWN RD, NORTH ANDOVER, MA. SCALE: 1 " = 60' DATE: 08/02/07 I CERTIFY THAT THE PRIMARY STRUCTURE SHOWN CONFORMS TO THE HORIZONTAL SETBACK REQUIREMENTS OF THE LOCAL APPLICABLE ZONING BY-LAWS IN EFFECT WHEN CONSTRUCTED. (THIS CERTIFICATION DOES NOT CONSIDER ANY OTHER RESTRICTIONS SUCH AS COVENANTS,WETLANDS,EASEMENTS, ORDERS OF CONDITIONS,ETC.) THIS DRAWING SHALL NOT BE USED BY THE CLIENT FOR ANY PURPOSE OTHER THAN THAT OUTLINED ABOVE,EXCEPT WITH THE WRITTEN PERMISSION OF CHRISTIANSEN R SERGI INC. FURTHERMORE THIS DRAWING IS THE COPYRIGHTED PROPERTY OF CHRISTIANSEN & SERGI 114 lb% MANY UNAUTHORIZED USE IS PROHIBITED.CHRISTIAN �>�R4Y_ TAKES. NO RESPONSIBILITY FOR THE UNAUTHORIZE �i -T}8S DROkG OR ANY INFOR- uennM rnuTAiucn u CHRISTIANSENSERGI PROF SIOSNUAL EYORS NGINEERS LAN160 SUMMER ST. HAVERHILL,MA. 01830 TEL. 978-373-0310 @2007 BY CHRISTiANSEN & SERGI INC. MICHX. No. DRAWING NO. 97066010 EASEMENT LOT 6 \ \ LOT 7 EXISTING FOUNDATION ELEV. =208.9' o �'� \ 322 LOT 8 ZONING DISTRICT R-2 Q MIN. AREA = 21,780 S.F. MIN. LOT WIDTH = 100' MIN. FRONTAGE = 100' M/N. FRONT SETBACK = 20' MIN. SIDE SETBACK* = 20' M/N. REAR SETBACK = 20' (* — THE STRUCTURE MAY BE PLACED UPON A SIDE LOT LINE WITHOUT A SIDE SETBACK, PROVIDED THAT THE ADJACENT LOT TO WHICH THE ZERO SETBACK /S LOCATED HAS THE REQUIRED SIDE YARD SETBACK.) FOUNDATION LOCATION PLAN CLIENT. NORTH ANDOVER REALTY THIS CERTIFICATION /S MADE AND LIMITED TO THE ABOVE CLIENT. LOCAT/ON., MOLLY TOWN R0, NORTH ANDOVER, MA. SCALE: 1 " = 60' DATE: 08/02/07 I CERTIFY THAT THE PRIMARY STRUCTURE SHOWN CONFORMS TO THE HORIZONTAL SETBACK REQUIREMENTS OF THE LOCAL APPLICABLE ZONING BY-LAWS /N EFFECT WHEN CONSTRUCTED. (THIS CERTIFICATION DOES NOT CONSIDER ANY OTHER RESTRICTIONS SUCH AS COVENANTS,W£TLANDS,EAS£MENTS, ORDERS OF CONDITIONS,ETC.) THIS DRAWING SHALL NOT BE USED BY THE CLIENT FOR ANY PURPOSE OTHER THAN THAT OUTLINED ABOVE,EXCEPT WITH THE WRITTEN PERMISSION OF CHRISTIANSEN 8• SERGI INC. FURTHERMORE THIS DRAWING IS THE COPYRIGHTED PROPERTY OF CHRISTIANSEN & SERGI lW' tANY UNAUTHORIZED USE IS PROHIBITED.CHR/STIAN �>RCrJ TAKES, NO RESPONSIBILITY FOR THE UNAUTHORIZf F-fiHIS DRA G OR ANY INFOR- MATIDN M14TAtucn u CHRISTIANSENIQ SERGI PROFESSIONALENGINEERS LAND SUR160 SUMMER ST. HAVERHILL,MA. 01830 TEL. 978-373-0310 @2007 BY CHRISTIANSEN & SERGI INC. MIGHX. J. No. 3: �ES`• D s DRAWING N0. 97066010 07'22;'2008 08:'26 9'837239h13 ,NF'.Iai IGt�'9Etkl •�: '�,cR �T CHRISTI NSEN & SERGI, INC.. PROFESSIONAL ENOMEERS AND LAND SURVEYORS 160 SUMMER STREET, HAVERHILL, MA 018SO-6318 (573)3"73-T.310 FAX: (9T8)372.3960 July u2, 2008 Vis. Judy Tyrnan, Town Planner Town of Nortb Andover Planning Departrnent 1000 Osgood Street No Andover, MA 01345 Re: 018 i'3olly Towne Road (Lot '7 "Autumn Chase") Bear W Tyman In accordance wit's. Condition 412a of the PRD Special Permit Approval, issued. by the Planning Board.,1 hereby certify that the building and site layoiit on Lcir 7 substantially comply with the plans approved by the Planning Board, Vero truly yours, Christi . sen Ser Inc. ."