HomeMy WebLinkAboutBuilding Permit #677 - 32 EMPIRE DRIVE 3/26/2012TOWN OF NORTH ANDOVER
APPLICATION FOR PLAN EXAMINATION
Permit NO: Date Received
Date Issued:
I IMPORTANT: Annlicant must complete all items on this nage I
LOCATION S ole/Y
Print
MAP NO:107C PARCEL:§//ZZONING DISTRICT:Tt
Historic District yes no
Machine Shop Village yes no
100 year-old structure yes no
TYPE OF IMPROVEMENT
PROPOSED USE
Residential
Non- Residential
Y, New Building
❑ Addition
❑ Alteration
Volne family
❑ Two or more family
No. of units:
❑ Industrial
❑ Commercial
❑ Repair, replacement
❑ Demolition
❑ Assessory Bldg
❑ Other
❑ Others:
hep is ®ell
Wr/S ewer
ood ain ® elands
0 Wa c "'shed 4 is ct�
/� DESCRIPTION OF WORK TO BE PERFORMED:
l_ON U Swr. Z,4�- a irn L� AWeLONX. 73-- F&DP.aOM s
% FA -14 S 2— —54A1 O ,AG'.— n A r)',&i _ t J Aln, ra/
(Identification Please Type or Print Clearly)
OWNER: Name:Okal 14C=12
�) i LL Ar L LLC- Phone: -2g-7 %%'306
Address;27"?' ASfl) IJ S-4cre+ C&C Q&Q1 dJ P /9 A .6&3q
CONTRACTOR Name7i�b4 11A L5s w a Phone:gJ9 ' W% `3 / g6
Address: X7710A0WG_T�t0 9*ectL40&LAaJO
Supervisor's Construction License: '/a % / Exp. Date.
Home Improvement License:/ 7Z% Exp. Date:
ARCHITECT/ENGINEER ,,o irr� QJ - Phone: c/79- 352-93/
Address���S�/�%l��fi'.e 1--,- [itlA Q��33 Reg. No. �77�i�j`
FEE SCHEDULE: BULDING PERMIT. $92.00 PER $9000.00 OF THE TOTAL ESTIMATED COSTBASED ON $125.00 PER S.F.
Total Project Cost: $ [, C�I�C� FEE: $ +/00 C,y
Check No.: 5- 1 Receipt No.: :� S IC11, eq
NOTE: Persons contracting with unregistered contractors do not have access to the guaranty fund
-,- 17f\ A h. `, =A A tA . 151
a4-
Location
Date
No.
Check 4-9�00�
25130
TOWN OF NORTH ANDOVER
�
Certificate of Occupancy $ v/
Building/Frame Permit Fee $� t0
2
Foundation Permit Fee $
Other Permit Fee $
TOTAL $ 3 S
Buildi g Inspector
Plans Submitted V, Plans Waived ❑ Certified Plot Plan Stamped Plans IBJ
TYPE OF SEWERAGE DTSPOSAi,,,
Public Sewer I�Y1,/
Tanning/MassageBodyArt ❑
Sv'mingPools ❑
Well ❑
Tobacco Sales El
Food Packaging/Sales ❑
Private (septic tank, etc. ElPermanent
Dumpster on Site IL►7
THE FOLLOWING SECTIONS FOR OFFICE USE ONLY
INTERDEPARTMENTAL SIGN OFF - U FORM
PLANNING & DEVELOPMENT
COMMENTS
CONSERVATION Reviewed
DATE REJECTED
N
COMMENTS Q (57 1 a —) l(S Q\
DATE APPROVED
HEALTH Reviewed on Signature
COMMENTS
Zoning Board of Appeals: Variance, Petition No: Zoning Decision/receipt submitted yes
Planning Board Decision:
Comments
Conservation Decision: Comme
Water & Sewer Conn
DPW Town Engineer: Signa
FIRE DEPARTMENT - Temp
Located at 124 Main Street
Fire Department signature/date
CONROENTS
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
DomBuilding Permit Revised 2011 June/mi
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
MOTE: 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
MOTE: 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
CERTIFICATE OF USE & OCCUPANCY
TOWN OF NORTH ANDOVER
Building Permit Number 677-12 on 3/26/12 Date: July 10, 2012
THIS CERTIFIES THAT
Orchard Village LLC
THE BUILDING LOCATED ON 32 Empire Drive (Lot 5)
MAY BE OCCUPIED AS a single family home_IN ACCORDANCE WITH THE
PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER
REGULATIONS AS MAY APPLY.
