Loading...
HomeMy WebLinkAboutBuilding Permit #494-15 - 2 HAY MEADOW ROAD 11/21/2014BUILDING PERMIT TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit No#: Date Received . i l Date Issued: IMPORTANT: Applicant must complete all items on this LOCATION PROPERTY OWNER;L4 i�'U Print 100 Year Structure. yes no MAP PARCEL: ZONING DISTRICT: Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Residential Non- Residential ❑ New Building ❑ One family ❑ Addition ❑ Two or more family ❑Industrial ❑ Alteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg 0 Others: El Demolition ❑ Other _ ❑ Septic ❑ Well ❑ Floodplain ❑ Wetlands ❑ Watershed District ❑ Water/Sewer DESCRIPTION OF WUMM i U tst rtrcr�rcivitu: ,)IG:fiaY, / i,JaA4ken 1zvo,-,) \ Identification - Please Type or Print Clearly _ OWNER. Nam e: Phone: Contractor Name: Address: J/y J Supervisor's Construction License: 2164 +i'¢C' 4xp. Date: Home Improvement License: 111 f al, vva - Exp. Date - ARCHITECT/ENGINEER Phone: 4'' -2, > -- Io /G 'Al- 96 14 Address: Reg. No. FEE SCHEDULE: BULDING PERMIT: $12.00 PER $1000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. Total Project Cost: $ FEE: $ q ( Check No.: �. �� 2 Receipt No.:—a oZ NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund nature of Agent/Owner Signature of contr 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 Reviewed On COMMENTS CONSERVATION COMMENTS HEALTH �,OMMENTS. Reviewed on Signature. 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: FIRE DEPARTMENT - Temp Dumpster on site yes_ Located at 124 Main Street Fire Department signature/date COMMENTS Located 384 Osgood Street no Dimension Number of Stories: Total square feet of floor area, based on Exterior dimensions. Total land area, sq. ft.: ELECTRICAL: Movement of Meter location, mast or service drop requires approval of Electrical Inspector Yes No DANGER ZONE LITERATURE: Yes No MGL Chapter 166 Section 21A —F and G min.$100-$1000 fine imv i to ana LJA i A — (t -or department use ❑ Notified for pickup Call Email Date Time Contact Name Doc.Building Permit Revised 2014 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 Li Building Permit Application o Workers Comp Affidavit o Photo Copy Of H.I.C. And/Or C.S.L. Licenses L, Copy of Contract o Floor Plan Or Proposed Interior Work o Engineering Affidavits for Engineered products NOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks u Building Permit Application a Certified Surveyed Plot Plan o Workers Comp Affidavit u Photo Copy of H.I.C. And C.S.L. Licenses L, Copy Of Contract o Floor/Cross Section/Elevation Plan Of Proposed Work With Sprinkler Plan And Hydraulic Calculations (If Applicable) o Mass check Energy Compliance Report (If Applicable) o 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) Li Building Permit Application u Certified Proposed Plot Plan o Photo of H.I.C. And C.S.L. Licenses u Workers Comp Affidavit o Two Sets of Building Plans (One To Be Returned) to Include Sprinkler Plan And Hydraulic Calculations (If Applicable) Li Copy of Contract L, Mass check Energy Compliance Report L, 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 Location Mee, Date No.