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HomeMy WebLinkAboutBuilding Permit #624 - 20 HAROLD STREET 2/29/2012TOWN OF NORTH ANDOVER APPLICATION FOR PLAN EXAMINATION Permit N0: 2-`l Date Received Date Issued: -d�- l - `Z - MAP NO: IMPORTANT: Applicant must complete all items on this © k4,z,,In f6- PARCEL: Print L/ LGzef/z o O Print ZONING DISTRICT: _ Historic District yes no Machine Shop Village yes no TYPE OF IMPROVEMENT PROPOSED USE Re idential Non- Residential ❑ New Building ne family ED] Addition ❑ TWO or more family ❑ Industrial Iteration No. of units: ❑ Commercial ❑ Repair, replacement ❑ Assessory Bldg ❑ Others: ❑ Demolition ❑ Other in Septic D Well 0 Flood lain' ❑ Wetlands; P _ . . ❑Watershed District Water/Sewer DESCRIPTION OF WORK TO RF pFUFnuraur,. LA - Wowe. t q, e4_Lv L OWNER: Name: Address: CONTRACTOR Name: Address: Supervisor's Construction License Please Type or Print Clearly) Phone: 9If _,01 Home Improvement License: 1 00 Exp. Date: ARCHITECT/ENGINEER Phone: Address: Reg. No. FEE SCHEDULE: BULDING PERMIT. • $12.00 PER $9000.00 OF THE TOTAL ESTIMATED COST BASED ON $125.00 PER S.F. C� _ Tota! Project Cost: $ Jr ag FEE: $ Check No.: Receipt No. NOTE: Persons contract'ng 4withung' ered contractors do not have g g ``u4ture of cosi ` .. Ilinature of A ent/Own tra -37z-Y r 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 DATE REJECTED PLANNING & DEVELOPMENT ❑ COMMENTS CONSERVATION COMMENTS HEALTH COMMENTS y �L DATE APPROVED El Reviewed on Signature Reviewed on Signature .y 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 DEPARTMENT - Temp Dumpster on site yes no Located at 124 Main Street Fire Department signature/date 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 No, MGL Chapter 166 Section 21A —F and G min.$10041000 fine NOTES and DATA — (For department use ed for pickup - Doc:.Building Permit Revised 2008mi 1V r L 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 o Copy of Contract ❑ Floor Plan Or Proposed. Interior Work a Engineering Affidavits for Engineered products (VOTE: All dumpster permits require sign off from Fire Department prior to issuance of Bldg Permit Addition Or Decks o Building Permit Application o Certified Surveyed Plot Plan ` f, ❑ 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) a 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) t ❑ Building Permit Application ❑ Certified Proposed Plot Plan Ll 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: Doc.Building Permit Revised 2008mi Location No.,// Checkff 3151 Date TOWN OF NORTH ANDOVER Certificate of Occupancy Building/Frame Permit Fee $ Foundation Permit Fee Other Permit Fee TOTAL $ 25057 Building Inspector 02/29/2012 10:08 19785212751 ANTHONY&MALCOLM INS PAGE 02/03 DATE (MMIDDIYYYY) OBQM CERTIFICATE OF LIABILITY INSURANCE 2/29/12 _ PRoOu ;FR 978)373-S6Z3 FAX (978) 521-2751 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ( ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE ANTHONY & MALCOLM INSURANCE AGCY., INC- HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 3 50. CENTRAL ST. ALTER THE Nnn E AFFORDED BY THE POLICIES BELOW. BRADFORD, MA 01835 INSURERS AFRAGE NAIC INSURED Allan Veil eux, Jr. d/b a INSURERA- Phece Co. INSURER B: Sai'ceHeat Quest Insulation Company LLC ,NsuRERc: The 5 Shawsheen Rd. INSURER D: Lawrence, MA 