Certificate Issued to: Orchard Village LLC
277 Washington Street
Groveland, MA
01834
Buildi g Inspecto
Fee: PrePaid
Receipt: 25130
Check : 2851
O, ,kORTh 1
,sS4CHUSE4
CERTIFICATE OF USE & OCCUPANCY
TOWN OF NORTH ANDOVER
Building Permit Number 677-12 on 3/26/12 Date: July 10, 2012
THIS CERTIFIES THAT
Orchard Village LLC
THE BUILDING LOCATED ON 32 Empire Drive (Lot 5)
MAY BE OCCUPIED AS a single family home_IN ACCORDANCE WITH THE
PROVISIONS OF THE MASSACHUSETTS STATE BUILDING CODE AND SUCH OTHER
REGULATIONS AS MAY APPLY.
Certificate Issued to: Orchard Village LLC
277 Washington Street
Groveland, MA
01834
ZL� -
Buildi g Inspecto
Fee: PrePaid
Receipt: 25130
Check: 2851
0
z
t/]
s:
Lo
:.o c
c
C N
C
O
V C.3
CZE.
• �: R
m C
:mss
�o
m
�E a
,..
O c
y
C
, t
C.3 $
:oma E
CO R
® G N y
y co 3
cm
ca_m
R O
EIy
CD
av co
y m =
os
co Q �.
a.ct m
4D C2
c o 0
Z
R Cif
.: C Q p C
= m o C2 N
CO)LAJ
R L m w
•UJ CS.0 R C Z
L2 a 0 g
F- 2 a Ci_.. m F.
a
4
U
2
O
co
O
CD
O
Z °'
CL
O y
Q C
I c c'
CO2
O
O.�
h O O
�� m m
C.. ~_.+
.00 O �
CL)
03 o
iv D a
c
CL C Q
GO
c
O O
co
C Z CD
C3 CL
V h
O C
� C
R
a
H
0
to
19W
W
19
W
C4
a
o
ll
Z.
CZ0 - -
`
W
En
o
'oma'
o°
m on
�_ �� o
C.
o
®
w o
o
v '•. 0
o
Li.
w U
a: is.
c)
rL' w
W cn cn
Lo
:.o c
c
C N
C
O
V C.3
CZE.
• �: R
m C
:mss
�o
m
�E a
,..
O c
y
C
, t
C.3 $
:oma E
CO R
® G N y
y co 3
cm
ca_m
R O
EIy
CD
av co
y m =
os
co Q �.
a.ct m
4D C2
c o 0
Z
R Cif
.: C Q p C
= m o C2 N
CO)LAJ
R L m w
•UJ CS.0 R C Z
L2 a 0 g
F- 2 a Ci_.. m F.
a
4
U
2
O
co
O
CD
O
Z °'
CL
O y
Q C
I c c'
CO2
O
O.�
h O O
�� m m
C.. ~_.+
.00 O �
CL)
03 o
iv D a
c
CL C Q
GO
c
O O
co
C Z CD
C3 CL
V h
O C
� C
R
a
H
0
to
19W
W
19
W
C4
C �
m C
O
V :
OC O
y
C
O
t �[
• V V
•dam
s
�o
m
m c
o a
V)
C
m
v ,-
m C mi
E
SQ' CyrO � L
O O
C.
y y
y mcm :111
3
C m J
.�
:.0 C y
Go O C
O
E v)
m
HE
cm
o ac 32
CL m
m .Q
ca y o . L
v•�Z o
_oa c
CL
= mCOD
m w C N
t
W Ore
C42 CLA
'E: coi y o
_w m _
COD d m't I, 'o
�- = sCLE = 5
r
U
0
U
9
I
I
!tip!
co
O
a)
L
0 �
Z °'
CL
O CO)
O cm
Ip "O
CA
y O �O
•E m m
w C3 CD
L � �
CD
CZ)
CD o
cc o a
o- CMa
c
O 4C C
O O
V J .O
cz O
C Z CD
CD
C.2 y
O C
c
d
CO2
uj
Y♦
LLI
V/
W
W
W
C4
%)
•�
GG.
