The URL can be used to link to this page

Home My WebLink AboutBuilding Permit #493-2011 - 180 BERRY STREET 12/20/2010I BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit NO: �� Date Received / A Date Issued:4 IMPORTANT: Applicant must complete all items on this page O RTIC �N 0*�,(LED 16 0 2 y6 i a O LOCATION IJQ �e K-RY ST Print PROPERTY OWNER �<zNcrs o � i� �c,.PGr_1rseS L.+ -.e-- Print MAP 210 ' PARCEL: ZONING DISTRICT:_ Historic District. yes. Machine Shop Village yes o TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential IX New Building IKOne family ❑ Addition ❑ Two or more family ❑ Industrial ❑ Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other b Septic Well ❑ Floodplain ❑ Wetlands ❑ Watershed District. ❑ Water/Sewer DESUKIF I IUN Ur VVUMM i v 6a rr-mrumiviw. C0r15T72 UCT ^1 C of 5y,-GLL j q.� tLy /flJr�C= Identification Please Type or Print Clearly) OWNER: Name: KzN�s oar P,'01�FRrse-s Lz� - To.�y �e�-�z.oSR Phone: &o3-gyy �F'5 Address: dd T0a r=(VL(-s N Pt 0,�)0- 1 . .. CONTRACTOR Name: Phone- 3 " 9 y y _G3 Address: Pa 8 X 1 ie 1I0— Y �^� �'rt c S N # X385'% Supervisor's Construction License: Exp. Date: L ��/ AV Home Improvement License: Exp. Date: ' ARCHITECT/ENGINEER Phone: Address: 5^7y / �c/�.�lf �Nv �z�,v S�z�sB�,ey ,W//' Reg. No. FEE.SCHEPULE: BULDING PERMIT. $92.00$ R PER S.F. $1000.00 OF THE L TOTAL �c ESTIMATED COST BASED ON 3(o'�DOO, — FEE: $ / / 4 T Total Project Cost: $ f - Check No.: D�) Receipt No.: aak05" NOTE: Persons contracting with unregistered contractors -do not have access to the guar fund r'� '4:, --. .a..••h �''•.r*'t�.'s' r —mit Signature of Agent/Owner Signature of contractor F Location C r No 144 Date Id NORTH TOWN OF NORTH ANDOVER 3? .. '• O F s Certificate of Occupancy $� sACMUst<� Building/Frame Permit Fee $� y Foundation Permit Fee $0 Other Permit Fee $ TOTAL $ Check #a? 7/6 23EC;5 s Building Inspector Plans Submitted ❑ Plans Waived ❑ Certified Plot Plan ❑ Stamped Plans ❑ TYPE OF SEWERAGE DISPOSAL Public Sewer [4 Tanning/Massage/Body Art ❑ Swimming Pools ❑ Well Q Tobacco Sales ❑ Food Packaging/Sales ❑ Private (septic tank, etc. ❑ Permanent Dumpster on Site ❑ THE FOLLOWING SECTIONS FOR OFFICE USE ONLY INTERDEPARTMENTAL SIGN OFF - U FORM DATE REJECTED DATE APP OVED PLANNING & DEVELOPMENT ❑ f COMMENTS CONSERVATION Reviewed COMMENTS HEALTH COMMENTS Reviewed o r Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes Planning Board Decision: Comments Conservation Decision:. Comments Water & Sewer Connection/Signature & Da 12' Drivewa Permit fc"' 3e.-- $sTG (low DPW Town Engineer: Signature: Located 384 Osgood Street FIRE DEPARTMENT - Tem Du st' Temp yam- no— c Located at 124 Main Street { Fire Department sig nature/date: lU COMMENTS, - Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine NOTES and DATA — {For department use ® Notified for pickup - Date Doc.Building Permit Revised 2010/October _. 1►r•7 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 OTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit In all cases if a variance or special permit was required the Town Clerks office must stamp the decision from the Board of Appeals that the appeal period is over. The applicant must then get this recorded at the Registry of Deeds. One copy and proof of recording must be submitted with the building application Doc: Building Permit Revised 2008 9 BERRys TW'EE'T 180 Berry Street 14--/, v FOUNDA TION LOCA T/ON PLAN CLIENT- ANTHONY FRANCIOSA THIS CERTIFICATION IS MADEAND LIMTED