&fj'f Check #r L; J TOWN OF NORTH ANDOVER Certificate of Occupancy $ Building/Frame Permit Fee $ i Foundation Permit Fee $ Other Permit Fee $ TOTAL $j_= L2) Building Inspector The Commonwealth ofMassachusetts - Department of IndustriglAeeid nts Office of Investigations 600 Washington Street Boston, AIA 02111 -www mass gov/dia wQrkers' Compensation Insurance Affidavit: Builders/Contractors/El Pleas Print r Applicant Information , f Name (Business/Organizationllndividual):A9 t —rl Address:AxJkt/4- Caty/Sfa�e/Zip:77 Phone#•�0�� Are an employer? Cheekth� appropriate box: 4. El am a general contractor and I ram 1. a employer with employees .full and/or art -time) * have ned the sub -contractors 2. ❑ I am a sole proprietor or partner- listed on the attached sheet These sub -contractors have ship and'have no employees working me in any capacity. workers' comp. insurance. .for [No workers' comp. insurance 5. ❑ We area corporation and its officers have exercised their required.] 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no employees. [No workers' insurance required.] t comp. insurance required.] Type of project (required): 6. ❑ New construction j 7. 0 Remodeling S. ❑ Demolition 9. ❑ Building addition 10.❑ Electrical repairs or additions 11.❑ Plumbing repairs or additions 12. ❑ Roof repairs 13.❑ Other 'Any applicant that checks box#f mustalso fill outthe section below showing their workers' compensationpolicy information. [-Homeowners who submit this affidavit indicating they �'re doing all work and then hire outside contractors must submit a new affidavit indicating such. ?Contractors that cheAthis box mast attached an additional sheet showing the name of the sub -contractors and their workers' comp. pollcy information. X am an employer that is providing worlters' compensation insurance for my employees: Below is the policy and joh site information. Insurance Company Policy # or Self ins. Lic. #: Wt /�i V 7 4Y _Y/Y Expiration Date:. Job Site Address: City/State/Zip: Attach a copy of the workers' compensation -policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL o. 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 WORD ORDER and a fine of -up to $250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DTA for insurance coverage verification. X do Hereby cert antler tlaepains andpenalties ofpeYjury that the information provided above is true and correct. Official use Only. Do not write in this area, to be completer) 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. EIectrical 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 ofhire,- 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 aAcceased 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 Iicense 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 -contractors) 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 Departmenthas 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 (ifnecessary) 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 maybe 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 orpermit 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 ofYfassarhwetLq Departwmt dhadustdal AccUmts Offilco ofInvestigat iona 6QG Waslai &ji Strut Boston, MA Q.2l. 1 Z TOJ, #- 617-7.27 4900 at 40,6 ox k -877 -MASSA FF Revised 5-26-05 Fax 0 617-727-7749 urww=1agOV1Ma FDATE(MM/DDMYYY) CERTIFICATE OF LIABILITY INSURANCE06/03/2014 NO RIGHTS UPON THE CERTIFICATE HOLDER. T HIS THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS ALTER THE COVERAGE AFFORDED BY THE POLICIES CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR BETWEEN THE ISSUING INSURER(S), AUTHORIZED BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. If SUBROGATION IS WAIVED, subject to IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. does not confer rights to the :`m the terms and conditions of the policy, certain policies may require an