+
a
o•
��
W
i`�✓
0
Q
o
w
w U a
w
Cl)DO
w
cn cn
cn
C �
m C
O
V :
OC O
y
C
O
t �[
• V V
•dam
s
�o
m
m c
o a
V)
C
m
v ,-
m C mi
E
SQ' CyrO � L
O O
C.
y y
y mcm :111
3
C m J
.�
:.0 C y
Go O C
O
E v)
m
HE
cm
o ac 32
CL m
m .Q
ca y o . L
v•�Z o
_oa c
CL
= mCOD
m w C N
t
W Ore
C42 CLA
'E: coi y o
_w m _
COD d m't I, 'o
�- = sCLE = 5
r
U
0
U
9
I
I
!tip!
co
O
a)
L
0 �
Z °'
CL
O CO)
O cm
Ip "O
CA
y O �O
•E m m
w C3 CD
L � �
CD
CZ)
CD o
cc o a
o- CMa
c
O 4C C
O O
V J .O
cz O
C Z CD
CD
C.2 y
O C
c
d
CO2
uj
Y♦
LLI
V/
W
W
W
C4
FR
n
O
z
Lo
i
O
O
O
c y
' O C
•� O
IU•d=
R O
�b cc
• �E a
m CF
cD
o c.
N
C
"J2
ci
:mom E
CD m
N m 3
c 1. m J �
b _
co s
Vlk
to
V y O C2
43
N Q
cm
' C•r
L = O Of
CLQ C
• O
♦r N �
13
C13
CD
.: •:CLo c
n
.��y-mo 0
= o
i- o
VMS
ca
t
W o
�... •N •n= C Z
O 'r m N O
LU •m o w m r
n COD o •L3 cm
cc
a aJ
�- = 2 MOM m
p
U
0
z
u
624
U6
co
Cl
CD
0
o �
Z m
CL
O y
0 �
43 cm
CO)
p�
C
H m m
L- CD G3
H
CL dp-o
G3 -Aft
m
CD L
cc o a
CL ca
c
COO)
ccc
v Cc
CO2
C Z 4D
C3 CL.
V h
R C
C
d
25
LU
Y/
W
W
19
W
U)
13
ZW
OJLw
v
w
z
v .
v
a°' w
° mu
ww
w8 cin
//i
O
z
Lo
i
O
O
O
c y
' O C
•� O
IU•d=
R O
�b cc
• �E a
m CF
cD
o c.
N
C
"J2
ci
:mom E
CD m
N m 3
c 1. m J �
b _
co s
Vlk
to
V y O C2
43
N Q
cm
' C•r
L = O Of
CLQ C
• O
♦r N �
13
C13
CD
.: •:CLo c
n
.��y-mo 0
= o
i- o
VMS
ca
t
W o
�... •N •n= C Z
O 'r m N O
LU •m o w m r
n COD o •L3 cm
cc
a aJ
�- = 2 MOM m
p
U
0
z
u
624
U6
co
Cl
CD
0
o �
Z m
CL
O y
0 �
43 cm
CO)
p�
C
H m m
L- CD G3
H
CL dp-o
G3 -Aft
m
CD L
cc o a
CL ca
c
COO)
ccc
v Cc
CO2
C Z 4D
C3 CL.
V h
R C
C
d
25
LU
Y/
W
W
19
W
U)
v ttc., eb -ryO
APPLICATION FOR CERTIFICATE OF OCCUPANCYANSPECTION
AR^rE�5 BUILDING PERMIT 7 7
'SSACHUS
ADDRESS/LOCATION OF PROPERTY: - 52 00 A105-
Map C- ParcelllZ Lot Number zl�e 6—
I
SUBDIVISION: LL -1 E
DATE REQUESTED FILED/READY FOR INSPECTION: 2,
CLOSING DATE ON PROPERTY: %�,� b2,
FIVE (5) DAYS NOTICE PRIOR TO CLOSING DATE IS REQUIRED
ALL WORK AND SIGN -OFFS MUST BE COMPLETED WITHIN THIS TIME FRAME. A
REINSPECTION FEE OF TWENTY DOLLARS ($20.00) WILL BE CHARGED IF THE STRUCTURE
DOES NOT MEET ALL APPLICABLE CODES.