T O THE ABOVE CLIENT LOCATION. NORTHANDOVER,MA. DATE. 1/6/11 SCALE: I"=40' 1 CERTIFY THAT THE PRIMARY STRUCTURE SHOWN CONFORMS TO THE HORIZONTAL SE7BACKREQUIREMENTS OF THE LOCAL APPUCABLEZONING BY-LAWS IN EFFECT WHEN CONSTRUCTED. (THIS CERTIFICATION DOES NOT CONSIDERANY OTHER RESTPJC77ONS SUCH AS COVENA)VTS, WETLANDS,EASEMENTS ORDERS OF CONDITIONS ETC) THIS DRAWING SHALL NOT BE USED BY THE CLIENT FOR ANY PURPOSE OTHER THAN THAT OUTUNED ABOVEEXCEPT W/TH THE WRITTEN PERMISSION OF CHRISTIANSEN B SERW INC. FURTHERMORE THIS DRAWING IS THE COPYRIGHTED PROPERTY OFCHR/STiANSENBSERGIINC . AND ANY UNAUTHORIZED USE IS PROHIBITED.CHRISTLANSEN A SERW TAKES NO RESPONSIBILITY FOR THE UNAUTHORIZED USE OF THIS DRAWING OR ANY INFOR- M4 TION CONTAINED HEREON. PROFESSIONAL ENGINEERS & LAND SURVEYORS CHRISTIANSEN & SERGI INC. 160 SUMMER STREET, HAVERHILL, MASSACHUSETTS 01830 WWW.CSI-ENGR.COM TEL. 978-373-0310 FAX 978-372-3960 D WG. NO.:10071.001.006 180 Berry Street FOU BERRY 149.9' LOT2 Exist. Fnd. =150.0' 50.1' Aer N LOCA TION PLAN CLIENT.ANTHONY FRANCIOSA THIS CERTIFICATION IS MADE AND UM?ED TO THEABOVE CLIENT LOCA TION.• NORTHANDOVER,MA. DATE. 1/6/11 SCALE. I"=40' 59.1. 4) 1p� /CERTIFY THAT THE PRIMARY STRUCTURE SHOWN CONFORMS TO THE HORIZONTAL SETBACKREQUIREMENTS OF THE LOCAL APPLIC.ABLEZONING 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 CHRIST14NSEN & SERGI INC. FURTHERMORE THIS DRAWING IS THE COPYRIGHTED PROPERTY OF CHRISnANSEN&SERGIINC . AND ANY UNAUTHORIZED USE IS PROHIBITED. CHRISTIANSEN & SERGI TAKES NO RESPONSIBILITY FOR THE UNAUTHORIZED USE OF THIS DRAWING OR ANY INFOR- MATION CONTAINED HEREON. PROFESSIONAL ENGINEERS & LAND SURVEYORS CHRISTIANSEN & SERGI, INC. 160 SUMMER STREET, HAVERHILL, MASSACHUSETTS 01830 WWW. CSI-ENGR.COM TEL. 978-373-0310 FAX 978-372-3960 D WG. NO.:10071.001.006 Lon K CERTIFICATE OF USE & OCCUPANCY Building Permit Number 493-2011 Date: June 30, 2011 THIS CERTIFIES THAT THE BUILDING LOCATED ON 180 Berm Street, Lot #2, North Andover, MA 01845 Kings Oak Properties, LLC MAY BE OCCUPIED AS single-family IN ACCORDANCE WITH THE PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER REGULATIONS AS MAY APPLY. Certificate Issued to: Fee: $100.00 Receipt: 23 805 Kings Oak Properties, LLC P.O. Box 166 Hampton Falls, N.H. 03844 , -, 9/' " , /' - � - Building Insp ctor .I. t T t Gehna5 5tactural �nqneerinq I. C Daniel L. Gelinas, P.E. 579A North End Blvd. Salisbury, MA 01952-1738 March 7, 2011 Anthony W. Franciosa III, President Kings Oak Properties, LLC PO Box 166 Hampton Falls NH 03084 Phone 978.465.6436 Fax 978.465.5160 email danlgelinas@comcast.net RE: Lot 2 Berry St., North Andover, MA Dear Mr. Franciosa: You have requested Gelinas Structural Engineering LLC (GSE) provide observations of the framing at the above address. The following are the results of our observations: Executive Summary: Provided the revisions are made as shown on Rev 1 Drawing 9 and SKSG-9A attached, the framing observed is substantially complete and satisfies the drawing requirements and the requirements of the Massachusetts State Building Code 7th Edition "One and Two Family Dwellings" DANIEL L. Very Truly Yours,`ci GELiNAS STRUCTURAL N0.33994 Da el lina G5 framing observations 10182.doc /QryA! E �� i ,GELINAS STRUCTURAL ENGINEERING LLCSHEETNO.