° hristianser a �'-qISTIAN,"E.N i U ciV"t O.C. James Carmll, ?north An �� ' PAGE 02/02 6elina5 5hdural �ngineerinq LLC Daniel L. Gelinas, P.E. 579A North End Blvd. Salisbury, MA 01952-1738 December 20, 2007 Carroll Construction Jim Carroll 163 Highland Road Andover, MA 01810 cell 978.479.2776 fax 978.475.0942 phone 978.623.3386 Phone 978.465.6436 Fax 978.465.5160 email danlgelinas@adelphia.net Subject: Lot 7 - 18 Molly Town Road, North Andover, MA Dear Mr. Carroll: You have requested Gelinas Structural Engineering LLC (GSE) to comment on the framing for the above address. The framing satisfies the requirements of the Massachusetts State Building Code 6h Edition Chapter 36 and the design drawings. Please call with any questions Very Truly Yours, Daniel L. Gelinas, P.E. A -07903 Lot 7 - 18 Molly Town Road 12-20-07.doc DANIEL L. GELINAS v STRUCTURAL No. 33994 M 6elina5 5tmdural �ngineerinq LLC Daniel L. Gelinas, P.E. 579A North End Blvd. Salisbury, MA 01952-1738 December 20, 2007 Carroll Construction Phone 978.465.6436 Fax 978.465.5160 email danlgelinas@adelphia.net Jim Carroll cell 978.479.2776 163 Highland Road fax 978.475.0942 Andover, MA 01810 phone 978.623.3386 Subject: Lot 7 - 18 Molly Town Road, North Andover, MA Dear Mr. Carroll: You have requested Gelinas Structural Engineering LLC (GSE) to comment on the framing for the above address. The framing satisfies the requirements of the Massachusetts State Building Code 6t' Edition Chapter 36 and the design drawings. Please call with any questions DANIEL L. GELINAS STRUCTURAL Very Truly Yours, No. 33994 ik Daniel L. Gelinas, P.E. A -07903 Lot 7 - 18 Molly Town Road 12-20-07.doc H d :p ®o C CD CA 0 ® n0 r CL y ® CD CD CL C7 a d1 CD CCD ® CCD CD WHa CD CL CA C CD CD zCD� 0 CD C o =0 -0 ? -O m Z N aCD a_ a o -0 y CD m C7 T) G y CD �C2 3 Z a-" ?-o N moi =r CL..0 a m CD =r m d O CO) CO) --4 O m a —.' OO n Z:S. n CD ►�, C ? H CL a � m R = car.• m o � c � c m co � y :� nco aCD: ♦� o m z as ch �'' • = VJ CCD m d Ham' 0 o O m H m C C CD cn cn CD } go �. GN. Vim: = OCD mmq- - C = I ", *=*T oni 0 9 0 � �' O z o ?.I D ^ O � m �,.� f: m :U O � c "-1 0 a- r 'z71 a- b w ro �� 0 � �' O z : .7 .0 Date ...... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ...................................... .......................................... has permission to perform .... ............ ....... wiring in the building of ....... ............. *....' at.— ........... ....... . North Andover, Mass. Lic. No. .......... A-1--?&- ELEcTRicAL NspEcToR . ............. Check # 61-19F . V 7 168 /?90 i N P -C\- Commonwealth of Massachusetts Official Use Only Permit No. %��0 Department of Fire Services a Occupancy and Fee Checked BOARD OF FIRE PREVENTION REGULATIONS [Rev. 9/05] (leave blank) APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: 12 -- 2 4VI ' 0/ City or Town of: i 1 , A * c>oyr ', To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to erform the electrical ork described below. Location (Street & Number) LOT -sl Owner or Tenant G/t1v TZitp, A,, J t;;raLge ri *,.J Telephone No. Owner's Address -:!:PAmf _ IJ? Lou Is this permit in conjunction with a building permit? Yes ' No ❑ (Check Appropriate Box) Purpose of Building Utility Authorization No. 7 3 Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service t90 Amps 120 / 140Volts Overhead ❑ Undgrd No. of Meters Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: LA l r4-1 W ( rel Gigli 141fze Completion of the following table may be waived by the Inspector of Wires. No. of Recessed LuminairesNo. Gni of Ceil.-Susp. (Paddle) Fans No. o Transformers Total KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires I jy Swimming Pool Above ❑ n-❑ rnd. grnd. o. of Lmergency Lighting Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches q -O No. of Gas Burners o. o Detection and Initiating Devices No. of Ranges ( No. of Air Cond. Tonal , D No. of Alerting Devices No. of Waste Disposers Heat Pump7'' umber ons ......................... o. of Self-contained Totals:......... Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ unicipal ❑ Other Connection No. of Dryers1 Heating Appliances KW Security Systems: No. of Devices or Equivalent No. of Water KW o. o No. o Data Wiring: Heaters Si ns Ballasts No. of Devices or Equivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or Equivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated'Value of Electrical Work: (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURAN E ❑ BOND ❑ OTHER ❑ (Specify:) I certify, under the pai s nd p !ties f perjury, that the information on d plication is true and complete. FIRM NAME: 1, I LIC. NO..&72992- Licensee: ,E;>! 0,0 Signature LIC. NO.: (If applicable, enter "exempt" in the license number line.)99 '' Bus. Tel. No.-*.7eP' pis, A b&I Address: -50 0.4 4) 041 sect�./� Alt. Tel. No.: *Security System Contractor License required for this work; if applicable, enter the license number here: OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent o Signature Telephone No. PERMIT FEE: $ BS�� l V( -z ptz7 L v - -, I 1 Iq 4L I 0-7i CERTIFICATE OF LIABILITY INSURANCE PROOUCER I —ILL4y 200: M.P. ROBERTS INS AGCY INC ONI YCANDFICONFERS SNO RIGHTS UPON D AS A MATTEROTHEN CERTIFICATE 1060 Osgood Street ALTER THE AFFOR ED BYYNOT THE POLEXTEND OR ICIES ES BELOW. North Andover, MA 01845 978 B$3-8073 INSURERS APFOROING COVERAGE INSURED NORTH ANDOVER NAIL# REALTY CORP. INSURER A,, 459 EAST BROADWAY INSURER 8: INSURER C: AAVERHILL, MA 01830 INSURCR D: I 97 - COVERAGE$ INSURER E: Fjj�tjTIJQI icE THE FOLICIRBAFINcIIaeMr-c cT�. ANY REQUIREMENT, OF ANY CONTRACT OR OTHER''m QrUN R ibUtO TO THE INSURED NAMED ABOVE FOR THE POLICYPERIOD INDICATED, NOTWITHSTANDING MAY PERTAIN, THE INS RRANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN ISENT SUBJECT 7ITH RESPECT AL,L THE TERMS, EXCLUSIONS AND C DMONS OF SUCCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, o'L tRAL LIABILITY COMMERCAL GENERAL LIABILITY _I CLAIMSMADE CI OCCUR GEN'L AGGREGATE LIMIT POLICY 7I PRO- JECT AUTOMOBILE LIABILITY —I ANYAUTO ALL OWNED AUTOS SCHEDULEDAUTOS HIREDAUTOS . �I NON.OWNEDAUTOS GARAGE LIABILITY �I ANYAUM EXCESS/UMBRELLA LIABILITY OCCUR 1_1 CLAIMSMADE D�lJCT18LE RETENTION S WCRf�FSC OMPENSATION AND I EG1PLoYCR5 LIA3ILITY nNYPA0P9lET0FVFARTNM'ExeavrrVE WC 683-35—$6 D OyRRCEzd.EMeER EXLUOIIDT SP1!; AL' RO�ntlaNS bvlvw jZET OPENING RIPTIONOFOPERATIONS/Lorrnnnlsn.cui , TOWN OF NORTH ANDOVER 400 OSGOOD STREET NORTH ANDOVER, MA 01845 ,CORD 26 (2001108) OccugAR3NCE PREMISES Pso occuren� S MED EK !Any one pe(son) S PGRSONAL&ADVINJURY b GENERAL AGGREGATE _ PROOVCTS-COMPIOPAGG S COMBINED SINGLE LIMIT ' {Faacatlanq BOOILYINJURY S (Per Parson) (A�aDocodonURY S E AWAG,E S AACCIDENT EAACC S A3,3 S 03/13/07 103/13/08 C 07/11/07 07/11/08 IPE: $10,000 JTISPECIAL PWAVIAln.. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE E)NRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 GAYSWRITTEN T NOTICE TO THE CERTIFICATE HOLLER NAMED TO THE LEFT, BUT FAILURE0 DO Sb SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR 0 TION 1988 ASN The Commonwealth of Massachusetts Department of Industrial Accidents `VRI 1. Office of Investigations 600 Washington Street Boston, MA 02111 _4 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information f� 1 Please Print Legibly Name(Business/Organization/Individual): 'North Wtyec QeAl (OC e. Address: City/State/Zip:1-6A,11 PM o l oo v Phone #: 5 -78 SS(- `i 8 -_� q Are u an employer? Check the appropriate box: 1. I am a employer with 1 4. ❑ I am a general contractor and I employees (full and/or part-time).