APPLICANT SIGNATURE
Permit Issued to:OtLbyE-
Address:
CA{�r'-o ��� 1q/NUg6Y e eAl�uEApAA018.3q�Y e e�le0(�E�p A, 018.3
ROUTING PA
TOWN ENGINEER, SITE PLAN — D VE -WAY REVIE
CONSERVATION
X71,
� ro1
PLANNING
DPW -WATER METER
SEWER CONNECTION
DPW MUST INDICATE THAT THE WATER METER HAS BEEN INSTALLED PRIOR TO
SUBMITTAL OF THE ANCY/INSPECTION REQUEST
DPW 7�
SIGNATURE
File: Application for OC form revised Jan 2007/2011
/fit •,'- _ '6 OL
y° APPLICATION FOR CERTIFICATE OF OCCUPANCYANSPECTION
i a T
TED BUILDING PERMIT # 67
�SSACHUS
ADDRESS/LOCATION OF PROPERTY:��/�/�fly.
mapZd7C Parcel/fes Lot Number
P/t
SUBDIVISION: ��c � t� oZ_L14
DATE REQUESTED FILED/READY FOR INSPECTION:
CLOSING DATE ON PROPERTY: %119
WAM
FIVE (5) DAYS NOTICE PRIOR TO CLOSING DATE IS REQUIRED
ALL WORK AND SIGN -OFFS MUST BE COMPLETED WITHIN THIS TIME FRAME. A
REINSPECTION FEE OF TWENTY DOLLARS ($20.00) WILL BE CHARGED IF THE STRUCTURE
DOES NOT MEET ALL APPLICABLE CODES.
APPLICANT SIGNATURE
Permit Issued to: 0ac9 -l_o Utl_Lmie
Address:r iq94(N!�?T6/J S'ice+gAL)F APP
ROUTING
TOWN ENGINEER, SITE PLAN — D E -WAY REVIEW% -;---
CONSERVATION 7/1
PLANNING 44
DPW -WATER METER LT �°�'2-��y
SEWER CONNECTION
DPW MUST INDICATE THAT THE WATER METER HAS BEEN INSTALLED PRIOR TO
SUBMITTAL OF THE ANCY/INSPECTION REQUEST
DPW 1 7�-
SIGNATURE
File: Application for OC form revised Jan 2007/2011
°
APPLICATION FOR CERTIFICATE OF OCCUPANCYANSPECTION
g0R'7ED ,a <5 BUILDING PERMIT # y
1SSAC14US
41'ADDRESS/LOCATION OF PROPERTY: 5� l ly
Map �G Parcel x112— Lot Number. ._
SUBDIVISION: C
DATE REQUESTED FILED/READY FOR INSPECTION:
CLOSING DATE ON PROPERTY: %119,/
FIVE (5) DAYS NOTICE PRIOR TO CLOSING DATE IS REQUIRED
ALL WORK AND SIGN -OFFS MUST BE COMPLETED WITHIN THIS TIME FRAME. A
REINSPECTION FEE OF TWENTY DOLLARS ($20.00) WILL BE CHARGED IF THE STRUCTURE
DOES NOT MEET ALL APPLICABLE CODES.
APPLICANT SIGNATURE
Permit Issued to: OacgA L L %ao -��-
Address: ��% l� �'94l N����Y e e�I 0FtAyPA����1� 694 N����Y e e�I 0FtAyPN�'����$
ROUTING
TOWN ENGINEER, SITE PLAN — DVE-WAY REVIEW%
a ia-
CONSERVATION
PLANNING 414
DPW -WATER METER
SEWER CONNECTION
DPW MUST INDICATE THAT THE WATER METER HAS BEEN INSTALLED PRIOR TO
SUBMITTAL OF THE ANCY/INSPECTION REQUEST
DPW -�
SIGNATURE
File: Application for OC form revised Jan 2007/2011
MAScheck COMPLIANCE REPORT
Massachusetts Energy Code
MAScheck Software Version 2.01 Release 2
CITY: North Andover
STATE: Massachusetts
HDD: 6322
CONSTRUCTION TYPE: 1 or 2 Family, Detached
HEATING SYSTEM TYPE: Other (Non -Electric Resistance)
DATE: 3-21-2012
DATE OF PLANS: 7/30/09
TITLE: The Willow
PROJECT INFORMATION:
Orchard Village, Lot 5, #32 Empire Drive
COMPANY INFORMATION:
Orchard Village, LLC
COMPLIANCE: PASSES
Required UA = 450
Your Home = 226
Permit #
Checked by/Date
Area or
Cavity
Cont.