� 579A North End Blvd.VW BYeL� bdr DATE�� Salisbury, MA 01952-1738 F ,9r FL r � 41 Phone: 978.465.6436 (Fax 5160) e-mail: danlgelinas@comcast.net JOB 16- 2i " sq, 1�V% 1ft, Reorder From NESS CUSTVM'printing service 1-80}8EB-6327 NESS, Inc, Peterborough, NH 03458 m atiebs.com P,ef. No: G 3333rn641 ^ S —9 f ^ —9 A 11 O w IN, 9 ►�Im 1�ivAit f I�oni�l 'p • ��i� ��ill�l • g 1.z MWtw r D ^ —9 A 11 O Z f 'p g 1.z r D e ^O L 1 N � L Fc r N pn V- q�— BERRY STREET FOUNDATION LOCATION PLAN CLIENT ANTHONY FRANCIOSA 7M8CBt DgCA77AM6M4WAWLMTM707MABOVECLeVT LOCATION.• 190 BERRY STREET NORTHANDOVERAIA. DATE.• 3/7111 SCALE.11=40' ACER7FY7H4T71EPY WjWSTRLACTVR SHOWNCOAOVRACB 7D 7WhVlR2QMrK SE7R4CXRE0(Iffa9NEW73OF7MLOCAL APPL.ACAB E2n11 M BYLAW AN EFFECT MOV OOAWnWJCYM MW 0827 M-4TAOV DOES NOT CONS@ ERANYOTMR RE37RIGT ow SUCHAS 00VBMAAT3, OWERS Of COMNYf MUM) ThMDRA*W SHALL NOrDE USW BY 7W CLMTFORANY PAI WMOPM THAN THAT ounkNED ABOVEDWgPTWTTHTHE WRITMP VOF Ct#WTWAMV 8 SSM AMG F7AR/iAMIDW TMS DR4MWIG 6 TWCOIPYAPJfTAOM FROPERTYOFCI+W MNSE AASERGYBVG AAVANY ~"09= USEISPR0ffiWMCAHBS7LAALSENd SSW TAKES AID RESPOAMUTYFOR nZ LD*UIIORf W USE OF IM DR4WBW CRANYPAV& NATJOVCONTARED iOWM .4 .r' PROFESSIONAL ENGINEERS & LAND SURVEYORS CHRISTIANSEN & SERGI; INC. 160 SUMMER STREET, HAVERHILL, MASSACHUSETTS 01830 WWW CSI-ENGItCOM TEL. 978.373-0310 FAX 97&372-3960 D WG. NO.:10071.001.006 100 BERRY STREET FOUNDATION LOCATION CLIENT.- ANTHONY FRANCIOSA 77MCfiRn An01NlSAWDEANDLWnV7C7WA8MFCLA3NT LOCATION. -190 BERRY STREET NORTHANDOVERMA DATF.- 3/7/11 SCALE.1 WO' CSi7FY711ATi EPRIINARY87RI1C1Lwavowm W TWHCJUMWALSE7R4WAEDVfU3ffAnOFDELWA APPLICA8LE2CSI WMAYOSN@qqsL7riewcoAwnwIC7m MW C9MFlrATALwWWN0TC0GVERAW07Mt 1i871ichON9 SUCHAS C0YENAN7 *fnANMfA88WENM ORDERS OFCOAVMVA XM) 7M M4W W Sl` U WTSfE USED 8Y7WCL9NTPORANYA OSEOPER77AW MT OU7LN® AOOW-ZRBPTW1W7W KNTMWP6WAOSIO 1OF CMB7MSE N d S9W W. ROi7hlER OW VW DRYI*M 0 771E COPYFJ MOM PROIPOV Y OF 0OWTfANSM & SOW # AWANYWMAM10RMUSENPROwl1W1MCf1wn4N WA SEW TAKM NO AFM 711E UNW"10002W USE OF"W DR4WMOR.4WMFUOi-YATMCONrA#WV#AML PROFESSIONAL ENGINEERS & LAND SURVEYORS CHRISTIANSEN & SERGI, INC. 160 SUMMER STREET, HAVERHILL, MASSACHUSETTS 01830 WWW.CSI-ENGftCOM TEL. 978-373-0310 FAX 978-372-3980 D WG. NO.:10071. 001.006 Energy Code: Location: Construction Type: Glazing Area Percentage: Heating Degree Days: Climate Zone: Construction Site: Lot 2 - Berry Street North Andover. MA REScheck Software Version 4.4.0 Compliance Certificate 20091ECC North Andover, Massachusetts Single Family 20% 6322 5 Owner/Agent: Compliance: 0.7% Better Than Code Maximum UA: 408 Your UA: 405 The % Better or Worse Than Code index reflects how dose to compliance the Crouse is based on code trade -of rules. It DOES NOT provide an estimate of energy use or cost relative to a minimum�code home. Designer/Contractor: Ceiling 1: Flat Ceiling or Scissor Truss 1468 38.0 0.0 44 Wall 1: Wood Frame, 16" o.c. 2688 21.0 0.0 122 Window 1: Vinyl Frame:Double Pane with Low -E 473 0.350 166 Door 1: Solid 20 0.190 4 Door 2: Glass 60 0.350 21 Floor 1: All -Wood JoistlTruss:Over Unconditioned Space 1468 30.0 0.0 48 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 2009 IECC requirements in REScheck Version 4.4.0 and to comply with the mandatory requirements listed in the REScheck insp ction Checklist. hvn- .,, AArx o Q Name - Title ignature Date Project Title: Report date: 12/07/10 Data filename: Untitled.rck Page 1 of 4 REScheck Software Version 4.4.0 Inspection Checklist Ceilings: ❑ Ceiling 1: Flat Ceiling or Scissor Truss, R-38.0 cavity insulation Comments: Above -Grade Walls: ❑ Wall 1: Wood Frame, 16" o.c., R-21.0 cavity insulation Comments: Windows: ❑ Window 1: Vinyl Frame:Double Pane with Low -E, U -factor: 0.350 For windows without labeled U -factors, describe features: #Panes _ Frame Type Thermal Break? _ Yes _ No Comments: Doors: ❑ Door 1: Solid, U -factor. 