endorsement A statement on this certificate � certificate holder in lieu of such endorsement(s). CONTACT PRODUCER NAME: Aon Risk Services central,. Inc. PHONE (866) 283-7122 FAX 800 363-0105 (A1C. No. Ext): (AIG. No.): -° 2 Southfield MI office E-MAIL ° 2 3000 Town Center ADDREss: Suite 3000 NAIL# Southfield MI 48075 USA INSURER(S) AFFORDING COVERAGE INSURER A: old Republic Insurance Company 24147 INSURED 1 Indemnity Insurance CO Of North America 43575 INSURER e: Builder services Group. Inc. ACE American Insurance company 22667 d/b/a Quality InsulationINSURER C: A Masco corporation Company ACE Fire Underwriters Insurance Co. 20702 110 Perimeter Road INSURER D: Nashua NH 03063-1301 USA INSURER E: INSURER F: CERTIFICATE NUMBER: 570054003261 REVISION NUMBER: COVERAGES ISSUED OVE FOR THE POLICY PERIOD TO THE INSURED NAMED AB THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. Limits shown are as requested EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS Iffg S POLICY NUMBER MMIDD/YYYY MM/DD/YYYY LIMITS LTR TYPE OF INSURANCE INSD WVD 14 1 $2,000,000 EACH OCCURRENCE MWZY5552S14 A X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $2,000,000 CLAIMS -MADE OCCUR PREMISES Ea occurrence 125,000 MED EXP (Any one person) PERSONAL B ADV INJURY $2,000,000 N GENERAL AGGREGATE $5,000,000 0 GEN'L AGGREGATE LIMITAPPLIES PER PRO- PRODUCTS -COMP/OP AGG $lO , OOO, OOO N X POLICY ❑ JECT F-1 LOC 0 OTHER - MwrB 18398-14 06/30/2014 06/30/2015 COMBINED SINGLE LIMIT $5,000,000 A AUTOMOBILE LIABILITY Ea accident ° BODILY INJURY ( Per person) Z X ANY AUTO BODILY INJURY (Per accident) d ALL OWNED SCHEDULED AUTOS PROPERTY DAMAGE @ U AUTOS X HIRED AUTOS X NON -OWNED Per accident) d AUTOS U EACH OCCURRENCE UMBRELLA LIAB OCCUR AGGREGATE H EXCESS LIAR CLAIMS -MADE L--fI DED RETENTION OT -b6/30/2014 06/30/2015 STATUTE ERH WLRC47$$$414 X B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY YIN Deductible - AOS E.L. EACH ACCIDENT $1,000,000 C ANY PROPRIETORIPARTNER/EXECUTIVE NIA WLRc47888402 06/30/2014 06/30/2015 E.L. DISEASE -EA EMPLOYEE S1,000,000 OFFICER/MEMBER EXCLUDED? Ded - CA, MA (Mandatory in NH) E.L. DISEASE -POLICY LIMIT $1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below $2 , 000, 000 06/30/2014 06/30/2015 Deductible — c Excess WC wcuc47888438 Included Self -Insured States Limit (1) SIR applies per policy terns & condi ions 22 DESCRIPTION OF OPERATIONS /LOCATIONS 1 VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Evidence of Insurance. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Builder Services Group, Inc. AUTHORIZED REPRESENTATIVE dba Quality Insulation Y/7 A Masco Corporation CompanyGX�O �c/ 110 Permieter Road 70o.c�(GYK/oaz — Nashua NH 03063 USA 1 ©1988-2014 ACORD CORPORATION. All rights reserved. The and logo are registered marks of ACORD ACORD 25 (2014/01) ACORD name �/ ''��.'"' Office of consumer Affairn B rness Regulatio s us n 10 Park Plaza - Suite 51.70 Boston, Massachusetts 02116 Home Improvement"Contractor Registration Registration: 179141 Type: Supplement Card Fmirntinn F1g517MA tSUILUCK :71=KVIUt5 UKUW-, IN RICHARD SCHWARTZ 110 PERIMETER RD NASHUA, NH 03063 'w Update Address and return carts. Mark reason for change. w' J ,address F-1 Renewal Employment Lost Card SCA 1 0 201%4 -MI 1 - fiice of Consumer Affairs & Business Regulation License or registration valid for individul use only ME IMPROVEMENT CONTRACTORbefore the expiration date. If found return to: Office of Consumer Affairs and Business Regulation 2egistration 179141 Type; 10 Park Plaza - Suite 5170 Expiratict .. 