Glazing/Door
Perimeter
-------------------------------------------------------------------------------
R -Value
R -Value
U -Value
UA
CEILINGS 1258
38.0
0.0
38
WALLS: Wood Frame, 16" O.C. 2115
21.0
0.0
121
BSMT: Conc. 8.0' ht/7.0' bg/0.0' insul 0
0.0
0.0
0
GLAZING: Windows or Doors 140
0.300
42
DOORS 79
0.000
0
FLOORS: Over Unconditioned Space 768
30.0
0.0
25
HVAC EQUIPMENT: Furnace, 96.0 AFUE
HVAC EQUIPMENT: Air Conditioner, 13.0 SEER
-----------------------------------------------------7-------------------------
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 requirements of the Massachusetts
Energy
Code.
The heating load for this building, and the cooling load if appropriate,
has been determined using the applicable Standard Design Conditions found
in the Code. The HVAC equipment selected to heat or cool the building
shall be no greater than 1250 of the design load as specified in
Sections 780CMR 1310 and J4.4.
Builder/Designer Date
Massachusetts Energy Code
MAScheck Software Version 2.01 Release 2
The Willow
DATE: 3-21-2012
Bldg.l
Dept.I
Use I
I CEILINGS:
[ ] I 1. R-38
I Comments/Location
I
WALLS:
[ ] I 1. Wood Frame, 16" O.C., R-21
Comments/Location
I
BASEMENT WALLS:
[ ] I 1. Conc. 8.0' ht/7.0' bg/0.0' insul, R-0 (uninsulated)
I Comments/Location
I
I WINDOWS AND GLASS DOORS:
[ ] I 1. U -value: 0.3
I For windows without labeled U -values, describe features:
# Panes Frame Type Thermal Break? [ ] Yes [ ] No
I Comments/Location
I
I DOORS:
[ ] I 1. U -value: 0
I Comments/Location
I
FLOORS:
[ ] I 1. Over Unconditioned Space, R-30
I Comments/Location
I
HVAC EQUIPMENT:
[ ] I 1. Furnace, 96.0 AFUE or higher
I Make and Model Number
[ ] 1 2. Air Conditioner, 13.0 SEER or higher
I Make and Model Number
I
I AIR LEAKAGE:
[ ] i Joints, penetrations, and all other such openings in the building
envelope that are sources of air leakage must be sealed. When
I installed in the building envelope, recessed lighting fixtures
I shall meet one of the following requirements:
I 1. Type IC rated, manufactured with no penetrations between the
I inside of the recessed fixture and ceiling cavity and sealed or
I gasketed to prevent air leakage into the unconditioned space.
I 2. Type IC rated, in accordance with Standard ASTM E 283, with no
I more than 2.0 cfm (0.944 L/s) air movement from the the
I conditioned space to the ceiling cavity. The lighting fixture
I shall have been tested at 75 PA or 1.57 lbs/ft2 pressure
I difference and shall be labeled.
I
I VAPOR RETARDER:
[ l I Required on the warm -in -winter side of all non -vented framed
ceilings, walls, and floors.
MATERIALS IDENTIFICATION:
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, glazing U -values, and heating and
cooling equipment efficiency must be clearly marked on the building
plans or specifications.
DUCT INSULATION:
Ducts shall be insulated per Table J4.4.7.1.
DUCT CONSTRUCTION:
All accessible joints, seams, and connections of supply and return
ductwork located outside conditioned space, including stud bays or
joist cavities/spaces used to transport air, shall be sealed
using mastic and fibrous backing tape installed according to the
manufacturer's installation instructions. Mesh tape may be
omitted where gaps are less than 1/8 inch. Duct tape is not
permitted. The HVAC system must provide a means for balancing
air and water systems.
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.
HVAC EQUIPMENT SIZING:
Rated output capacity of the heating/cooling system is
not greater than 125% of the design load as specified
in Sections 780CMR 1310 and J4.4.