0.190 Comments: ❑ Door 2: Glass, U -factor: 0.350 Comments: Floors: ❑ Floor 1: All -Wood Joistlfruss:Over Unconditioned Space, R-30.0 cavity insulation Comments: Floor insulation is installed in permanent contact with the underside of the subfloor decking. Air Leakage: ❑ Joints (including rim joist junctions), attic access openings, penetrations, and all other such openings in the building envelope that are sources of air leakage are sealed with caulk, gasketed, weatherstripped or otherwise sealed with an air barrier material, suitable film or solid material. ❑ Air barrier and sealing exists on common walls between dwelling units, on exterior walls behind tubs/showers, and in openings between window/door jambs and framing. ❑ Recessed lights in the building thermal envelope are 1) type IC rated and ASTM E283 labeled and 2) sealed with a gasket or caulk between the housing and the interior wall or ceiling covering. ❑ Access doors separating conditioned from unconditioned space are weather-stripped and insulated (without insulation compression or damage) to at least the level of insulation on the surrounding surfaces. Where loose fill insulation exists, a baffle or retainer is installed to maintain insulation application. ❑ Wood -burning fireplaces have gasketed doors and outdoor combustion air. Air Sealing and Insulation: ❑ Building envelope air tightness and insulation installation complies by either 1) a post rough -in blower door test result of less than 7 ACH at 33.5 psf OR 2) the following items have been satisfied: (a) Air barriers and thermal barrier: Installed on outside of air -permeable insulation and breaks or joints in the air barrier are filled or repaired. (b) Ceiling/attic: Air barrier in any dropped ceiling/soffit is substantially aligned with insulation and any gaps are sealed. (c) Above -grade walls: Insulation is installed in substantial contact and continuous alignment with the building envelope air barrier. (d) Floors: Air barrier is installed at any exposed edge of insulation. (e) Plumbing and wiring: Insulation is placed between outside and pipes. Batt insulation is cut to fit around wiring and plumbing, or sprayed/blown insulation extends behind piping and wiring. M Comers, headers, narrow framing cavities, and rim joists are insulated. Project Title: Report date: 12/07!10 Data filename: Untitled.rck Page 2 of 4 (9) Shower/tub on exterior wall: Insulation exists between showers/tubs and exterior wall. Sunrooms: D Sunrooms that are thermally isolated from the building envelope have a maximum fenestration U -factor of 0.50 and the maximum skylight U -factor of 0.75. New windows and doors separating the sunroom from conditioned space meet the building thermal envelope requirements. Materials Identification and installation: Materials and equipment are installed in accordance with the manufacturer's installation instructions. ❑ insulation is installed in substantial contact with the surface being insulated and in a manner that achieves the rated R -value. Materials and equipment are identified so that compliance can be determined. Manufacturer manuals for all installed heating and cooling equipment and service water heating equipment have been provided. Insulation R -values and glazing U -factors are clearly marked on the building plans or