61 rs12D16; Supplement Card Boston, MA 02116 BUILDER SERVICES GROUP, INC. RICHARD SCi iWARTZ . ,; 260 JIMMY ANN DRIVE DAYTONA BEACH, FL 32114 --; Undersecretary Notture rx co � X� 418 IM ca iG rx co � 405 QWZ IM ca iG b r L /I SN J W 2 U. 0 O m L u a+ LL E Y H to u to 0 U d N Z Z :DJ m O ;F, 'a LL t K > c U _ Ii 0 0. z z co 4. s OC _ LL 0 V W N Z V U.1 W t K cn _ LL c' 0 U a CA N (9 t cr _ LL W uj 2 Q W ui0 25 U. CO O z + { j +� N Q ai Y {n C C 0 � O V .Q L J cu C4) .� CD H O Q r N L C CU Q J L cn m as 'C > O = O N d O �=N > N O 'a H _ N i +�+ � L-oo a Z - Noo L Q CDQ c 0 .N w.: c CD o c asrl4) ea a 0_ ai CO) a) m Lu = +�+ Ow uj O LLd R y C �cLO v 0 LUam m 0 ai � L V a 0 -0 a) N N .0 > O I- t I Q. o <.i lam: w N W O Eo z O N o Nom �E m m W ` cc �^ Q 0 0 cO Q Q CF)a o cc cc V J � �CL O O CL U c c cc CL U) 0 O LU CL0 m �a 0 i CL V1 W I.L. fi O C x Z V W c W _1 ar Z m � 0 c 0 N d t O Z O Q J O lam: w N W O Eo z O N o Nom �E m m W ` cc �^ Q 0 0 cO Q Q CF)a o cc cc V J � �CL O O CL U c c cc CL U) 0 I Job Number 502$ Client address city I town contractor 1.WEATHERSTRIPPINGICAULKING QUANTITY Door Kits Q -Lon or Equiv. 4 Door Sweeps (Regular) 3 Door Sweeps (Automatic) 1 Reglaze Windows /ln.inch Window.Weathstr Schlegel per side Recessed light cover per SWS, Not a tenmet cover attic sealing 2 part foam attic sealing 1 part foam 1 basement and living space air sealing 1 part 1 SUBTOTALS 2A.INFILTRATION / INSULATION Domestic pipe Hot Water Tank 1st 6' 1 Sill Two Part Foam w/ Fiberglass Batt 132 1" T-max only foam boardPerimeter per IECC& SWS sq. ft. 2" T-max only foam boardPerimeter per IECC& SWS sq. ft. Drape DOOR R-5 or T-max only Tape Joints (Aluma Grip only) per hr. Duct Ins w/ Tape sq. ft. R-5 conditioned space Duct Ins w/ Tape sq. ft. R-8 unconditioned crawl/garage/attic Hydronic pipe insulation to 1" R-5 Hydronic pipe ins.1.25"- 2" R-5 Steampipe Ins. 1.25"- 2" iron pipe R-5 Steampipe Ins. 2.5 "- 3" iron pipe R-51 Air Conditioner Meeting Rail Air Conditioner Cover Air Conditioner Cover Special Order SUBTOTALS 2B. INSULATION Open Unrestricted R 49 Open Unrestricted R 38 Open Unrestricted R 30 Open Unrestricted R 20 Open Unrestricted R 10 Restrict FL/Sloped R 38 Restrict FL/Sloped R 30 Restricted FUSloped R 20 Restrict FUSloped R 10 1218 R-19 FGB open rafters/walls/kneewalls R-11 FGB open raftershnralls/kneewalls Attic Stairs(stairwell & common wall) Cover Pull Down Stairs Thermadome up to R49 per 1 Site built pull down stairs 2" foam box DATE TOTAL 204.00 52.92 26.00 0.00 0.00 0.00 0.00 70.00 70.00 422.92 17.70 324.72 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 342.42 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1778.28 0.00 0.00 0.00 450.00 0.00 Patricia Pendergast 2 Hay Meadow Rd North Andover, MA 01845 Quality AUDITOR NOTES. All white Main/3 Bathroom Sinks AUDITOR NOTES I Looking to add to floored attic Attic / Kneewal Floor Transition. Dense pack cellulose 0.00 W.S. Hatch O -Lon or equal 0.00 W.S. & bat Hatch,dam around etc. complete to attic R value 0.00 Kneewall R-12 cell behind Per.Memb 0.00 Open Rafter R-20 Cell. /w poly 0.00 Open Rafter R-30 Cell. 1w poly 0.00 Basement Overhead R-19 fiberglass 0.00 Basement Overhead R-30 fiberglass 0.00 Crawlpace Overhead <4' high R19 0.00 Crawlpace Overhead < 4' high R30 0.00 Garage Ceiling cavity filled w/ cellulose 0.00 Wood, Shake,Clapboard,Shingles Vinyl 1952 3904.00 Asbestos (single nail) / Asphalt 0.00 Asbestos (doub. Nail) /Aluminum 0.00 Brick/Stucco 2 hole 0.00 Vinyl over Asbestos 0.00 Multi -layered 3 or more layers 0.00 Drill rough plaster or finish wood plug 0.00 Drill finish plaster 103 219.39 Test Drill Walls (all 4) 1 67.00 SUBTOTALS 6418.67 2. INSULATION TOTAL 2A.