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.
HVAC PIPING INSULATION:
HVAC piping conveying fluids above 120 F or chilled fluids
below 55 F must be insulated to the following levels (in.):
CIRCULATING HOT WATER SYSTEMS:
Insulate circulating hot water pipes to the following levels (in.):
PIPE SIZES (in.)
NON -CIRCULATING CIRCULATING MAINS & RUNOUTS
HEATED WATER TEMP (F): RUNOUTS 0-1" 0-1.25" 1.5-2.0" 2.0+"
PIPE
SIZES
(in.)
HEATING SYSTEMS:
TEMP (F)
2" RUNOUTS
0-1"
1.25-2"
2.5-4"
Low pressure/temp.
201-250
1.0
1.5
1.5
2.0
Low temperature
120-200
0.5
1.0
1.0
1.5
Steam condensate
any
1.0
1.0
1.5
2.0
COOLING SYSTEMS:
Chilled water or
40-55
0.5
0.5
0.75
1.0
refrigerant
below 40
1.0
1.0
1.5
1.5
CIRCULATING HOT WATER SYSTEMS:
Insulate circulating hot water pipes to the following levels (in.):
PIPE SIZES (in.)
NON -CIRCULATING CIRCULATING MAINS & RUNOUTS
HEATED WATER TEMP (F): RUNOUTS 0-1" 0-1.25" 1.5-2.0" 2.0+"
170-180 0.5 1.0 1.5 2.0
140-160 0.5 0.5 1.0 1.5
100-130 0.5 I 0.5 0.5 1.0
----NOTES TO FIELD (Building Department Use Only)-------------------------
The Commonwealth ofMassachusetts
Department oflndustrialAccidents
Office of Investigations
600 Washington Street
Boston, MA. 02111
www.ma_ssgov/dia
Workers' Compensation Insurance Affidavit: ]3uilders/Contractors!Electricians/PIumbers
Vicant Information PlpaaP Prim T.nrr;i,l,
Name (Business/Organization/lndividual):
Address z�7 7 IJI.%AS9/A)6 I n .&i
City/State/Zip U 15-7 LA,
�i7 MA-6J!R3q Phone#:DD-�
Are you an employer? Check the appropriate box:
L ❑ I am a employer with
4. ❑ I am a general contractor and I
2. opImployees (full and/or part-time).*
have hired the sub -contractors
am a sole proprietor or partner-
listed on the attached sheaet t
ship and have no employees
These sub -contractors have
working for me in any capacity,
[No workers' comp. insurance
workers' comp. insurance.
5. ❑ We are a corporation and its
required.]
3. ❑ I am a homeowner doing
.officers have exercised their
all work
right of exemption per MGL
myself. [No workers' comp,
C. 152, § 1(4), and we have no
insurance required.] f
employees. [No workers'
comp, insurance required j
Type of project (required):
6. NrNew construction
7. ❑ Remodeling
8. ❑ Demolition
9. ❑ Building addition
10. ❑ Electrical repairs or additions
1111 Plumbing repairs or additions
12.0 Roof repairs
13.0 Other f
*Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. I
Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew 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.
lam an employer that isproviding workers' compensation insurancefor my employees Below is thepolicy and job site
information.
Insurance Company
Policy # or Self -ins. Lie. M
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 required under Section 25A ofMGL 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 ofthis statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby ce under the pains and
,�enaldes ofperjury that the information provided above is true and correct.
6—I- k1 A „
M
"JJ"caac 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): ,
I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical
6. Other Inspector S. Plumbing Inspector
Contact Person:
Phone M
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 apartinents 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'vvithhold 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
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), addresses) 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 infonnation (if necessary) and under "Job Site Address" the applicant should write "all locations in � (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town ,may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you is 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 Co,--w,-Aonwc-aU-, of J`jassachlisetts
Department of Zndustriai .Accidents
Office of Investigations
600 Washington Street
Boston; M -A Q2111
TO. # 617-727-4900 ext 406 or 1:.877-.MASS.AFR
Revised 5-26-05 Fax #X61.7,727 7749
www.mass.gQvjdia
r
a
r
c
FOUNDA TION L OCA TION
CLIENT.- ORCHARD VILLAGE, LLC
THIS CERTIFICATION IS MADE AND LIMITED TO THE ABOVE CLIENT
LOCATION.•#32 EMP/RE DR. NORTH ANDOVER,MA.