01843 INSURER E: PERIOD POL CY NOTW THE POLICIES OF ICSTEDIT LOW HAVE BEEN ISSUE' OF ANY CONTRACTOR OTTHE HER DO UMENT INSURED WI H R SPECT TO WH CII ED ABOVE FOWTHE(THIS CERTIF CAITE MAY BE ISSUED OR DING ANY REQUIREMENT, TERM OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 15 SUBJECT TO ALL THE ?FRMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID L IMSEFFECTIve POLICY EXPIRATION LIMITS SR DD TYPE OF INSURANCE POLICY NUMBER EEL GENERAL LIABILITY CPP07132S3 12/27/201.1 12/27/2012 EACHOCCURRENCF $ 1 000,00 DAMAGE TO RENTED $ 50 , 00 COMMERCIAL GENERAL LIABILITY aF¢ lFR ten MED EXP (Anyone perean) 3 5 , 0O CLAIMS MADE a OCCUR PERSONAL & ADV INJURY S 3.1000000 A GEN'L AGGREGATE LIMIT APPLIES PER: POLICY jE� LOC auroMo>31LE LIABILITY S 02142 1COM05 12/26/2011 12 ANY AUTO ALL OWNED AUTOS X SCHEDULED AUTOS B X HIRED AUTOS X NON -OWNED AUTOS GA �RAGE LIABILITY ^ I ANY AUTO EXCESSIUMBRELLA LIABILITY OCCUR ❑ CLAIMS MADE OEDUCTIOLE RETENTION S WORKERS COMPENSATION AND 636OUB9609L39011 11/08/2011 11� EMPLOYQRS' LIABILITY C ANY PROPRIETORIPARTNERIE%ECUTIVE OFFICERIMEMBER EXCLUDED1 H Yee, deeorbe under SPECIAL PROVISIONS below OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS nsulation Town of North Andover Inspectional Services 1600 Osgood St. Bldg. ZO Suite 2/36 North Andover, MA 01845 GENERALAGGREGATE $ 2 PRODUCTS - COMPIOP AGO i Z COMBINED SINGLE LIMIT g (ER occident) BODILY INJURY S (Por person) BODILY INJURY $ (Per accident) PROPERTY DAMAGE (Per Rrx ldanl) AUTO ONLY . EA ACCIDENT S OTHER THAN EAACC 1 $ AUTO ONLY: AGO S EACH OCCURRENCE S AGGREGATE $ 1,000 $ 3 WC STATU• OTH- E.L,EACH ACCIDENT S 12000100— 000,00E.L. E.L. DISEASE - EA EMPLOYEE S 1,000 OOO E.L. DISEASE. -POLICY LIMIT S 1, 000 00 SHOULD ANY Of THE ABOVE DESCRI9E0 POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INDURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE GERTTFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SMALL IMPOSE NO OBLIGATION OR LIANLITY OF ANY KIND UPON TME INSURER, ITS AGENTS DR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE 12. Frederick Malcolm Jr. ]A� ACORD 25 (2001!08) FAX: (978)688-9542 ®ACORD CORPORATION 1988 E w O O F=4 �I w A cd =o m c �o 0 a o w° a cit w° w0' U w a � w w p°G u w x :J �,°• u, w z Q O o � c y co : *r Q L) c3 ''� ; •a'o CLO ev ev m c o` y A y�y,�,•'I � Q r,'d, � � 9 m Q z = D y=., m *- y ° a E S 0 Q `C2 m <L c G0 �! O N y .0• CD c V H� L16, O C3y CS �p � m J C C � m H A • E 00 CLCD 0C_-) ` CIO m ��oa CDss C� -y lO vV�'Z. ' O r.+ . C O. O C=2 C S CD C h ayL.., 2 H m W LU .y C � .m C W •E C3 'O V y cm C.3 o 0mc COD O. O O 10 CL S ea .m0`h-' H t s O.* m li E a V) CO) i COD C 7 cm m ac O Q! C •C N m t r 0 Z O 8 CD5 7 a a "'Oil p U O CD O O O v Z CD CL O ca C Cm I C C coq O \V im N_ Ag O O m m 0 O O L O � O � � CD C 0 R O Q a CMac C O � C C CA Z CD U V� � C C h cd =o m c �o O o � c y co : *r Q L) c3 ''� ; •a'o CLO ev ev m c o` y A y�y,�,•'I � Q r,'d, � � 9 m Q z = D y=., m *- y ° a E S 0 Q `C2 m <L c G0 �! O N y .0• CD c V H� L16, O C3y CS �p � m J C C � m H A • E 00 CLCD 0C_-) ` CIO m ��oa CDss C� -y lO vV�'Z. ' O r.+ . C O. O C=2 C S CD C h ayL.., 2 H m W LU .y C � .m C W •E C3 'O V y cm C.3 o 0mc COD O. O O 10 CL S ea .m0`h-' H t s O.