* 2. ❑ I am a sole proprietor or partner- ship 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 have hired the sub -contractors listed on the attached sheet. $ These sub -contractors have workers' comp. insurance. ❑ 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): 6. �ew construction 7. ❑ Remodeling 8. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12.❑ Roof repairs 13.❑ Other *Any applicant that checks bot. must also fill out the section below showing their workers' compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. A ,� Insurance Company Name: �} Policy # or Self -ins. Lic. #:—W C 3 3 5 Expiration Date: 63-1,3-08 Job Site Address: Mo 114 iilwt PC9A t City/State/Zip: Ilk , 42,A(A d 10S Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereb&certify under the pains and penalties of perjury that the information provided above is true and correct. Phone #: U Q ?a :Sjsgo R8 3`/ 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' 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 Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia OZ Q > J Cv v C (D 0 - LU W :D Z Oz o p 0 v J 'J o n a C c r" cP c;i .-- O Z C) C o 0 0 CC) U tX N U J Z m LU— J � IrI :V• G I N W� p 0 N D �0 •. m � � Z I12, LL c _ lLL O � ° v ir N O .Y Z: r,� a N 3 uj G V. REScheck Software Version 3.7.3 Compliance Certificate Project Title: PLAN NO.3843 Report Date: 05/30/07 Data filename: C:\Program Files\Check\REScheck\PL3843.rck Energy Code: 2000 IECC Location: North Andover, Massachusetts Construction Type: Single Family Glazing Area Percentage: 16% Heating Degree Days: 6322 Construction Site: Permit Date: 3-5-03 Owner/Agent: Designer/Contractor: Permit # Permit Date <it� �3* td✓x : x E" -.a. .x- ut atFrtw,v s vs -mit, x x -r..,� r , a �Complianc' eP�asses�������` '� ,;Max�m�ur��UA�580�` �;Your,�HometUA49,8 � 14 1,/o BetterThan,-,Code�(tJA) Ceiling 1: Flat Ceiling or Scissor Truss: Wall 1: Wood Frame, 16" o.c.: Window 1: Vinyl Frame:Triple Pane with Low -E: Door 1: Solid: Basement Wall 1: Solid Concrete or Masonry: 2173 30.0 30.0 37 3145 13.0 13.0 123 492 0.350 172 96 0.350 34 2239 19.0 19.0 132 Compliance Statement. The proposed building design described here is consistent with the building plans, specifications, and other calculations submitted with the permit application. The proposed building has been designed to meet the 2000 IECC requirements in REScheck Version 3.7.3 and to comply with the mandatory requirements listed in the REScheck Inspection Checklist. A'2 1)7 Q/ � ':;�14 -&d4ilwil (a —M tFer'/Designer C mo pany Name Date Project Notes: Previously saved project information: COLONIAL HOUSE BRUNO ASSOC. 28 BERKELEY ROAD N ANDOVER MA 01845 PLAN NO.3843 Page 1 of 4 1 CREScheck Software Version 3.7.3 �(i Inspection Checklist Date: 05/30/07 Ceilings: ❑ Ceiling 1: Flat Ceiling or Scissor Truss, R-30.0 cavity + R-30.0 continuous insulation Comments: Above -Grade Walls: ❑ Wall 1: Wood Frame, 16" o.c., R-13.0 cavity + R-13.0 continuous insulation Comments: Basement Walls: ❑ Basement Wall 1: Solid Concrete or Masonry, 8.0' ht/7.0' bg/4.0' insul, R-19.0 cavity + R-19.0 continuous insulation Comments: Exterior insulation must have a rigid, opaque, weather -resistant protective covering that covers the exposed (above -grade) Insulation and extends at least 6 in. below grade. Windows: ❑ Window 1: Vinyl Frame:Triple Pane with Low -E, U -factor: 0.350 For windows without labeled U -factors, describe features: #Panes Comments: Frame Type Thermal Break? Yes No Doors: ❑ Door 1: Solid, U -factor: 