specifications. Duct Insulation: Lj Supply ducts in attics are insulated to a minimum of R-8. All other ducts in unconditioned spaces or outside the building envelope are insulated to at least R -6 - Duct Construction and Testing: Building framing cavities are not used as supply ducts. All joints and seams of air ducts, air handlers, filter boxes, and building cavities used as return ducts are substantially airtight by means of tapes, mastics, liquid sealants, gasketing or other approved closure systems. Tapes, mastics, and fasteners are rated UL 181A or UL 181 B and are labeled according to the duct construction. Metal duct connections with equipment and/or fittings are mechanically fastened. Crimp joints for round metal ducts have a contact lap of at least 1 112 inches and are fastened with a minimum of three equally spaced sheet -metal screws. Exceptions: Joint and seams covered with spray polyurethane foam. Where a partially inaccessible duct connection exists, mechanical fasteners can be equally spaced on the exposed portion of the joint so as to prevent a hinge effect. Continuously welded and locking -type longitudinal joints and seams on ducts operating at less than 2 in. w.g_ (500 Pa). Duct tightness test has been performed and meets one of the following test criteria: (1) Postconstruction leakage to outdoors test: Less than or equal to 234.9 cfm (8 cfm per 100 ft2 of conditioned floor area). (2) Postconstruction total leakage test (including air handler enclosure): Less than or equal to 352.3 cfm (12 cfm per 100 ft2 of conditioned floor area) pressure differential of 0.1 inches w.g. (3) Rough -in total leakage test with air handler installed: Less than or equal to 176.2 cfm (6 cfrn per 100 ft2 of conditioned floor area) when tested at a pressure differential of 0.1 inches w.g. (4) Rough -in total leakage test without air handler installed: Less than or equal to 117.4 cfm (4 cfm per 100 ft2 of conditioned floor area). Heating and Cooling Equipment Sizing: C] Additional requirements for equipment sizing are included by an inspection for compliance with the International Residential Code. For systems serving multiple dwelling units documentation has been submitted demonstrating compliance with 2009 IECC Commercial Building Mechanical and/or Service Water Heating (Sections 503 and 504). Circulating Service Hot Water Systems: Circulating service hot water pipes are insulated to R-2. F1 Circulating service hot water systems include an automatic or accessible manual switch to turn off the circulating pump when the system is not in use. Heating and Cooling Piping Insulation: Lj HVAC piping conveying fluids above 105 degrees F or chilled fluids below 55 degrees F are insulated to R-3. Swimming Pools: ❑ Heated swimming pools have an on/off heater switch. Pool heaters operating on natural gas or LPG have an electronic pilot light. {� Timer switches on pool heaters and pumps are present. Exceptions: Where public health standards require continuous pump operation. Where pumps operate within solar- and/or waste -heat -recovery systems. 