* m li E a V) CO) i COD C 7 cm m ac O Q! C •C N m t r 0 Z O 8 CD5 7 a a "'Oil p U O CD O O O v Z CD CL O ca C Cm I C C coq O \V im N_ Ag O O m m 0 O O L O � O � � CD C 0 R O Q a CMac C O � C C CA Z CD U V� � C C h 0 1 or oM� ^ . s y Fxpga t�atonRo�FM 9�rars& � ,� Qu,� ST/S tt ✓3 6oTco qC�N$sSRe ss NR4oro q News z`�FC/ lhssiev ;osuiLe - Depaa'ir lew 44 C'uf),Iis ',.di:ti Board of Buildim, Reoulations and Standards, Construction Supervisor Specialty License' License: CS SL 99215. . Resfrlcted to: WS,IC ALLAN VEILLEUX JR 5 SHAWSHEEN ROAD ,r , LAWRENCE, MA 01843 v Expiration: 8/19/2012 f,inr.:i<�iuiarr Tr,": 99215 �' i Job Number 1.W EATHERSTRIPPING/CAULKING Door Kits Q -Lon or Equiv. Door Sweeps (Regular) Door Sweeps (Automatic) Reglaze Windows lln.inch Window.Weathstr Schlegal per side Attic/Sasement bypass sealing man/hr Attic sealing with 2 -part foam man/hr SUBTOTALS 2A.INFILTRATION / INSULATION Domestic pipe Hot Water Tank 1st 6' Sill Insulation R-19 CF Sill Two Part Foam wt Fiberglass Batt Drape Perimeter R-5 Anch. Sq. ft. Drape DOOR R-5 Anch. Tape Joints (Aiuma Grip only) per hr. Duct Insulation & Tape In_ ft. Rigid Foam Board Anch. 1" Hydronic pipe insulation to 1" R-5 Hydronic pipe ins.1.25"-1.5" R-5 -Steampipe Ins. tof.25" iron pipe R-5 Steampipe Ins. 1.5"- 2" iron pipe R-5 Steampipe Ins. 3" iron pipe R-5 Air Conditioner Meeting Rail Air Conditioner Cover Air Conditioner Cover Special Order SUBTOTALS 28. INSULATION Open Unrestricted R 49 Open Unrestricted R 38 Open Unrestricted R 30 Open Unrestricted R 20 Open Unrestricted R 10 Restrict FUSioped R 30 Restrict FUSloped R 20 Restrict FUSloped R 10 R-19 FGB open rafterslwalislkneewalis R-1 1 FGB open raftersAvalls/kneewails Attic Stairs(stairwell & common wall) Cover Pull Down Stairs Thermadome Site built pull down stairs 2" foam box Attic / Kneewal Floor Transition. Dense pack cellulose 4084 Client address city l town contractor QUANTITY 1 0 1 0 0 4 0 1 86 0 0 1 0 0 0 12 0 0 0 0 0 0 0 0 877 0 0 0 0 225 0 0 0 0 0 0 DATE 14 -Nov -11 DAVID LICCIARDO 978-337-3724 20 HAROLD STREET NORTH ANDOVER MA 01845 HEAT QUEST TOTAL 43.00 0.00 22.00 0.00 0.00 240.00 0.00 305.00 15.00 129.00 0.00 0.00 44.00 0.00 0.00 0.00 39.00 0.00 0.00 0.00 a.o0 0.00 0.00 0.00 227.00 0.00 1227.80 0.00 0.00 0.00 0.00 303.75 0.00 0.00 0.00 0.00 0.00 0.00 TO OUT (IN KNEEWALL I STOP 112 OF SLOPES I Page 2 AUDI70R:N0TES:`°s:r 74 177.60 W.S. & bat Hatch R-19 /Q -Lon or = W.S' & bat Hatch R-30 /Q -Lon or = Kneewall R-12 cell behind Per.Memb Open Rafter R-20 Cell. /w poly Open Rafter R-30 Cell. /w poly Basement Overhead R-19 fiberglass Basement Overhead R-30 fiberglass Crawipace Overhead <4' high R19 Crawipace Overhead <4' high R30 Garage Ceiling cavity filled w/ cellulose Wood,Shake,Ciapboard,Shingles Vinyl Asbestos (single nail) /Asphalt Asbestos (doub. Nail) /Aluminum Brick/Stucco Vinyl over Asbestos Multi -layered 3 or more layers Drill rough plaster or finish wood plug Drill finish plaster Test Drill Walls (all 4 ) SUBTOTALS 2. INSULATION TOTAL 2A.