+2B. 6761.09 3. STORM WINDOWS! DEADLITES Plexiglass up to 88 u.i. Additional per UI over 88" Dead light SUBTOTALS S. OTHER MATERIAL Ridge vent In ft. Gable Vent rectangular Varipitch Vent Roof Vent 135 (1 aq ft NFV) Large Roof Vent 865 (A sq ft NFV) Small 3 Soffit Vent Rectangular Turbine Vents All Stack Vent Acuvent proper (Must be this product) available @ H 31 Permable House Wrap 6 mil poly on ground Energy Star R-4 Rigid Vinyl Repl 94-101 U.I. AUD If AUDITOR NOTES 0.00 _ 0.00 0.00 0.00 0.00 0.00 0.00 0.00 270.00 0.00 0.00 0.00 142.60 0.00 0.00 0.00 SUBTOTALS 412.60 6./7. E.C. MATERIAULABOR 7596.61 AUDITOR NOTES Vent every other ba 8a. HEALTH & SAFETY AUDITOR NOTES CO detector 0.00 Vent Bath / Kitchen Fan 0.00 Make Sure Bath Fans are Vented Dryer vent w/ exhaust duct Heartland 0.00 Dryer Transition Duct only 1 45.00 Bath fan 50 CFM ( replace exsisdng ) fan only 0.00 Bath fan 50 CFM (new install) with timer 0.00 Bath fan Smart timer 0.00 Blower Door Test Pre Post 1 45.00 SUBTOTALS 90.00 8b. REPAIR MATERIALILABOR Basement outside door solikt core Inc all hardware 0.00 Basement outside door wl Jambs inc all hardware 0.00 Basement outside door site built per SWS inc all hardware 0.00 Door Repl pre hung 32-36" Steel" w / Lite 0.00 Door Repl interior solid core 28-32" 0.00 Door Repl pre hung 32-36" wood** w / Lite 0.00 Window Replacement w/ SIR less than 1 0.00 Basement Window Repl. Awning/ Hopper 0.00 Basement Window Repl. With a frame 0.00 Lockset ( door) Schlage or equal 0.00 Repair! Refit Door 0.00 Replace Side Stop 0.00 Replace Casing 0.00 Glass Replacement to 64 u.i. 0.00 Glass Replacement per u.i. over 64 0.00 Thermo pane Glass replacement 0.00 Sash Sidelock !Top Replacement 0.00 Threshold (Wood) 0.00 Threshold (Aluminum) 0.00 Slide Bolts / pull handle 0.00 Cut / finish attic-kneewall access 0.00 Cut / close attic-kneewall access 0.00 Labor Rate Hours 2 134.00 Labor Rate Hours 0.00 Labor Rate Hours 0.00 Labor Rate Hours 0.00 Labor Rate Hours 0.00 Permits / Fees (Wap only) 96.00 SUBTOTALS 230.00 TOTAL REPAIR + HEALTH & SAFETY 320.00 GRAND TOTAL WORK ORDER # (A) 5026 7916.61 Any alterations or deviations from the above specifications involving extra costs must be cleared in writing before installation. The Work Order must be complete within 15 working days from acceptance date below: CONTRACTORICOMPANY: ACCE PTANCE:Company/Contractor AUTHORIZED SIGNATURE: AGENCY APPROVALS: CTI Authorized Signature: GLCAC Authorized Signature: I Install Pull Down I Quality Date Date Date r Greater Lawrence Community Action Auditor: on Bruno Phone: 978-657-4825 Job #: Date : Client First Name: Patricia Last Name: Pendergast Address: 2 Hay Meadow Rd (978)685-0087 Phone 2: HouseType: 1 fam 2 faro 3 faro duplex 4 family Cape Split Victorian Colonial Tenement Siding Type Wood Vinyl Alumn Asb Single Asb Dble Vin 1 overAsb T111 Brick/Stucco Asphalt Condition Good Fair Poor Comments: Roof Type Gable Hip Flat Gambrel Condition M Fair Poor Asphalt Slate Rubber Tar &Gravel Age of House: 36yrs_ 1978 Heating System Manufacturer: Burnham CAZ Base Reading : Pre - G Post: CAZ Worst after zeroing out :,Pre -/. Z Post: No subtraction needed House Draft limit in Pascals according to CAZ depressure limit Draft needed in Pascals vs acceptable draft range per temp Draft INWC in