0 Heated swimming pools have a cover on or at the water surface. For pools heated over 90 degrees F (32 degrees C) the cover has a minimum insulation value of R-12. Project Title: ~' Report date: 12/07/10 Data filename: Untitled.rck Page 3 of 4 Exceptions: Covers are not required when 60% of the heating energy is from site -recovered energy or solar energy source. Lighting Requirements: E) A minimum of 50 percent of the lamps in permanently installed lighting fixtures can be categorized as one of the following: (a) Compact fluorescent (b) T-8 or smaller diameter linear fluorescent (c) 40 lumens per watt for lamp wattage <= 15 (d) 50 lumens per watt for lamp wattage > 15 and <= 40 (e) 60 lumens per watt for lamp wattage > 40 Other Requirements: ❑ Snow- and ice -melting systems with energy supplied from the service to a building shall include automatic controls capable of shutting off the system when a) the pavement temperature is above 50 degrees F, b) no precipitation is falling, and c) the outdoor temperature is above 40 degrees F (a manual shutoff control is also permitted to satisfy requirement'c'). Certificate: r-1 A permanent certificate is provided on or in the electrical distribution panel listing the predominant insulation R -values; window U -factors; type and efficiency of space -conditioning and water heating equipment. The certificate does not cover or obstruct the visibility of the circuit directory label, service disconnect label or other required labels. NOTES TO FIELD: (Building Department Use Only) Project Title: Report date: 12/07/10 Data filename: Untitled.rck Page 4 of 4 �(20091ECC Energy j Efficiency Certificate Ceiling / Roof 38.00 Wall 21.00 Floor I Foundation 30.00 Ductwork (unconditioned spaces): Gfass &"noorxfatmgFactor �SHGC Win.. �.::.s.,_. zK� � �.,.,�- �� .�. a�# ��_� F.. Y�.� s..��uWindow 0.35 0.70 Door 0.35 0.70 Heating System: Cooling System: Water Heater: Name: Date: Comments: *-! `tassachusetts - Department of Public Safet} Board of Building Rc�*>ilations and Standards Construction Supervisor License License: CS 59036 Restricted to: 00 li . f ANTHONY W FRANCIOSA 111 k PO BOX 166 i HAMPTON FALLS, NH 03844 C'��nunisiuner Expirltion: 11 Jj 7J2011 Tr#: 1601 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 pen -nit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sur&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 pen-nit/license number which will be used as a reference number. In addition, an applicant that must submit multiple pen-nit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future pen -nits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston} MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 5-26-05 www.mass.gov/dia l 0 8 0 z o :a CD o CD � :w C h : C� O ' � O V V CL C13 : A ev m os o � S --E a cn is L; • ` "r o •: :oar O C O o A: yr 4L • m c miE L ® a L o 42 3 _ c I y-- Y� c m J L�/• �' v y eo O �y W U L 'C � �m0.cm CLC-) L m CD r^ O C" (J) • r. r '" 'O C W '~ C "v' C ya � W p�Ct �O •O G � m 3V y O G c Z c ~a Q L h m C Q = O d Z W rCD P •H dZ O C Z o+r a. L .m a®ec g. y a c� �-CDmem �10 v 1 U 0 s' U P4 4.4 Qr 2 0 I O Cm C C N2CD 'fl LACD �O CO CO 0 co co .= Q 3� Clco Q m o a C .,, CMQ CO) C O CJ .�_ J 'a Q CD /C Z ts ai CL v C cv C v O LE v cn a U A a ° O u. O w v ,. U C w a o w � p w C ii. a w U w po rx cn w a o � d a2 - u:, z w w as ° cn Q cn o :a CD o CD � :w C h : C� O ' � O V V CL C13 : A ev m os o � S --E a cn is L; • ` "r o •: :oar O C O o A: yr 4L • m c miE L ® a L o 42 3 _ c I y-- Y� c m J L�/• �' v y eo O �y W U L 'C � �m0.cm CLC-) L m CD r^ O C" (J) • r. r '" 'O C W '~ C "v' C ya � W p�Ct �O •O G � m 3V y O G c Z c ~a Q L h m C Q = O d Z W rCD P •H dZ O C Z o+r a. L .m a®ec g. y a c� �-CDmem �10 v 1 U 0 s' U P4 4.4 Qr 2 0 I O Cm C C N2CD 'fl LACD �O CO CO 0 co co .= Q 3� Clco Q m o a C .,, CMQ CO) C O CJ .�_ J 'a Q CD /C Z ts ai CL v C cv C = a COP) I- Y♦ LLI Y♦ W W W U)