+2B. 3. STORM WINDOWS I DEADLITES Plexiglass up to 88 W. Additional per UI over 88" Other (Negotiated Price) SUBTOTALS 5. OTHER MATERIAL Ridge vent In ft. Vents Gable rectangular Varipitch Vent Vent Roof 135 (1 sq ft NFV) Large Vent Roof 865 (A sq ft NFV) Small Vent Soffit Round Vent Soffit Rectangular Turbine Vents All Stack Vent Propa Vent Permable House Wrap Vapor barrier Energy Star R-4 Rigid Vinyl Repl to 73" U.I. Energy Star R-4 Rigid Vinyl Rep[ 74-84" U.I. Energy Star R-4Rigid Vinyl Repl 84-93" U.I. Energy Star R-4 Rigid Vinyl Rep194-101 U.I. SUBTOTALS 6.I7. E.C. MATERIALILABOR 8a. HEALTH & SAFETY Vent Bath / Kitchen Fan Dryer vent w/ exhaust duct Heartland Dryer Transition Duct only 0 0 0 .84 0 0 0 0 0 a 1506 0 0 0 0 0 0 84 0 0 0 0 0 0 0 0 5 0 0 0 0 0 0 0 0 0 0 0 0.00 0.00 0.00 147.00 0.00 0.00 0.00 0.00 0.00 0.00 2560.20 0.00 0.00 0.00 0.00 0.00 0.00 152.04 0.00 4568.39 4795.39 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 380.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 380.00 5480.39 IFINISHED KNEEWALL I HIGH Page 3 0 0.00 0 0.00 1 - 90 FOR DRYER 0 0.00 Blower Door Test Pre Post SUBTOTALS 8b. REPAIR MATERIAiJLABOR Basement outside door only Basement outside door w/ jambs Door Repl pre hung 32-36" Steel" Door Repl interior solid core 28-32" Door Repl pre hung 32-36" wood" Window Replacement w/ SIR less than 1 Basement Window Repl. Awning/ Hopper Basement Window Rept With a frame Lockset ( door) Schlage or equal Repair / Refit Door Replace Side Stop Replace Casing Glass Replacement to 64 u.i. Glass Replacement per u.i. over 64 Sash Sidelock trop Replacement Threshold (Wood) Threshold (Aluminum) Slide Bolts Plug Plate Cover Cut / finish attic-kneewall access Cut / close attic-kneewall access Labor Rate Hours Permits / Fees (Wap only) SUBTOTALS TOTAL REPAIR + HEALTH & SAFETY 0 0.00 0.00 0 0.00 0 0.00 0 0.00 0 0.00 0 0.00 0 ....... 0.00 0 0.00 0 0.00 0 0.00 1 50.00 0 0.00 0 0.00 0 0.00 0 0.00 0 0.00 0 0.00 0 0.00 0 0.00 0 0.00 0 0.00 0 0.00 0 0.00 0 0.00 50.00 50.00 GRAND TOTAL WORK ORDER# (A) 4084 5530.39 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: NO ASBESTOS TO OUT CONTRACTORICOMPANY: HEAT QUEST ACCEPTANCE:Company/Contractor AUTHORIZED SIGNATURE: AGENCY APPROVALS: CTI Authorized Signature: Date Date GLCACAuthorized Signature: ,_ . Date Greater Lawrence Community Action Adutitor. Renee Tofanelli _. Phone: 978-857-7841 .lob # � Date: 11-1V.11 Client First: Last: GICC//�ed/ .. licaress: o?O 114"eor..o cgzr 1 s fir $'/A/,�� City.' sv% Av" o Zip Code 4X,0 4fj' _ Phone 45:% ,ZV Phone 2 House Type: Cape Ranch Split fa 2 fam 3 fam duplex 4 family Victotia8cegm Tenement Siding Type: WooVin Alumn Asb Single Asb Dble Condition Good Fair Poor Viny ve sb T111 Brick/Stucco Asphalt Comments., plumber of occupants Number of smokers o Number ofpets D �.. _:A_ mbient...GO Readings: Stove _Oven_ Br_oiler- J2 -_.._Dryer.. Flame Color oct1E 02 Roof Type Roof Material able ip Flat Gambrel Asphalt late Rubber Tar & Gravel Condition Good Fair Poor Yes No Heating SystemNJRA; -. A0.. Ambient CO Manufacturer: _ W e16 /r?C°�iy' Efficiency BACHARACH, INC. 437 *F Excess Air r, �5'G. Pyrite Insight154 SN: oQrl� CAZ Base Reading :Pre, Post: Stack Temp gy Gallons .SO Temp Setfing g, CAZ Worst Reading : Pre Post: Primary Tem Time: 11:33:18 AM Draft n o. so Spillage Yes /&wT en Date: 1v14/II -Oxy Draft - o. o-5 FHW am FHA Space Heater CO 2 O Fuel Oil Electric CO Nat Gas Wood Pellet Coal CO Air Free d� plumber of occupants Number of smokers o Number ofpets D �.. _:A_ mbient...GO Readings: Stove _Oven_ Br_oiler- J2 -_.._Dryer.. Flame Color oct1E 02 20.7 % Treated Ducts : Age W f W 0 ppm Yes No Eff Coz -. A0.. Ambient CO omestic Hot Water Tank Aowlrexo