Pascals H Steam FHA Space Heater Oi Gas Electric_Wood Pellet Treate ucts: Yes Pipes: Yes No Domestic Hot Wa Gas Oil Electric es Print Out x en 4.40% CO 1 ppm Efficiency 83.30% CO -2— 12.33% Stack temp 528 !r temp 63.5 xcess Air 24,80% Go ree air I ppm ame Color blue Age + Ambient Smoke Reading eferred to HWAP Yes no Date referre Spillage ass ra -0,0646 f►uu o neer or pipe wrapt Yom, Nu . CO detectors: Yes/No Locations: Comments: Number of occupants 3 Number of smokers 0 Number of pets 4 Ambient CO Readings . Stove &_ Oven Broilers Dryer " " " House draft limit is based on System type Draft needed in Pascals is based on outside temp. Doors Sween Location Kits IAuto I Reg Caulk Caulk Repairs lReplace Drape Solid Hollow Comments Damper Yes/ No F=ire place IN OUT Front to out X x white Front to Hall Rear to out side to Garage X X whxe To attic Multi Family To Basement x x white Basement to out X x white rear to hall Knob and Tube Yes NO Locations Date inspector called Blower Door Air Sealing Im gmmILV.0"'70 7 Make sure bath fan is vented out Fans Bath 1 Might w/o light Cfms Bath 2 Might w/o light Cfms CO detector yes no Location Condition Damper Yes/ No F=ire place Living room GoodiWorking damper closed Space Heaters Asbestos Blower Door Pre Post Done by contractor Multi Family pics of readings needed. Vermiculite Knob and Tube Yes NO Locations Date inspector called Blower Door Air Sealing Im gmmILV.0"'70 7 Make sure bath fan is vented out Fans Bath 1 Might w/o light Cfms Bath 2 Might w/o light Cfms CO detector yes no Address; 2 Hay Meadow Rd Direction Windows 15 Bedroom 2 ■■■■■■■■■■■■■■■ 2 Hay Meadow Rd Basement Conditioned X Unconditioned Crawl space Dirt floor Asbestos No Location Basement Overhead Garage Overhead Sills Drape perimeter Add poly to crawl space Done Steam Iron 1/2 inch 3/4 inch 1 inch 1114 inch 1/1/2 inch 2 inch 2 1/2 In Done Yes No Measurments Existing R 0 Pipes steam i Ducts Added R R19 w/ foam Mastic seams Square footage Basement Airsealing air seal chimney and plumbing follow pipes CO detector yes no SQ. Feet 132' FHW hrs Basement Door Drape Repair Caulk Ei weep 2 Hay Meadow Rd Walls Floor Plan w ,C1 �1 Z v 5 Comments 1z W iss sq. z 47 29 HAY OLr Fug 1st g Yes it c 484 Sq.ft 22 22 FSA 1218 Sq.ft 2nd 8, Yes Il 29 27 {o 29 l�35Z� 3rd47 Sq Feet 2436" Common Ad' Total Exterior wall 1st 8 x 119 952 Exterior wall 2nd 8 x119 952 plus 48' for over garage rear of house Please Indicate: Unheated /////// Interior wall LG 8 x 13 104 Common + + + + + [ .-JAW&( Address 2 Hay Meadow Rd Attic Loose Wool or F / G 2.2 Cellulose 3.6 FIG or Wool batts 3.2 Vermiculite 2.3 Vents Type Size Location Amount Present gable/soffit 12sIg Logo ,�' ZS cNIr zf. - . Z&I Needed Insulation Existing R R Added Square Feet Notes Unfloored sqSOMt 4XIO0.2 12x 12 0.38 6x 16 Floored 12x 16 0.54 8 x 16 0.45 12x 18 0.62 SoMt dbl 51n Slopes 12 x 24 1 0.86 3 sect all open .98 per 10 ft Turbine 3 it 3 sect center open Kneewalls Roof 135 Lrg 1 ft Kneewall Floor .98 per 10 ft 865 smi Flat Roof Triangle Gbl with 21 114 legs .4 to .8 Attic Air Sealing Notes Hatches Weathers tri and Batt Cut And Close Attic Walk u (T -Dome-) Cut and Finish Knob & Tube -sono Storage to move Yes No Recessed Lights Uable Ox 10 0.35 sqSOMt 4XIO0.2 12x 12 0.38 6x 16 0.32 12x 16 0.54 8 x 16 0.45 12x 18 0.62 SoMt dbl 51n .43 per 10 It 12 x 24 1 0.86 3 sect all open .98 per 10 ft Turbine 3 it 3 sect center open .33 per 10 ft Roof 135 Lrg 1 ft Ridge Vent .98 per 10 ft 865 smi 0.4 Triangle Gbl with 21 114 legs .4 to .8 Attic Air Sealing Notes N 41 I t. 0 d r C ro e b o c =2 5 y N b b Q S � r C V a a c .