DATE -3112112 SCALE -1 "=30'
I CERTIFY THAT THE PRIMARY STRUCTURE SHOWN CONFORMS
TO THE HORIZONTAL SETBACK REQUIREMENTS OF THE LOCAL
APPLICABLEZONING BY-LAWS IN EFFECT WHEN CONSTRUCTED.
(THIS CERTIFICATION DOES NOT CONSIDER ANYOTHER
RESTRICTIONS SUCH AS COVENANTS, WETLANDS,EASEMENTS,
ORDERS OF COND177ONSETC.)
THIS DRAWING SHALL NOTBE USED BYTHECLIENTFORANY
PURPOSE OTHER THAN THATOUTLINED ABOVE,EXCEPTWITH
THE WRITTEN PERMISSION OF CHRISTIANSEN &SERGI INC.
FURTHERMORE THIS DRAWING IS 771E COPYRIGHTED PROPERTY
OF CHRISTIANSEN & SERGI INC. AND ANY UNAUTHORIZED USE IS
PROHIB17ED.CHRISTIANSEN&SERGITAKES NO RESPONSIBILITY
FOR THE UNAUTHORIZED USE OF THIS ORA WING ORANY
INFORMATION CONTAINED HEREON.
PROFESSIONAL ENGINEERS & LAND SURVEYORS
CHRIS TIANSEN & SERGI, INC.
160 SUMMER STREET, HAVERHILL, MASSACHUSETTS 01830
WWW. CSI—ENGR.COM TEL. 978-373-0310 FAX 978-372-3960
O WG. NO.: 06029.001.04 7
W
i•1
LLJ
CLO
Xo-') G
Lo
. C 0
i.
G N
C
' O
' v V
u .Q C
R W
D C
O CD
. r=a
�- CD CF
on
N
c
Go ".
m c
y•p L
m m
+' N
m3
N •~
c m
_m
=
N
N OC G
O
N
O
CD ca cm
O.(.3 L O
®N O
= Z = O Cf
L.= OfG
G O Q �'
•� C O
m
Z
G L O C
cc
cm
CLD CSO
N O _
W O •O y'„ C r=.+ •�
� •N d.0 A � Z
O.0 O
.O Ob- 8 OCA O
O) J
yv O_ o
N a N O
O
F— t � dam-. M
z
u
Cf)
f
2
O
O
4)
L
Z CD
C.
O y
D =
a�
CM
ICA c�
h
m m
L- 0 CD
E"' Z
CLCm♦-+
as
CD i
env o a
CL CMQ
Q-0-9 c CcC
C.2
'FL C3
C CD
0 CL
V V2
� C
�C C
C.
0
i
ui
0
U)
LLI
C4
W
W
19
W
N
O
w
a)
C/)
0
�
s
.�
O
w
�
O
w
�
U.
�
G
u.
0
a
�
O
•�
G
°
w
�
O
�
,�
G
�
O
co
a
w
G
2
�i
0
O
n
LLJ
CLO
Xo-') G
Lo
. C 0
i.
G N
C
' O
' v V
u .Q C
R W
D C
O CD
. r=a
�- CD CF
on
N
c
Go ".
m c
y•p L
m m
+' N
m3
N •~
c m
_m
=
N
N OC G
O
N
O
CD ca cm
O.(.3 L O
®N O
= Z = O Cf
L.= OfG
G O Q �'
•� C O
m
Z
G L O C
cc
cm
CLD CSO
N O _
W O •O y'„ C r=.+ •�
� •N d.0 A � Z
O.0 O
.O Ob- 8 OCA O
O) J
yv O_ o
N a N O
O
F— t � dam-. M
z
u
Cf)
f
2
O
O
4)
L
Z CD
C.
O y
D =
a�
CM
ICA c�
h
m m
L- 0 CD
E"' Z
CLCm♦-+
as
CD i
env o a
CL CMQ
Q-0-9 c CcC
C.2
'FL C3
C CD
0 CL
V V2
� C
�C C
C.
0
i
ui
0
U)
LLI
C4
W
W
19
W
N