Smoke Reading i� T -STK 437 *F Oil Electric Tank less Referred to HWAP V FAT -AIR He.s Gallons .SO Temp Setfing g, Date referred Co (0) - "PPM Draft n o. so Spillage Yes /&wT Spillage d) Amb CO: 2P Stack CO-_ Draft - o. o-5 Differential Pressure Add 6 Feet of pipe wrap / NO -0.01 inwc - plumber of occupants Number of smokers o Number ofpets D �.. _:A_ mbient...GO Readings: Stove _Oven_ Br_oiler- J2 -_.._Dryer.. Client --- Doors Front to Hall ��ra�e��■�■a� r Location Fire place Ala Space. Heaters Blower Door Pre Post Knob and Tube Yes NO Locations Date inspector called s 'VA&e:;,e WI(f 4777& Condition Reason not doing BlowerpoorMr Sealing Damper Yes No Client a6�r�2��, �r� �t/o A•voa v� Direction Windows- ISI L ��■■■■■■■■■■■■ rf .y...c SEE • �■■■■■■■■■i■■■■ ■ IMEMEEMEMEEEME ■■■■■■■ ' , / 1, ■IEEE■■M■MM MMMMM • ■r■i■EMMEMME■EM■ ■■■■■■■■■■■■■■■■■■ ®IMMM■MMEM ■■MIEM ■■■■■ NOME MMEM ■■MIME■■MMEENO■E ■■■■■■■■M■■■■■■■■ • IMIMEM■M■EEE MEM■ - ss■■■■■■E■■■■■ �s NESIMEEM■MMEME■E■ � ■■■■■EMMEME■ - � ■��■®■■MME■■■ Client .Malls Floor Plan w x � a o Comments est �. SOME 2nd ;7 J 2� 3rd Sq Feet Common Ad' Total - aderzor wall isr B• X _ / jZ Exterior wall 2nd 7j X 'm Please hxrwate: Unheated /!///// lintedor wall A/ X 69 d7�6r.� tfry Client L o y� Basement Conditioned Unconditioned .Asbestos No Location _ 2< Crawl space Dirt floor Fxi ng -R Added R Basement Overhead Garage Overhead Sills 2 Drape perimeter Crawl Space Done Steam Iron 112 inch 314 inch - 1114 inch 1/1/2 inch 2 inch 2112 in .. PIM WIA Pipes Steam / SQ. Feet Ducts Mastic seams ., .,....- ......... �_......... - -_ .... Square footage Basement Basement Door.` rape Repair Caulk Kit & Sweep Client Attic Loose Wool or FIG 2.2 Cellulose 3.6 FIG or -Wool batis 3.2 Venniculife 2.3 Vents Type size Location Amount Present Sq soffit 4 x 16 0.2 12x16 0.54 8X16 0.45 Needed 4 Turbine 3 ft I Ridge 1.98 per 10 feet Attic Air Sealft Insulation Existing R R Added Square Feet - Notes Unfloored Floored Slopes "S IN Kneewalls ZYL* �-ZOAI� Kneewall Floor 7 7121ftg-177o4l Flat Roof -/X paw -A:!U Hatches Weatherstrip- and Batt Cut And Close Attic Walk T -Dome -Cut-end-Finish Knob- & Tube; Yes No Storage to move Yes No Recessed Lights Cheeks I 4-194 // dfrzd eA /W Gable BxIB 0.35 Sq soffit 4 x 16 0.2 12x16 0.54 8X16 0.45 12x18 1 0.62 1 Roof 1135 Lrg 1 ft 12x24 0.86 1 111115 SMI 0.4 Turbine 3 ft I Ridge 1.98 per 10 feet Attic Air Sealft Notes ZYL* �-ZOAI� GLCAC INC. Inprogrees Q C Report Address:,& &AhAf__ Contractor : Date . inspector : Attic Depth Level OK No Access OK No Hatches OK No Venting OK No Air sealing OK No Bath vent OK No Commenfs OK NO OK NO Caulking in OK NO OK NO Caulking out OK NO OK NO Glass OK Basement OK Genera! Heat toss Air sealing Chimney Pipe Wrap Ducts Sills Dryer Vent Dryer Hose Comments OK NO Door Kits OK NO OK NO Sweeps OK NO OK NO Locks/Striker OK NO OK NO Caulking in OK NO OK NO Caulking out OK NO OK NO Glass OK NO OK NO Glazing OK NO Walls Windows Installed OK No Dense Pack OK NO Plug & Patch OK NO Density OK NO Installed OK No Caulked in OK No Caulked out OK No Work Additional Measures Dead lights OK No Added by Inspector Missed by Auditor Work order to be changed Yes No !h- N The Commonwealth ofMassachusegs 4. El am a general contractor and I Department oflndustrialAccidents �• :r'. Office of Investigations listed on the attached sheet t 600 Washington Street :X °� 3`I Boston MA 02111 workers' comp. insurance. www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors[Electricians]Plumbers 30cant Information . _ . Please Print Lep ihb Name (Business/Organization/Individual): Address:_ City/Staie/Zip::K. +IIG t"[ Oj Phone #: T- 3(Q t 42 Are you an employer? Check the appropriate box: 1 VI am a emplo .