� CL QVN o 41 I t. 0 a r C ro e b o 5 S r 41 I t. 0 R m s t g b 5 R m s t Attic Inspection Form Mandatory for all Attic Insulation Jobs Client Name Patricia Pendergast Section A: I To be filled out by WAP auditor during initial Interview with cl, Are there any recessed lights in this dwelling ? YES Locations: ,7 Don't Know Section B: I To be filled out by auditor upon Inspection of the ceiling area beneath the at 9 Recessed Lighting Fixtures Other potential Heat prod Section C: Number of recessed lights Furnace flues Other heat Producers Total Guards needed Section D: I have Installed Date : guards. To be completed by the insulation contractor at the time of Instal Should agree with Section 9: To be signed by insulation contractor after completion Contractor signed Section E To be signed by the weatherization client. I agree that the number of insulation guards indicated have been installed as noted above. 1 have received the notice to the client that was attached below Signature: Date: --------------------------------------------------------------------------- Detach here and give to Client Notice to Weatherization clients: The purpose of the insulation guards Is to ensure that your dwelling is In compliance with the National Electric code .The Insulation used meets all Federal test spefications. However since insulation retains heat, It is essential that heat producing sources be protected. For this reason it is Important that the insulation guards not be removec altered or covered. Be sure to use insulation guards if you install new recessed light fixtures or some similar fixture. Also be certain not to obstruct any attic ventilation devices. GLCAC INC. • In, Progress Q C Report Address: 2 Hay Meadow Rd Date : Contractor : 0ARBONNS90 Inspector Attic Depth Level OK No Access OK No 1 Hole OK Hatches OK No Venting OK No Dense Pack OK Air sealing OK No Bath vent OK No Plug & Patch OK Comments Caulked out OK No Density OK NO Dead Lights OK No Basement General Heat Loss Air sealing OK NO Door Kits OK NO Chimney OK NO Sweeps OK NO Pipe Wrap OK NO Locks/Striker OK NO Ducts OK NO Caulking in OK NO Sills OK NO Caulking out OK NO Dryer Vent OK NO Glass OK NO Dryer Hose OK NO Glazing OK NO Comments Comments Work Additional Measures Added By Inspector I Missed by auditor Work order to be changed Yes No Walls Windows 1 Hole OK NO Installed OK No Dense Pack OK NO Caulked in OK No Plug & Patch OK NO Caulked out OK No Density OK NO Dead Lights OK No Comments Work Additional Measures Added By Inspector I Missed by auditor Work order to be changed Yes No Contractor Employee Declaration Page I, Company Address Make the following declaration under the Statutory Declaration Act 1959 I declare that only employees that were approved by Creative Services were used to perform work on this project. Project Name: Address: City / Town : Date of job : Patricia 2 Hay Meadow Rd North Andover 0 I Understand that a person who intentionally makes a false statement in a statutory declaration is guilty of an offence under section 11 of the Statutory Declaration Act 1959, and I believe that the statements in this declaration are true in every particular. Signed Declared at on of 20 c- - Nt n,70. PIt It i q' :'C 'L'". t. � f 1���.Illi"� .1 jjj SII `\ - - A ` :'II' �p °_ _ I�pjll�l, L II r Lh I - I: Ujil �44 `4,6, ;tff OT!PIX!, y. gv .'A J { � I rt Y kik � �"; �Jmuoonam ae i f a' . .. r 1�� J fc r 'tJ, '•�?ia }1