0.350 Comments: Air Leakage: ❑ Joints, penetrations, and all other such openings in the building envelope that are sources of air leakage must be sealed. ❑ Recessed lights must be 1) Type IC rated, or 2) installed inside an appropriate air -tight assembly with a 0.5" clearance from combustible materials. If non -IC rated, the fixture must be installed with a 3" clearance from insulation. Vapor Retarder: ❑ Required on the warm -in -winter side of all non -vented framed ceilings, walls, and floors. Materials Identification: ❑ Materials and equipment must be installed in accordance with the manufacturer's installation instructions. L) Materials and equipment must be identified so that compliance can be determined. ❑ Manufacturer manuals for all installed heating and cooling equipment and service water heating equipment must be provided. ❑ Insulation R -values and glazing U -factors must be clearly marked on the building plans or specifications. Duct Insulation: ❑ Ducts in unconditioned spaces must be insulated to R-5. Ducts outside the building must be insulated to R-6.5. Duct Construction: ❑ All joints, seams, and connections must be securely fastened with welds, gaskets, mastics (adhesives), mastic -plus -embedded -fabric, or tapes. Tapes and mastics must be rated UL 181A or UL 181 B. Exception: Continuously welded and locking -type longitudinal joints and seams on ducts operating at less than 2 in. w.g. (500 Pa). ❑ The HVAC system must provide a means for balancing air and water systems. PLAN NO.3843 Page 2 of 4 Temperature Controls: ❑ Thermostats are required for each separate HVAC system. A manual or automatic means to partially restrict or shut off the heating and/or cooling input to each zone or floor shall be provided. Service Water Heating: ❑ Water heaters with vertical pipe risers must have a heat trap on both the inlet and outlet unless the water heater has an integral heat trap or is part of a circulating system. ❑ Insulate circulating hot water pipes to the levels in Table 1. Circulating Hot Water Systems: ❑ Insulate circulating hot water pipes to the levels in Table 1. Swimming Pools: ❑ All heated swimming pools must have an on/off heater switch and require a cover unless over 20% of the heating energy is from non-depletable sources. Pool pumps require a time clock. Heating and Cooling Piping Insulation: O HVAC piping conveying fluids above 105 degrees F or chilled fluids below 55 degrees F must be insulated to the levels in Table 2. PLAN NO.3843 Page 3 of 4 Y Table 1: Minimum Insulation Thickness for Circulating Hot Water Pipes Table 2: Minimum Insulation Thickness for HVAC Pipes Insulation Thickness in Inches by Pipe Sizes Insulation Thickness in Inches by Pipe Sizes Non -Circulating Runouts Circulating Mains and Runouts Heated Water Piping System Types Range ff) Temperature (°F) Up to 1" Up to 1.25" 1.5" to 2.0" Over 2" 170-180 0.5 1.0 1.5 2.0 140-169 0.5 0.5 1.0 1.5 100-139 0.5 0.5 0.5 1.0 Table 2: Minimum Insulation Thickness for HVAC Pipes NOTES TO FIELD: (Building Department Use Only) PLAN NO.3843 Page 4 of 4 Insulation Thickness in Inches by Pipe Sizes Fluid Temp. Piping System Types Range ff) 2" Runouts 1" and Less 1.25" to 2.0" 2.5" to 4" Heating Systems Low Pressure/Temperature 201-250 1.0 1.5 1.5 2.0 Low Temperature 120-200 0.5 1.0 1.0 1.5 Steam Condensate (for feed water) Any 1.0 1.0 1.5 2.0 Cooling Systems Chilled Water, Refrigerant and 40-55 0.5 0.5 0.75 1.0 Brine Below 40 1.0 1.0 1.5 1.5 NOTES TO FIELD: (Building Department Use Only) PLAN NO.3843 Page 4 of 4