�_ 4. El am a general contractor and I employe full and/o part-time).* have hired the sub -contractors 2. ❑ I am a s . or or partner- listed on the attached sheet t ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required] officers have exercised their 3. ❑ I air a homeowner doing all work right of exemption per MGL . inyself. [No workers' comp. c. 1,52, § 1(4), and we have no insurance required.] T employees. [No workers' comp. insurance required.] Type of project (required): 6. 0 New construction 7. ❑ Remodeling 8. n Demolition 9. ❑ Building addition 10.❑ EIectrical repairs or additions 11.0 Plumbing repairs or additions 12.0 Roofrepairs " / 13.[11 Other /1 1% v0.f�t -any applicant that checks box #I must also fill out the section below showing their workers' compensation policy information. t I lomeowners who submit this affidavit indicating they aie doing all work and then hire outside contractors must submit anew affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors aiid their workers' comp. policy information. fam an employer that is provirCng w rkers, cco pensation insurance for my employees. Below is the policy and job site information. - Insurance Company Policy # or Self -ins. Lie. 0 Expiration Date: � "V/_ Z - Job Site Address: r__,:�o 12 S7- City/State/Zip: /v1, A7,� Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration dat7.&_* r( Failure to secure coverage as required under Sedtion 25A of MGL c. - 152 can lead to the imposition of criminal penalties of a tine 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 d day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA f,gr irMuE#ngo�poyeAe verification. X do hereby ofpesyury that the infoMafion provided afi`6 veItrue and cor ect.' /Z -- ra-11WIPIsAM Official use only. .Do not write in.tbis area, to be completed by city or town of�cial. City or Town: Permit/License # Issuing Authority (circle one): I. 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 express or implied, oral or written." "...every person in the service of another under any contract of hire, 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 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 ofpublic work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants PIease 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. He 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 ifyou 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 pennit/lieense number which will be used as a reference number. In addition, an applicant that must submit rnultiple�permit/Ifeense 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 cornmercial 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, Ocmmgnwcalth of Massachusetts Department of Industrial.Accidenis Office of investigations 600 Washington Street Foston, MA 02111 Tel. # 617-727-4900 exp406 or 1-877 MASSAFE Revised 5-26-05 Fax # 617-727 !74-4 www mass.gov#dia